Child Safeguarding Practice Reviews

The Kingston and Richmond Safeguarding Children Partnership (KRSCP) has a statutory duty to have a learning and improvement framework, which helps all agencies work together in Kingston to look at situations involving children and families where there has been good or concerning practice. This helps us look at our safeguarding learning and systems. You can access Kingston and Richmond's Learning and Improvement Framework here.

Local Learning


This Learning Lessons' review was undertaken by Kam Singh and Deborah Glassbrook. It concerns a young woman and her experience of neglect.  There is learning about dealing with historic concerns for children, hearing the child's voice and ensuring children understand how and why professionals are working with them.  This review gives professionals a springboard to implement signs of safety interventions with families.

The Executive Summary is here

Family L

Two young children went missing in Kingston in early 2016. The Kingston and Richmond Safeguarding Children Partnership (KRSCP) commissioned a lessons' learnt review using a systems' approach.  The authors were Sarah Johnson, Caroline Mark and Sian Thomas.  There is learning about communication, responding to injuries, child in need planning and Section 47 strategy meetings, transient families, identifying people when home visits are made and flagging vulnerabilities.

The Executive Summary is here

Stanbridge Earls School Hampshire LSCB Serious Case Review 2015. More information here.

Family A
Family A Serious Case Review was published in November 2015.  The independent authors were Edina Carmi and Nicki Walker Hall. The mother killed her children in April 2014.

Key themes: neglect; risk assessments; and working with children with complex needs.

Please find for download below, the overview report, LSCB response and SMA Support UK information sheet and press release statement:

Child B
Child B Serious Case Review, independent author Susan Ellery, was published in June 2015. Child B, 15, sadly took his own life in 2014.

Key themes: working with concerns of self harm and suicide; online gaming; and interventions with minority ethnic groups.

  • Child B Serious Case Review in Kingston Executive Summary - 
  • Download
  • Child B Serious Case Review Final 2015 - Download
  • Resources for parents, carers and professionals to support online safety and gaming: what to do if you are worried

Kingston DHR November 2014
A woman was stabbed to death by her partner in 2011; she had a young child.

Key themes: risk assessment; information sharing; communication; and child abduction.

For more information please click: 
Domestic Homicide Review 2011 (Agapito)

Tom and Vic SCR Kingston 2013
Tom and Vic were adolescents injured in 2012 and involved in criminal activity.

Key themes: working with vulnerable adolescents; risk assessments; missing children; and evaluation of outcomes when working with children and young people.

For more information please click: 
Tom and Vic Serious Case Review - October 2013

Southbank International School SCR -  Hammersmith & Fulham, Kensington and Chelsea and Westminster LSCB
For more information please click - 
Summary of the Westminster LSCB Southbank School Serious Case
Review January 2016

Child G Learning Lessons Richmond 2013
This 7 week old baby died as a result of unknown natural causes. A learning lessons review was undertaken.
Key themes: timely pre-birth assessment; planning for looked after young people, who become parents; working across borough borders; the value of reflective supervision for those who work with vulnerable adolescents.

Child F SCR Richmond 2012
Child F died of an overdose - he was 13 years old. For many years, he thought that his maternal grandparents were his parents.

Key themes: information sharing; risk assessment for adults with substance misuse concerns who have contact with children; recording and analysing family history; pre-birth assessment; young carers; recognition of risks for agencies working with adults; medicalisation of social concerns; escalations of concerns between agencies.

National learning

Brighton LSCB Serious Case Review - July 2017                   Brighton LSCB published a Serious Case Review in July 2017 regarding the tragic death of two brothers in Syria in 2014. There is learning about radicalisation and the vulnerability of young people to grooming for extremism. The review is here:

Colin - XLSCB 2016
X Local Safeguarding Children Board (XLSCB) conducted a Serious Case Review into the death of a child “Colin”. Colin died following an incident which took place while he was in the care of professionals during a planned activity.
Full Learnings can be downloaded here

Child CN – Devon LSCB 2014
In June 2013, the stepfather was convicted and imprisoned for sexual offences against his two stepdaughters. The youngest daughter took part in the serious case review and said it would have made a difference if she had felt that her mother would have listened to, and believed her, so that she could have confided in her. She also said she wished that social workers would have visited the home and so have seen what things were like rather than seeing her at school. There was learning about assessing males in the family home, information sharing, sexual abuse and the rule of optimism.

Further information can be found on the Devon LSCB website.

Daniel Pelka – Coventry LSCB 2013
Daniel, 4, was the middle child in a Polish family of three children. He was the subject of chronic neglect by his mother, torture and physical abuse by his stepfather. There were concerns of domestic abuse between the couple. The school struggled to recognise Daniel’s neglect and his mother explained his hunger and weight loss as a genetic concern, which the school did not question. Few attempts were made to hear Daniel’s voice. He died as the result of a head injury inflicted by his stepfather. He was found to be severely malnourished.

Further information can be found on the
Coventry LSCB website.

Child G – East Sussex LSCB 2013
This young person was involved in a relationship with her school teacher. Despite concerns from school students, the young person’s family, and staff at the school did not see this as an abusive situation and considered the teacher to be a victim; the LADO involvement was not effective. Child G was taken abroad by her teacher in 2012 leading to high profile media campaign before she was found and returned to the UK. Her teacher was subsequently convicted and imprisoned for child abduction and sexual offences.

Further information can be found on the
East Sussex LSCB website.

Young people 1, 2,3,4,5 & 6 – Rochdale LSCB 2013 
Rochdale Borough Safeguarding Children Board (RBSCB) has published two serious case reviews in to the response of services in Rochdale Borough to the sexual exploitation of 7 young people between 2003 to 2012. Problems identified include: poor front-line understanding and implementation of policy and procedures; an absence of high quality supervision, challenge and line management oversight; failure to intervene early to protect 6 of the 7 exploited young people from damaging experiences including neglect and domestic violence. The reports make a number of recommendations including: RBSCB to map and scrutinise work on practice improvement that has already taken place and identify what further action is now required.

Further information can be found on the
Rochdale Borough LSCB website

The sexual abuse of children in a foster home - SCR by City and Hackney LSCB 
Between September 2013 and November 2014, the City and Hackney Safeguarding Children Board conducted a Serious Case Review (SCR) about the sexual abuse of a number of children by two men. One was an approved foster carer, the other a member of his family. The abuse of foster children is known to have taken place between 1999 and 2008.

Further information can be found on the
City and Hackney LSCB website

Two Serious Case Reviews published by Thurrock LSCB - Megan & Julia 
Thurrock LSCB has published two helpful Serious Case Reviews. Megan has learning for agencies around early help for an older teenager. Julia's review is around CSE (Child Sexual Exploitation).

Further information can be found on the 
Thurrock LSCB website

Daniel - A Serious Case Review published by Kent LSCB 
Kent LSCB's review regarding Daniel in 2013 is also about CSE and substance use. 

Further information can be found on the Kent LSCB website 

Child J - A Serious Case Review published by Lambeth LSCB 
Lambeth LSCB's Child J Serious Case Review is about a teenage young woman who had mental health concerns and took her own life. 

Further information can be found on the 
Lambeth LSCB Website

Child F - A Serious Case Review published by Havering LSCB

This serious case review concerns a 17 year old who took their own life. You can read an overview of the learning here and access the executive summary here.

National repository of published case reviews
The NSPCC and Association of Independent LSCB Chairs have been working together to develop a national repository of case reviews that have been published in the UK. This is a resource to access and share learning on a local, regional and national level. Please click here to access the NSPCC repository.  

Bristol Safeguarding Adults' Board

Bristol Safeguarding Adults' Board published this review into a young person, Melissa, who was murdered by another young person  -  both young adults had just transitioned to adults' services. 
Please click here for the Case Review.
Please click here for the Learning Summary.

Thinking the Unthinkable

There is important learning about whistle-blowing for anyone in any organisation or agency, when other members of staff or volunteers exhibit possibly inappropriate behaviour. In Cambridge, a Consultant  Paediatrician Miles Bradbury, was found to be abusing children during his work. A receptionist raised the alarm following safeguarding training.  The learning around the Miles Bradbury case may be accessed here.

Child Z

Death of a 10-year-old boy from complications arising from his medical condition. Child Z complained of headaches in the days leading up to his death and instead of following a previously agreed pathway to go straight to the emergency department, his father, who is a GP, made a scheduled appointment at the hospital for a few days' time. On the way to this appointment, Child Z's condition worsened and he died later that day. Child Z was born with a disability that resulted in complex needs and restricted mobility. There was a history of disagreement between parents and professionals over Child Z's care and treatment including putting in place mobility adaptations. There were concerns about Child Z's lack of formal education, the adversarial stance of the parents and the mother's mental health. Issues identified include: the importance of a multi-agency approach and Child in Need status for children with disabilities; the neglect of children with complex needs; keeping the focus on the child whilst dealing with challenging parents; dealing with child protection concerns with professionals who are also colleagues; the need for decision making panels to have a safeguarding focus. 

The review makes recommendations to: oversee an audit of cases of children with complex needs to ensure each child has a multi-agency plan in place; ensure all children with plans have regular reviews; identify the lead professional for children with complex needs; provide training for staff where parents present a challenge to engage; conduct a review of home educated children; provide appropriate support available for parents of disabled children to help them come to terms with their child's condition or disability. You can access the full report here.