Case reviews

Each of the four UK nations has a process for holding Case Reviews where a child dies or is seriously harmed. Each nation has its own guidance and criteria around the process for conducting Case Reviews and around the dissemination of learning. The purpose of Case Reviews is to seek ways to reduce the risk of recurrence of similar incidents by identifying and sharing key lessons and themes, locally as well as nationally.

Common Principles across the four nations:

  • In each nation there is a clear criteria and referral process and framework in relation to how a practice review is undertaken.
  • Reviews are about learning to improve and embed good practice in the future and not about holding individuals or organisations to account.
  • The lessons learned from reviews should be shared with organisations, stakeholders and partners.
  • Understanding where there are themes and systemic issues can reduce the risk of the same mistakes occurring again.
  • Reviews contain very sensitive including personal information. Significant care needs to be taken to preserve the confidentiality of the subjects and others involved.

Child Safeguarding Practice Reviews (previously referred to as Serious Case Reviews)

In England Working Together to Safeguard Children 2018 requires Local Safeguarding Children’s Partnerships to make arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. They must commission and oversee the review of those cases where they consider it appropriate for a review to be undertaken. The responsibility for exploring how lessons are learnt from serious child safeguarding incidents nationally is held by the Child Safeguarding Practice Review Panel. Their Annual Report 2018-19 can be accessed here

The Department of Education publishes a triennial analysis of Case Reviews in England: which can be accessed here

Research in Practice has developed a range of resources exploring learning from Case Reviews which are accessible here


Child Practice Reviews

In Wales, a Child Practice Review (CPR) should be carried out where a child has died; sustained a potentially life-threatening injury or sustained serious and permanent impairment of health or development. Working Together to Safeguard People: Volume 2: Child Practice Reviews (2019) provides the key guidance for conducting Child Practice Reviews. A Child Practice Review can be either a Concise or Extended Review depending on whether the child involved was on the Child Protection Register or in care six months before the harm occurred. Final reports of Child Practice Reviews must be published by the Safeguarding Children Board and submitted to the Welsh Government. Child Practice Reviews must contain an Action Plan.

Northern Ireland

Case Management Review

In Northern Ireland, a Case Management Review must be held where a child dies or is significantly harmed when abuse or neglect is suspected, or where a child (or sibling) is in care or has been subject to a Care Protection Plan. The key guidance for conducting a Case Management Review is Learning from Practice - Case Management Review Process Multi-Agency Guidance (Safeguarding Board for Northern Ireland, 2017). 'Learning from practice' case management review process multi-agency guidance (PDF). The Case Management Review (CMR) Panel will, on considering all of the information, decide whether a Practice Review is required and appoint a review team and chair. The Case Management website also outlines the process and provides further resources and contacts. 

Department of Health, Social Services and Public Safety (2014) Guidance to Safeguarding Board for Northern Ireland (SBNI) (PDF)

Translating Learning into Action: An overview of learning arising from Case Management Reviews in Northern Ireland 2003-2008  (Queens University, NSPCC Northern Ireland and DHSSPSNI) can be accessed here


Learning Review

In Scotland, a Learning Review is required in cases which raise serious concerns about professional or service involvement and where a child has died and abuse, neglect or suicide is known or suspected to have been involved, or where the child is in care or has been on the Child Protection Register at any time. A Learning Review may also be held where a child has suffered or is at risk of significant harm and the case gives rise to concerns about professional involvement. 

The National guidance for child protection committees undertaking learning reviews (2021) replaces the National Guidance for Child Protection Committees – Conducting a Significant Case Review (2015). All references to ‘Initial Case Review’ and ‘Significant Case Review’ in other current policy and guidance documents will be understood as referring to a ‘Learning Review’ as defined by the present guidance.

The overall purpose of a Learning Review is to bring together agencies, individuals and families in a collective endeavour to learn from what has happened in order to improve and develop systems and practice in the future and thus better protect children and young people. The process is underpinned by the rights of children and young people as set out in the United Nations Convention on the Rights of the Child (UNCRC).

See also, Scottish Government National guidance for child protection in Scotland (2021) 

The Care Inspectorate for Scotland has published a review in 2019 of learning from significant case reviews between 2015-18. It can be accessed here

An Interim Review of Scotland’s Child Protection arrangements, “Protecting Scotland's children and young people: it is still everyone's job” was published in 2017 and can be accessed here



Further Information

The Association of Independent LSCB Chairs and the NSPCC launched the National Case Review Repository in 2013 where LSCB’s share their published Case Reviews. The Repository is a useful resource in understanding practice failures and lessons learned for practice development. 

The NSPCC has some country specific summaries of the Case Review process in each of the four UK nations. It can be accessed here.

A number of Case Reviews which relate to foster care and other family placements have been identified and details are available here.