Learning From Reviews

A Rapid Review must be carried out by the Partnership within 15 working days of the serious incident notification being made to the National Panel. During the Rapid Review process, partner agencies are asked to provide information on their involvement with the child and their family. The purpose of the Rapid Review is to identify potential learning and establish whether a more comprehensive Local Child Safeguarding Practice Review is required.

The purpose of a Local Child Safeguarding Practice Review (LCSPR), formerly known as a Serious Case Review, is to identify improvements to be made to safeguard and promote the welfare of children at both a local and national level. LCSPRs should seek to prevent or reduce the risk of recurrence of similar incidents, by outlining how learning should be implemented.

The BSCP, in partnership with 13 other Local Authorities across the wider West Midlands, has developed a Regional Framework and Practice Guidance aimed at those professionals specifically involved in commissioning, managing and contributing to Rapid Reviews and Local Child Safeguarding Practice Reviews.

LCSPRs published over the last three years are available to read and download below.  Each Review is accompanied by a one-page briefing note and PowerPoint presentation for use in team meetings and supervision.  A historical archive of all published SCRs/LCSPRs can be found in the National Case Review repository.

Case reference: BSCP2020-21-01

Publication date: 17.12.2024

This Child Safeguarding Practice Review briefing focuses on a one-month-old baby who sustained non-accidental injuries in August 2020 whilst in his parent’s care. After domestic abuse was witnessed by health professionals, incorrect information within the referral led to professionals stepping down their response, and despite information about the father’s history having been shared, this was also not considered. Furthermore, the mother’s denial of the witnessed domestic abuse was accepted and attempts by the referring agencies to escalate the concerns took too long. The parents were convicted of causing or allowing serious physical harm to a child.

Case reference: BSCP2021-22-01

Publication date: 04.09.2024

This Child Safeguarding Practice Review focuses on a family in which systematic physical assaults were carried out by the parents against their eldest children over a seven year period. The parents removed their children from mainstream schooling, to provide home and tuition centre education. Approximately three years later the eldest child disclosed physical assaults by the parents; medical examinations found scars consistent with regular beatings.

Case reference: BSCP2019-20-01

Publication date: 23.07.2024

This review focuses on parental substance misuse and neglect, which led to the death of a three-month-old baby. The family was known to agencies in Birmingham, predominantly due to drug and alcohol abuse. In the two years prior to the baby’s death there was a deterioration in the family’s circumstances and home conditions, and there were numerous opportunities where practitioners could have intervened earlier to safeguard the children.

Case reference: BSCP2022-23-02

Publication date: 12.06.2024

This review, entitled ‘Serious Youth Violence – Breaking the Cycle’, examines the lives of ten boys in the city; some were victims of fatal stabbings, and some were responsible for fatal attacks. All the boys were believed to have been involved with inner-city urban street gangs. Most of the boys had suffered significant childhood trauma and adverse childhood experiences.

Case reference: BSCP2018-19/01

Publication date: 21.02.2024

This review focuses on a 3-year-old child who suffered a life changing head injury, requiring specialist care and support for the rest of their life. The medical team found evidence of old fractures and previous bleeding on the brain. The child’s parents were young, married asylum seekers. They came to the UK from abroad. They had been known to agencies since the child’s premature birth.

Case reference: BSCP2020-21/02

Publication date: 10.10.2023

This was a rare and distressing review where an innocent young man lost his life in October 2020. He was fatally stabbed by his partner’s 14-year-old daughter, Child A. Although Child A was living in West Sussex at the time of the fatal incident, she had spent most of her life in Birmingham. Child A was the subject of numerous types of multi-agency support plans, Education Health and Care Plans, Child in Need Plans and Child Protection Plans.

Case reference: BSCP2017-18/03

Publication date: 01.09.2022

This review focuses on chronic neglect and parental substance misuse, which tragically led to the death of a seven year-old child following an asthma attack in November 2017.

National Review into the deaths of Arthur Labinjo-Hughes and Star Hobson

Publication date: 26.05.2022

The primary purpose of this review, undertaken by the national independent Child Safeguarding Practice Review Panel, was to attempt to understand how and why the public services and systems designed to protect Arthur Labinjo-Hughes and Star Hobson were not able to do so.

Learning Lessons Briefing Notes are available to download and circulate on this page. The short summary provides background of the case, identifies key learning and highlights areas for practice improvement. To support Team Meeting discussions a PowerPoint presentation for each case has also been developed – these are available below.

• Never, Ever Shake a Baby
• ‘I was too frightened to tell anyone’
• Never Assume – The importance of information sharing
• Serious Youth Violence – Breaking the Cycle
• The importance of multi-agency planning for children with a palliative care pathway
• The importance of early planning and continuity of care for children with complex health needs
• ‘Are you listening to me?’
• ‘I take care of myself whilst mum is asleep!’