A function of the three Safeguarding Children Partnerships is to conduct a Local Child Safeguarding Practice Review (LCSPR) after a child has died or is seriously harmed as a result of abuse or neglect whose permanent residence is within the relevant Local Authority area. The Pan Bedfordshire National & Local Child Safeguarding Practice Review Procedure & Guidance sets out the arrangements that are in place to respond to these reviews and what happens once a referral is made to the relevant Safeguarding Children Partnership under Chapter 4 of Working Together to Safeguard Children (2018).
The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children.
Reviews seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account.
‘Serious child safeguarding cases’ are those in which:
(a) Abuse or neglect of a child is known or suspected
(b) The child has died or been seriously harmed
Working Together to Safeguard Children (2018) states that serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health. This is not an exhaustive list. When making decisions, judgment should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred.
Meeting the criteria does not mean that the Safeguarding Children Partnerships must automatically carry out a LSCPR. Locally it is for the relevant Care Review Group, on behalf of their Safeguarding Children Partnership, to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice.
LSCPR reports will be published on this website to enable the sharing of learning across the children’s workforce. All reports are anonymised for publication.
Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel (the Panel) if –
- The child dies or is seriously harmed in the local authority's area; or
- While normally resident in the local authority's area, the child dies or is seriously harmed outside England.
16C(1) of the Children Act 2004
(as amended by the Children and Social Work Act 2017)
The local authority must notify the Panel of any event that meets the criteria within 5 working days of becoming aware that the incident has occurred. The local authority should also report the event to the safeguarding partners in their area (and in other areas if appropriate) within 5 working days. Where the child was Looked After, the local authority must also notify the Secretary of State and Ofsted that they have died, regardless of whether abuse or neglect is known or suspected.
The duty to notify serious child safeguarding events to the Panel rests with the local authority. Information on the process to be followed using the Child Incident Notification System can be found on GOV.UK.
Any partner agency may refer a case to the relevant Safeguarding Children Partnership’s Case Review Group if they believe that there are important lessons for multi-agency working to be learned from the case.
The three Case Review Groups have several functions and tasks delegated to them. In summary, they will coordinate the following inter-related activity:
- Make recommendations to the Independent Chair/Scrutineer as to: - whether a LSCPR should be carried out and the methodology to be used, or - whether a LSCPR should not be carried out but another type of review should be undertaken and the methodology to be used, or - whether other action should be taken by the relevant Safeguarding Children Partnership.
- Commission LCSPRs, positive learning reviews or other types of reviews on behalf of the Safeguarding Children Partnerships.
- Monitor partner agency and the appropriate Safeguarding Children Partnership’s action plans following the publication of child safeguarding practice reviews or completion of another type of review.
- Use the learning from local and national child safeguarding practice reviews to inform policy, practice and the three Safeguarding Children Partnership’s learning and development programme.
Each agency must have arrangements for identifying cases where the agency considers that criteria for either a local or national Child Safeguarding Practice Review (CSPR) may be met. It is important that any practitioner is able to discuss a case with their agency Case Review Group representative if they think a CSPR may be required.
Each Safeguarding Children Partnership’s Case Review Group representative should notify the relevant Business Unit of a referral and confirm this in writing within 48 hours using the
Pan Bedfordshire Serious or Non Serious Notification Form.
The relevant Business Unit will request agency information to assist in the Rapid Review of the case. Locally the three Safeguarding Partners have ultimate responsibility for deciding whether to conduct a CSPR or not. The Independent Chair/Scrutineer will also be informed to allow independent scrutiny of the decision making process.
Please see the Pan Bedfordshire Serious Incident Notification & Rapid Review Process flow chart for further information.
A case may be referred by the local Child Death Overview Panel to the Case Review Group that appear to meet the criteria and which they consider is likely to have important lessons for multi-agency working.
Bedford Borough Safeguarding Children Partnership (BBSCP);
Serious Youth Violence Thematic Review
Learning Briefing in regards to a Thematic Review of Serious Youth Violence (SYV) commissioned by the BBSCP following two incidents of SYV which resulted in the death of one young person and the serious injury of another. View the Serious Youth Violence Thematic Review - July 2021
For both young people there were concerns about drug misuse/selling and potential involvement in gangs. The BBSCP was keen to ascertain if issues for vulnerable young people including county lines and other forms of exploitation, drug misuse, SYV and involvement in gangs are being identified and responded to early enough.
The cases of these young people have provided a lens through which to consider current service responses, informing a wider case audit of young people identified as vulnerable or at risk of SYV.
Dr Julie Harris from University of Bedfordshire was commissioned to lead the Review and sought support and advice from colleagues within the International Centre Research on Child Sexual Exploitation, Violence and Trafficking.
Whilst completing this Review the National Child Safeguarding Practice Review Panel’s It was hard to escape – Safeguarding children at risk from criminal exploitation which looked at common patterns, similarities and differences between the approaches taken in local areas (including Bedford Borough).
Following the BBSCP signing off this Review the learning and recommendations have and are being addressed by the Partnership and monitored by the Partnership’s Case Review Group.
Examples how the BBSCP and partners are working together to address all forms of exploitation and the risks posed to children in Bedford Borough:
- Pan Bedfordshire Exploitation and Missing Strategic group and their Violence and Exploitation Strategy and Action Plan.
- Child Exploitation and Missing Reduction Group.
- Joint Serious Youth Violence Panel with Central Bedfordshire.
- Bedford Borough Contextual Safeguarding Meetings.
- Work of the Violence Exploitation and Reduction Unit(VERU) and their Bedfordshire Against Violence and Exploitation (BAVEX) Campaign.
- Research by University of Bedfordshire to include work on Contextual Safeguarding by Bedford Borough Council as good practice.
- There is collective responsibility for disruption and action within the partnership.
- Close work between partners and the Bedfordshire Police Boson and Public Protection Teams.
- The use of the Pan Beds Multi-Agency Information formto provide the Police with information to build a picture of exploitation and other issues.
- Proactive use of National Referral Mechanism.
Central Bedfordshire Safeguarding Children Partnership (CBSCP)
In the past year the CBSCP has carried out and published the following Child Safeguarding Practice Reviews:
Baby Euan Child Safeguarding Practice Review (January 2023)
Baby Euan 7 Point Briefing (January 2023)
Luton Safeguarding Children Partnership (LSCP)
A Thematic Child Safeguarding Practice Review was commissioned by LSCP and can be found here: (Add report here).
This review consider the multi-agency response to four young males who had been involved in serious youth violence and gang association. Three of the young males had received stabbing injuries as a result of their involvement in serious youth violence, and not all of them were known to youth offending or children's social care prior to these events. The cases of these young people have provided a lens through which to consider current service responses, informing a wider case audit of young people identified as vulnerable or at risk of SYV.
Following the LSCP signing off this Review the learning and recommendations have and are being addressed by the partnership and monitored by their Case Review Group. Examples how the LSCP and partners are working together to address all forms of exploitation and the risks posed to children in Luton:
Safeguarding Bedfordshire Training
Learning from local and national safeguarding cases is embedded across the Safeguarding Bedfordshire training programme. If you have identified training needs as an individual, or across your agency, please review our training offer here, or contact the training team to discuss further.
The national case review repository provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level.
National Case Review Repository
The NSPCC have put together a series of themed briefing documents highlighting the learning from published reviews. Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning.
Learning from Case Reviews