Child Safeguarding Practice Reviews

We have a statutory responsibility to consider serious incidents defined as those in which a child has died or been seriously harmed, and abuse or neglect is known or suspected, and determine whether a child safeguarding practice review should be undertaken, in consultation with the national Child Safeguarding Practice Review Panel. Where it is deemed they are necessary, child safeguarding practice reviews (CSPRs) may be held locally or undertaken by the national panel. The processes that must be followed are described in Chapter 4 of Working Together to Safeguard Children 2018 and supported by our KRSCP serious incidents policy and procedure. 

It is the general expectation that CSPRs are written for publication; however, there may be instances where local CSPRs are considered too sensitive for local publication and are therefore published anonymously via the NSPCC serious case review repository. The NSPCC also publishes thematic research on case reviews which can be accessed via their website. 

Access the national CSPRs and thematic reports undertaken by the Child Safeguarding Practice Review Panel.

Learning from local learning

You can find details of published local learning below, this includes local CSPRs, other local learning reviews, past serious case reviews (produced under the auspices of previous statutory multiagency local safeguarding children boards), safeguarding adults reviews, and domestic homicide reviews: 

Child V

This child safeguarding practice review concerns the death of a four year old.

Key themes: awareness and management of health conditions; response to medical neglect; response to domestic abuse; how agencies worked together to protect Child V and safeguard his welfare.

Read Child V CPSR Report.

Baby Ulric – a local learning review 

This local learning review was convened following a non-accidental injury to a baby.

Read Baby Ulric local learning review.

Richmond DHR and SCR – Maria 

The Domestic Homicide Review (DHR) and Serious Case Review (SCR) regarding Maria was published in March 2021 by Richmond Community Safety Partnership. The father tragically killed the mother, his two sons and himself in March 2018.  

One strategic learning point for this review is to ascertain how a migrant family in such financial stress could have sought and found assistance. 

The second strategic learning point is the need to ensure the link between financial difficulty and suicide is incorporated into the work of Safeguarding Adults and suicide prevention. 

Read the Domestic homicide review overview report into the death of Maria.

Serious case review into events at St Paul's School 

This Serious Case Review was published by Richmond Local Safeguarding Children Board (LSCB) in January 2020. The independent author was Jane Wonnacott, and the panel was chaired by Edina Carmi. 

Key themes: organisational response to abuse; development of safeguarding culture; responding to allegations against an adult working with children; multiagency relationships and to ensure effective of support and challenge; adequacy of regulatory systems; and complex investigation management and adequacy of related procedures. 

View the Serious case review into events at St Paul's School.

Family A

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

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


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. 

Read Child B serious case review final 2015.