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Learning From Reviews

In accordance with Working Together to Safeguard Children (2023), Local Authorities are required to notify the National Child Safeguarding Practice Review Panel within five working days of an incident where they know or suspect that a child has been abused or neglected and the child has died or been seriously harmed.

When the serious incident becomes known to the Safeguarding Partners, they must consider whether the case meets the criteria for a local review. Meeting the criteria does not mean that safeguarding partners must automatically carry out a Local Child Safeguarding Practice Review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice. The safeguarding partners therefore should promptly undertake a Rapid Review of the case.

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: BSCP2021-22/02

Publication date: 18.12.2025

This Local Child Safeguarding Practice Review was commissioned following the death of a premature baby who died in 2021, at just a few days old. At the time of the baby’s death, the mother lived with the baby’s father and her three children from a previous abusive relationship. The review focuses on the impact of domestic abuse examining partnership intervention during the mother’s pregnancy. The family were known to Children’s Social Care, due to domestic abuse on the mother and the children who were subject of a Child Protection Plan under the category of emotional abuse. The review identifies important learning that can help improve safeguarding partners’ practice.

Case reference: BSCP2025-26/01

Publication date: 04.12.2025

This thematic review focuses on the death of a number of young babies (under 12 weeks of age) during the Covid-19 pandemic and more recently. The majority of Sudden Unexpected Death in Infancy (SUDI) risk factors were present for all the babies considered. 

The thematic review concluded with a child’s perspective: ‘Will I feel safe, will I be fed, kept warm and dry, will I be put to sleep safely, what is known about my family and its history that might impact on my life, what have my other siblings experienced already?’

Case reference: BSCP2022-23/03

Publication date: 18.06.2025

This review is about the death of a three-week-old baby. The family are of British Pakistani heritage. Prior to the baby’s death the family were receiving universal services and were not known to either children’s social care or mental health services.  Their contacts with universal services were positive and there were no concerns about the child’s care or concerns about adult behaviour and relationships.  The review focused on what could be learnt from events of the 24hrs when father became acutely mentally ill and killed his child and injured his wife and mother.

Case reference: BSCP2022-23/04

Publication date: 04.06.2025

This Child Safeguarding Practice Review briefing note focuses on the death of a 3-year-old child who it is believed died in January 2020. The child’s remains were recovered from an address where the family had lived whilst in Birmingham, before moving to Somerset. The family are of Black British heritage, have strong religious beliefs, adhere to a strict dietary regime, and had an alternative lifestyle described as living ‘off-grid’, avoiding engagement with any universal services.

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 family are of the Islamic faith and are of Ghanaian heritage and culture. 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.

 

 

 

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.