‘Working Together’ – Serious Case Reviews and Local Safeguarding Children Boards

We are grateful to this contribution from Philiip Measures, a Social Worker. He is concerned about the current operation of Serious Case Reviews and the potentially damaging impact this may have on their integrity and focus. 

Serious Case Reviews are conducted when something has gone very badly wrong – for example a child has died. Here is an example of a Serious Case Review, carried out to investigate the death of Daniel Pelka when in the care of his mother and step father. 


Individual Management Reviews in Serious Case Reviews.

Under the new ‘Working Together to Safeguard Children (2013)’ multi-agency Guidance many people may be as surprised and amazed as I am to discover that the requirement for organisations to undertake Individual Management Reviews (IMR’s) in Serious Case Reviews (SCR’s) has been removed. IMR’s were the individual Agency Reports submitted to the SCR Independent Chair who could then pull them together and report from a, hopefully, informed and detailed basis and also seek further clarification on any matters arising.

See the summary of working together to safeguard children and http://media.education.gov.uk/assets/files/pdf/w/working%20together.pdf

SO, how do we ascertain and have faith in the integrity, independence and correct focus of Serious Case Reviews if so much detailed information does not now have to be provided?

My starting point had to be the Guidance- so I saw at Paras. 37 and 38 that:

37) Each child who has been referred into local authority children’s social care

should have an individual assessment to respond to their needs and to

understand the impact of any parental behaviour on them as an individual.

Local authorities have to give due regard to a child’s age and understanding

when determining what (if any) services to provide under section 17 of the

Children Act 1989, and before making decisions about action to be taken to

protect individual children under section 47 of the Children Act 1989.


38) Every assessment must be informed by the views of the child as well as the

family. Children should, wherever possible, be seen alone and local authority

children’s social care has a duty to ascertain the child’s wishes and feelings

regarding the provision of services to be delivered.

It is important to  understand the resilience of the individual child when planning appropriate services.

Communication with the Department of Education

I sent 2 emails to the Department of Education of a more general nature and received their responses:

Dear Mr Measures
Thank you for your emails of 9 December and 23 December, regarding serious case reviews (SCRs) and local safeguarding children boards (LSCBs). I am providing a single response as there are areas which cross over between the two emails, and I trust this is acceptable. I also apologise for the delay in replying.The government is clear that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. When things go wrong there needs to be a rigorous, objective and transparent analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.Our statutory guidance, ‘Working Together to Safeguard Children’ (2013), is clear that the final decision on whether to conduct a SCR rests with the Chair of the LSCB, who should be independent from any local agency in order to hold them to account.Where a decision is made not to initiate a SCR, information should be provided to the national panel of independent experts on SCRs to enable them to scrutinise the decision. Where a SCR is initiated, the LSCB should appoint one or more suitable individuals to lead the SCR who are independent of the LSCB and the organisations involved in the case.’Working Together to Safeguard Children’ (2013) has removed the requirement for individual agencies to provide independent management reviews, and gives LSCBs increased freedom to use a range of learning models. This includes methodologies which are designed to get professionals thinking about the systems that they work within, and to challenge those systems and identify where weaknesses exist.

The involvement of front line professionals, and family members, in the review process is the key to drawing out clear understanding of how things seemed at that time and why decisions were made. Those who have taken part in this type of SCR are clear that the learning begins as the review unfolds, which is quite different to the historical method of conducting SCRs.(redacted)

LSCBs make a vital contribution to our safeguarding agenda, and play an important role in keeping children safe. ‘Working Together to Safeguard Children’ (2013) sets out the legislation which underpins LSCBs and their statutory objectives and functions. It makes it clear that each local authority (LA) is required to establish a LSCB for their area, and specifies the organisations and individuals that should be represented on LSCBs. It is also clear that LSCBs should be independent in order to provide effective scrutiny, and should not be subordinate to, nor subsumed within, other local structures. The accountability of LSCBs has been strengthened by requiring the Chief Executive of the LA to be responsible for the appointment of the Chair, rather than the Director of Children’s Services as was previously the case. The Chief Executive, drawing on other LSCB partners and, where appropriate, the Lead Member, will also hold the Chair to account for the effective working of the LSCB.

I can confirm that LSCBs are not public authorities for the purposes of the Freedom of Information Act 2000. LSCBs aremade up of many agencies and information requests should therefore be directed to the LA or relevant partner agency.

From November 2013, Ofsted has been carrying out reviews of LSCBs, alongside their inspection of services for children in need of help or protection, children looked after and care leavers. This is an important development and is the first time that there has been an evaluation of this kind. This will provide increased rigour to the knowledge and understanding of the strengths and weaknesses in the overall system.


Thank you again for writing and I hope this is helpful.


Well, it was informative and rather an eye-opener:

a) LSCB’s are no longer Public Bodies

b) Their Chairs are now appointed by Local Authority Chief Execs.

c) OFSTED inspect them.

I also asked about the Independent Panel and the Department of Education DoE) responded as follows:

 The Independent Panel

Dear Mr Measures
Thank you for your further email of 9 January, regarding the role of the serious case review (SCR) panel and individual agency reports.The government announced in ‘Working Together to Safeguard Children (2013)’ that a national panel of independent experts would be established to advise local safeguarding children boards (LSCBs) about the initiation and publication of SCRs. The panel has been fully operational since July 2013. Each panel member draws on their own area of expertise when considering the decisions made by LSCBs.Panel members are:

  • Peter Wanless, Chief Executive of the NSPCC
  • Nicholas Dann, Head of International Development at the Air Accidents Investigation Branch (AAIB)
  • Elizabeth Clarke, practicing barrister and specialist in family law
  • Jenni Russell, journalist

In addition to the panel, the department is funding the NSPCC to run training courses for independent authors of SCRs and LSCB chairs and members. The training concentrates on the need to keep asking ‘why’ when carrying out SCRs, in order to delve beneath the surface and establish what, if anything, went wrong within organisations. ‘Working Together to Safeguard Children (2013)’ states that, as part of the review process, LSCBs may decide to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. However, it is for LSCBs to decide whether such an approach is appropriate and proportionate to the scale and level of complexity of the issues being examined.

Thank you again for writing and I hope this is helpful.



Concerns about the nature of  the available expertise

Well, frankly, NO I didn’t find it helpful – informative, yes, but helpful? No. An Air Accident investigator and a journalist – as ‘experts’? – come on DoE, whose leg are you pulling? Where are the ‘experts’ from Health, Education and the Police? These are 3 of the main agencies involved in Child Protection.

So does this new methodology represent a positive way forward? I absolutely believe that it doesn’t for the simple reasons that without access to a clear, and forensically detailed Chronology, how can it be possible to really tell the child’s story?

We need to be able to make sense of the full family background

Unless we can clearly make sense of the full family background (Social History) and see that important / significant events have been properly evaluated and assessed how can it be possible to even question on any authoritative basis the Conclusions of SCR’s because absolutely vital information may be absent – either my omission or commission? Agencies may provide reports which, if open to more detailed scrutiny, may require further investigation.

Also, in order to learn lessons we need the fullest information:

a) What significant events took place?

b) Did any meet the Threshold Criteria for intervention by any of the agencies who were aware? (to include legal intervention,  calling a multi-disciplinary Child Protection Conference; referral to MARAC etc.)

c) What responses, if any, ensued? (to include further information gathering and sharing / clarification with other agencies)

d) Were those responses (either positive or negative) relevant, targeted; monitored / reviewed and re-evaluated?

e) Who was ‘holding’ / co-ordinating the Case?

f) Who had management oversight and was offering support?

g) Was there evidence of effective multi-agency involvement?

h)  Were there clearly defined Aims and Objectives and ‘markers’ as to how progress / levels of improved safety were to be judged as being achieved or not?

i) Also, was there evidence of appropriate training / learning from any previous SCR’s?


I would finally make a call for the routine involvement in SCR’s of experienced practitioners who are independent of the Case and the Local Authorities / agencies concerned and also for their inclusion of Overview / Expert Panels.

Unless and until it can be clearly demonstrated that SCR’s are completely open and truly independent there can neither be professional, and even more importantly, public confidence in their integrity.


Philip J Measures,

Registered Social Worker; C.Q.S.W; Cert. in Social Work (Probation & Child Care); Advanced Cert. in Working with Child Abuse; Graduate Award in Management & Leadership  in Social Care


Contact him

Philip Measures is happy to be contacted directly if you have any queries

[email protected]


7 thoughts on “‘Working Together’ – Serious Case Reviews and Local Safeguarding Children Boards

  1. Philip Measures

    In respect of the ‘National Panel of Independent Experts’ I would just add that Peter Wanless of the NSPCC was also not a practitioner therefore only Elizabeth Clarke as a Barrister has any practitioner experience – so what ‘extra value’ does such a Panel have?

    I am pleased that already an MP will be raising the matters I have raised at ministerial level – so I will keep readers informed.

  2. Philip Measures

    The Link below is to an extremely worrying report produced today:


    IF some Local Safeguarding Children’s Boards do not know the definition of ‘serious harm’ and do not follow up Serious Case Review recommendations AND if the DoE Still feels the need for a good example of a SCR and IF there is still not deemed to be a need for multi-disciplinary detailed Chronologies to be produced (in order to identify who knew what and when; what actions (if any) were taken; how progress (or otherwise) was monitored then how on earth are we to learn any lessons.

    I see that the NSPCC-produced SCR’s are totally anonymised so that even the Local Safeguarding Children’s Board is not identified – what has happened to Mr Gove’s direction that SCR’s should be published in full and made widely available so that lessons can be learned?

    This annual Report of the so-called panel of Experts is extremely concerning – and given that most of them have no child-care experience and are worried – how much more should those of us be terrified who do have such experience? You really couldn’t make it up.

    Child Protection is in utter peril – but who really cares?

  3. Sam

    I looked at this https://www.whatdotheyknow.com/request/justice_4_jonas: as I remembered the name of the child. From what I recall it was a child who allegedly died through lack of medical attention whilst in foster care, despite the mother trying to alert the authority that in her opinion he needed it.

    It’s a bit of a long FOI request, most of which hasn’t been answered, whether that’s right or wrong I haven’t a clue but what sprung out at me is that there has not been a serious case review. I thought there had to be when a child died, who is known to the local authority.

    1. Sarah Phillimore Post author

      As I understand it, the medical evidence was clear that he died of natural causes – his respiratory system was overwhelmed by an opportunistic bacterial infection and he died very quickly. What was horrible about this case was that his parents asked the foster carers to take him to the GP a few days before he died as he was clearly not well. he was not taken to the doctors and the LA put out a press statement saying that he HAD been.

      so trust and confidence not exactly promoted there. But as far as I know there is no evidence to support an assertion that he was ‘murdered’ in foster care as some allege and not much evidence to support an assertion that if he had been taken to the GP he would not have died.

  4. Sam

    Thanks Sarah for clearing that up. I suppose because the reason natural causes there was no serious case review.
    This to me appears to be one of those cases where had there been partnership working, the mother may have been listened to. I am sure you know as a mother yourself you have a gut instinct about your child, it must have been beyond devastating for the parents.

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