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9.3 Process and Framework for Reviewing Cases below the SCR Threshold


This chapter recognises that there are occasions when a situation may not meet the threshold for a Serious Case Review but are of concern and provide invaluable learning for partner agencies. The chapter identifies these are either Critical Incident Reviews or Learning Reviews.


Learning and Improvement Framework, Working Together to Safeguard Children (2015)


Learning from Serious Case Reviews

This chapter was introduced into the manual in September 2015


  1. Introduction
  2. Single Agency Reviews
  3. Critical Incident and Learning Reviews
  4. Who is Involved in the Case Review?
  5. What is Involved in the Case Review Process?
  6. Case Review Methodology for Cases below the SCR Threshold
  7. Timescale for Completion of Reviews
  8. Engagement of Organisations
  9. Agreeing Improvement Action
  10. Publication of Reports
  11. Impact and Evaluation of Learning
  12. Significant Practice Events Chronologies

1. Introduction

The WSCB is a learning organisation and as such it uses a wide range of reviews and audits to reflect upon and improve practice. This includes undertaking multi-agency reviews on cases which did not meet the threshold (as stated in Working Together 2015) Serious Case Review (SCR) but which the SCR Committee decided would provide useful learning to the partnership. These reviews are either Critical Incident Reviews – undertaken where a child was harmed or injured, or caused injury, or Learning Reviews – undertaken where a child could have been harmed or injured.

The Principles for undertaking reviews are detailed in the WSCB Learning and Improvement Framework (LIF) which should be read alongside this document. Click here to access the LIF.

2. Single Agency Reviews

Where the criteria for undertaking either a SCR, Critical Incident Review or multi-agency Learning Review is not met, but there is likely to be learning for one agency, the SCR committee may request that a Single Agency Review is undertaken by that agency, and the review report is shared with the WSCB. The WSCB is aware that a number of partner agencies initiate their own reviews automatically in response to serious incidents using a variety of approaches and therefore we do not prescribe a particular approach or methodology to use but the WSCB does request that the review addresses the following key questions:

  • What did you feel went well with the case?
  • What did you learn from how the case progressed?
  • Were there any barriers to the intervention you were trying to provide?
  • What do you consider could have been done to provide a more effective approach to safeguarding this child/ young person?
  • Was your decision making supported by clear and effective policies, procedures and guidance?
  • What might the agency do differently in the future – what are the key safeguarding learning points?

3. Critical Incident and Learning Reviews

Where the WSCB considers the criteria for a multi-agency Critical Incident Review or Learning Review is met, the WSCB will decide the most appropriate methodology for conducting the review, ensuring all the appropriate methodological and outcome principles, as detailed in the Learning and Improvement Framework are met. The WSCB basis its review methodologies on the SCIE systems approach.

4. Who is Involved in the Case Review?

1. Lead Reviewers

The WSCB will appoint one or more suitable individuals to lead the Case Review. Lead reviewers will be drawn from the WSCB partnership and will be familiar with the requirements of undertaking a systems approach review.

2. Review Group

The Review Group should be made up of senior managers from relevant agencies and the Lead Reviewers who are independent of the case. The SCR committee will form the Review Group.

3. Case Group

The Case Group will be made up of the frontline practitioners and managers who were involved in the case, especially those involved in the Significant Practice Events. Case Group members can individually contribute to the case review, or different agency practitioners brought together in forums. The aim is to understand the practitioner’s view of the practice events and assist in analysing ‘contributory factors’ and how the safeguarding system can be improved.

The involvement of practitioners in the case review must be a safe way for them to contribute to identify the learning, and empower them to share and disseminate the learning. Case Group members must be informed and consulted on the findings from the case review and provided the opportunity to help the Review Group in correcting and enhancing the findings and learning.

5. What is involved in the Case Review Process?

The review process has a number of aspects:

  1. Introduction and preparation, including selecting the case, identifying members of the review team and case group, choosing the time period to review and assembling a ‘key dates’ timeline of different agency and professional involvement;
  2. Data collection and analysis - an iterative process of gathering information from case files, individual conversations with the case group, analysis by the review team, and opportunities for the case group to challenge, correct and amplify the review team’s analysis. The review team produces a report for each ‘follow on’ meeting with the case group;
  3. Final reporting and process reflections - Completion of full report by review team, and reflection on the process.

6. Case Review Methodology for Cases below the SCR Threshold

Timescale Review Group Case Group
Weeks One and Two Identification of Case group. Letters sent out to Case Group requesting full chronologies and audit of case files and completion of key questions. Practitioners audit of files, conversations with managers, completion of full chronologies and key questions.
Weeks Three and Four Return of information and analysis of responses and meetings with Case group members. Planning for Case group members to individually meet with Case group. One to one conversations with Review group members and planning for Case Review meeting.
Week Five 1:1 preparatory meetings with Case group members. 1:1 preparatory meetings with Review group members.
Week Six Review meeting with Case Group. Review meeting.
Week Seven Publication of Action Plan and Recommendations. Feedback about Action Plan and Recommendations.

7. Timescale for Completion of Reviews

The WSCB will aim for completion of Case Reviews within six months of initiating them (and within 12 months of the incident). If this is not possible (e.g. because of potential prejudice to related court proceedings, consideration by the National Panel etc), every effort should be made while the Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

8. Engagement of Organisations

The WSCB SCR Committee will provide oversight of the case review process and members will form the case Review Group.

The WSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review.

9. Agreeing Improvement Action

The WSCB will oversee the process of agreeing with partners what actions they need to take in light of the Case Review findings. Progress against actions will be reported into the Performance Committee on a quarterly basis and the committee will hold organisations to account for progress on behalf of the WSCB.

10. Publication of Reports

For cases below the SCR threshold, the WSCB is not required to publish a report and would not usually do so. However, the WSCB may produce a summary report of findings and recommendations which can inform learning for the WSCB and partner organisations. The report will contain the agreed partnership action plan and will also contain information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

11. Impact and Evaluation of Learning

Integral to the success of this framework will be the sharing of learning amongst the partnership to ensure transparency, accountability and consistent improvement to practice. The action plan will identify the actions required to effectively share the lessons to be learnt from the review. It will also include a series of impact measures which will be reviewed once the work has been completed.

The Performance committee will evaluate the impact of actions completed through audit and identify how these actions have contributed towards improving the outcomes for children and their families.

12. Significant Practice Events Chronologies

There is a strong commitment that robust and proportionate chronologies inform decisions to initiate case reviews and determine the scope and methodology for review. The use of Significant Practice Events (SPE) chronologies is integral to ensure clear parameters of any review are agreed based upon the circumstances of the case. Agencies should consider the following when preparing SPE chronologies:

  • Is this event one that changed/could have changed your assessment of the situation for the child?
  • Is this event symbolic or indicative of a pattern of events that individually would not otherwise be considered significant?
  • Is this a ‘statutory’ event e.g. Child Protection Conference, court hearing or similar?
  • Would this have been an event that the child perceived as significant in their life?
  • Would this have been an event that a significant adult would perceive as significant in their life or the life of the child?
  • Has this event got significance as a learning point for agencies?


SCIE Methodology 

Undertaking Serious Case Reviews using the SCIE Learning Together Systems Model Lessons from the Pilots

WSCB Learning and Improvement Framework