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Implementation and evaluation

Serious Case Review Quality Markers 

Quality statement

The Local Safeguarding Children Board (LSCB) integrates the learning from the Serious Case Review (SCR) and its decisions about how it is going to respond into its business plan and monitors actions to test whether improvements in services are being made.


A key function of the SCR is to improve professional practice. To achieve this the response of the LSCB and member agencies is as important as the report. Maximising the effectiveness of the response requires that actions are reviewed and outcomes evaluated. These should judge not only whether actions have been achieved but also whether they have made a difference to safeguarding practice.

The learning and actions emanating from an SCR are only one source of learning and improvement action, and feed into a bigger programme of work run and overseen by an LSCB. It is important that the action resulting from a single SCR is both seen and evaluated in the context of that bigger whole and as part of a continual learning process. In complex systems such as multi-agency safeguarding arrangements, the impact of change is often hard to anticipate with total accuracy and there may be unintended consequences. It is important therefore to ascertain whether the original response was the right thing or if the action needs adjusting.

How might you know if you are meeting this quality marker?

  1. Does the LSCB have systems in place for reviewing whether action has been taken in response to SCR findings/recommendations?
  2. Is the learning from this SCR going to be included and integrated into the learning and improvement framework?
  3. Does the monitoring of the actions include both consideration of whether agencies respond but also what the outcome for children will be?
  4. Is there going to be follow-up monitoring over time to check that change is maintained and if there are any unintended consequences?

Knowledge base

  • Double-loop learning as described by ‘Learning to reduce risk in child protection’ in ‘The Munro review of child protection part one: a systems analysis’ (Munro, 2010). 

Link to statutory guidance & inspection criteria

  • The Office for Standards in Education (Ofsted) inspection guidance requires that SCRs identify good practice to be disseminated where practice can be improved.

Tackling some common obstacles

  • Where monitoring the response to the SCR is an established part of the leaning and improvement framework, the SCR report is less likely to be treated as the end product rather than the response to the report’s findings/recommendations.
  • Where LSCBs have a number of SCRs underway it may be helpful to have a separate sub-group or equivalent that concentrates on evaluation and monitoring.
  • Something akin to succession planning can help address the loss of ownership of SCRs when significant people leave or change role.
  • When LSCBs are successful at prioritising their responses, it is less likely that their actions will be diluted by having committed to too much activity.
  • The LSCB can help address the challenge of interdependencies between agencies in change processes.