Skip to content

Bibliography for Serious Case Review Quality Markers

Knowledge base

  • Berwick, D. 2013. A promise to learn – a commitment to act. Improving the safety of patient in England. London: Crown copyright 2013
  • Dekker, Sidney (2012-10-01). Just Culture: Balancing Safety and Accountability (p. 82). Ashgate Publishing Ltd. Kindle Edition..
  • Fischhoff, B. (1975) Hindsight & foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance, 1 (2), 288-299
  • Morris, K., Brandon, M. & Tudor, P. ( 2013) ‘Rights,  Responsibilities and Pragmatic Practice: Family participation in Case Reviews’ Child Abuse Review (2013)
  • Published online in Wiley Online Library
  • Munro, E., (2010) The Munro Review of Child Protection Part One: A Systems Analysis. Department for Education ed.  London: The Stationery Office.
  • Munro, E., (2011) Munro review of child protection: interim report – the child’s journey. In D.F. Education ed.  London: Crowncopyright.
  • NHS England Patient Safety Domain. 2015. Serious Incident Framework. London: NHS England.
  • Nicolini, D., Waring, J. & Mengis, J. (2011) Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social Science & Medicine, 73 (2), 217-225.
  • Rawlings, A., Paliokosta, P., Maisey, D., Johnson, J., Capstick, J. & Jones, R., (2014) A Study to Investigate the Barriers to Learning from Serious Case Reviews and Identify ways of Overcoming these Barriers. London: Kingston University
  • Reason, J. (1997) Managing the Risks of Organizational Accidents. Farnham, Surrey: Ashgate Publishing Ltd.
  • The Chief Medical Officer, (2000) An organisation with a memory Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. London: Department of Health
  • The Health Foundation: Patient safety resource centre (2013). (accessed 19/3/2016)
  • National panel of independent experts on Serious Case Reviews, (2014) First annual report. In Department for Education ed.  London: The Stationery Office.
  • National panel of independent experts on Serious Case Reviews, (2015) Second report of the national panel of independent experts on Serious Case Reviews. Department of Education: Crown copyright
  • Ofsted, (2008) Learning lessons, taking action – Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008. Ofsted.
  • Ofsted, (2009) Learning lessons from serious case reviews: year 2.[accessed 8/1/2015]
  • Ofsted, (2010) Learning lessons from serious case reviews 2009–2010. Ofsted.
  • Vincent, C. (2004) Analysis of clinical incidents: a window on the system not a search for root causes. Quality & safety in health care, 13 (4), 242-243).
  • Woods, D., Dekker, S.W.A., Cook, R., Johannesen, L. & Sarter, N. (2010) Behind human error. Second edition. Farnham, Surrey: Ashgate.

Statutory and other guidance

  • Crown Prosecution Service & ADCS (2013) Protocol And Good Practice Model (“2013 Protocol”) Disclosure Of Information In Cases Of Alleged Child Abuse And Linked Criminal And Care Directions Hearings
  • Department for Education, (2013) National panel of independent experts on Serious Case Reviews – Information for LSCBs and Chairs on how the panel will operate.
  • HM Government, (2015) Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children. London: Crown copyright 2015.
  • Ministry of Justice (2010) Guidance for coroners and Local Safeguarding Children Boards on the supply of information concerning the death of children. London: The Stationery Office
  • National Policing Homicide Working Group (Child Death sub group) (2014) Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews – A Guide for the Police, Crown Prosecution Service and Local Safeguarding Children Boards.