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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: BSCP2018-1-/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.

Case reference: BSCP2017-18/02

Publication date: 05.10.2021

This independent review focuses on the tragic death of a 21-month old chid in November 2017 as a result of catastrophic brain injuries following a violence assault. The child had been placed with a relative under a Special Guardianship Order in March 2016.

Case reference: BSCP2019-20/02

Publication date: 21.09.2021

A Local Child Safeguarding Practice Review focusing on the fatal stabbing of a teenage boy, and two other young men who were with him at the time of the incident. In January 2020, the boy and young men, who were all from Birmingham and believed to have been involved in an urban street gang, travelled to a small country town where the violent assault took place.


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.

Are you listening to me?