Wales unveils new serious case review system

All the UK nations are assessing the way they handle reviews into child protection cases, with Wales this week unveiling its new approach, writes Molly Garboden

Serious case reviews (SCRs) have been at the centre of debate for some years but Wales has moved the argument forward. This week, it unveiled part of a new approach, which promises to cut costs and help councils implement effective changes quickly.

Perhaps it is no surprise Wales has been the first country to do so. The spate of teen suicides in Bridgend in 2008 alone resulted in five SCRs – at enormous cost to the small safeguarding children board involved and delaying its other duties, such as multi-agency training and guidance.

Wales has no removed the requirement to conduct a SCR in the event of teen suicide, but the main focus of reform has been saving professionals’ time.

“One of the main changes is the decreased timescales,” says Jonathan Corbett, assistant chief inspector for the Care and Social Services Inspectorate Wales.

“We don’t want to cut corners in terms of thoroughness, but we want to make sure this is an active learning process rather than a slow and costly one. At the moment, many SCRs don’t have a result for a year or more, at which point everyone expresses shock and horror, but that far down the line from the case, what’s a council supposed to do?”

Although the basic structure of the new system has been agreed, Corbett says more details need to be finalised before the official launch later this year.

One of these involves the SCR authors. Corbett points out that local safeguarding children boards (LSCBs) have often found it time-consuming and expensive to find SCR authors who are up to the task.

There are additional concerns about inconsistencies in quality and style. Corbett and his team, which has overseen the redesign, have proposed a government-selected pool of experts on which LSCBs can call. These authors would be trained to the same standard in order to reduce inconsistencies and the difficulties in finding someone to write a review. All Welsh child protection cases will be classed according to the following case continuum:


For any case where there is suspected child abuse or neglect, the LSCB will organise a multi-agency event to evaluate the case. The aim of this event is to give practitioners designated time and space to reflect on the next steps to take, what good practice exists and what might be going wrong or could be done better. It will also prevent duplication in the support a family receives from different agencies.


In a case where a child has died or has been seriously harmed because of abuse or neglect, the LSCB will undertake a concise review. These reviews will be completed in a similar way to the SCRs now conducted in England, starting with individual management reviews by the agencies involved. The reviews will be brought together into an overarching review, along with a chronology and action plan. Concise reviews will be completed in three months and cover the 12 months leading up to the serious incident only. All agencies involved with the case will come together under the auspices of the LSCB to review the report findings. This will include an analysis of likely media issues resulting from the case, based on a standardised template provided by the LSCB.


In more complex cases of death or serious harm, the LSCB will undertake a comprehensive review. The process will be the same as that of concise reviews, but agencies and authors will be given six months to complete it. Comprehensive reviews will also cover the 12 months leading up to the serious incident, unless the case is regarded as having exceptional circumstances.



The criteria for carrying out a serious case review is outlined in Chapter 8 of the government’s Working Together to Safeguard Children guidance.

It states an SCR should always be undertaken when a child dies or is seriously harmed and abuse or neglect is known or suspected to be a factor. In SCRs, the local safeguarding children board brings together individual management reviews produced by all agencies involved. One author, a sector expert, writes the final report. The decision to conduct an SCR must be made within one month of the LSCB chair being made aware of the incident and should be completed within six months, unless an alternative timescale is agreed with the relevant government office.

When an SCR is completed, the LSCB sends the document to Ofsted, which evaluates the report. There is currently a debate about whether this inspectorate role is necessary and is one aspect of the process being considered by Professor Eileen Munro in her review of child protection systems in England. Munro is also considering whether the systems-based model of SCRs proposed by the Social Care Institute for Excellence is better. Her final recommendations are due to be published this spring.

Last year, the government said all SCRs commissioned from June 2010 would be published in full.


An initial case review (ICR) determines whether a significant case review is necessary.
Any agency involved with a case can initiate an ICR and forward it to the local child protection committee. The committee then tells each agency involved in the case to complete its own ICR within 14 working days. The findings are submitted to the committee’s case review group.
If an SCR is not considered necessary, the findings are recorded and some follow-up action may result. If an SCR is needed, each agency must record its involvement and suggest findings and recommendations. The SCR team chair will draft the report, based on these contributions, but the findings and recommendations must be agreed by all members.
The team will decide how the SCR will be distributed case by case, although the Scottish government is considering whether a more standardised approach is needed.
Since the recommendations of an independent working group of multi-agency professionals in 2009, the Scottish government has promised to audit all SCRs, devise a template for full reports and executive summaries and, this spring, will produce an analysis of all past SCRs.


Northern Irish case management reviews (CMRs) are similar to serious case reviews in England in terms of criteria and the way they are carried out.
The system was introduced in Northern Ireland in 2003 and about 30 reviews have been undertaken. Although CMRs are not statutory, this is set to change later this year when the Northern Ireland Assembly passes legislation establishing a regional safeguarding board. The board will replace the Regional Child Protection Committee and will be sited in the Public Health Agency.
Only summaries of CMRs are made public and there are no other plans to change the process.
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