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Serious Case Review Quality Markers

Quality statement

The decisions about the precise form and focus of the Serious Case Review (SCR) to be commissioned take into account factors related to the case and the local context. They are made with input from Local Safeguarding Children Board (LSCB) members and in conjunction with the lead reviewer(s).


An SCR needs to produce learning in a proportionate manner. An individual review also needs to help nurture cultures and partnerships that are capable of learning and improving. Initiating the substantive work of the review therefore requires that further detail is added to initial decisions made about the kind of SCR to be undertaken. This includes specifying:

  • the breadth and depth of the investigation
  • any specific areas of focus or questions
  • the method or approach to be used to assemble the relevant information and deliver the required analysis
  • the knowledge and skills needed from the reviewer(s) to lead the process
  • the agencies that need to be involved.

The specifics of the case itself are a key factor in making these decisions, including:

  • types of strengths and vulnerabilities of the family and carers, kinds of risks posed to the child(ren) or young person 
  • the gravity and/or complexity of apparent concerns about professional practice in the case
  • any specific legal requirements (such as the Human Rights Act when a child or young person who was in state care has died).

Other relevant factors that need to be taken into account are contextual, including:

  • previous local learning and areas or issues about which less is currently known
  • availability of reviewers and their knowledge, skills and competence
  • public interest
  • local capacity relative to other ongoing learning and improvement activity
  • strategic learning and improvement plans and priorities
  • the capacity of the LSCB to carry out and learn from the review at that particular time and any factors currently affecting that capacity
  • features of the local context that impact on the capacity of practitioners to be openly involved at this time.

These factors are not discrete but interact with and influence each other, which means that making decisions about what is a proportionate approach is complicated and requires judgement. Involving LSCB members and working with the lead reviewer(s) to decide how best to accommodate this range of factors will enable the relevant information to be assessed and the right expertise to be brought to bear.

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

  1. Are LSCB members given the opportunity to input any information they think relevant to agreeing a proportionate approach for the review?
  2. Are the lead reviewers able to properly influence the scope, nature and approach of the SCR?
  3. Have the full range of factors related to both the case and context that are detailed in the rationale of the quality marker (QM) been considered in decision-making about what exactly is being commissioned?
  4. Does the scoping document or terms of reference for the SCR explain the rationale for decisions about proportionality that have been reached by referring to factors related both to the case and context?

Knowledge base

  • Practice experience highlights how powerfully contextual factors influence what can be achieved in an individual review. 

Link to statutory guidance & inspection criteria

  • ‘Working Together’, p 73 para 10 states that ‘the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined’.
  • It also provides detail about the requirements of lead reviewers (HM Government 2015: 78).
  • The National Panel has repeatedly stressed that a proportionate approach needs to be adopted to enable the aims of the SCR process to be met in a way that is flexible and relevant to the individual case circumstances, without incurring excessive cost or workload. See for example, ‘First report’ para 20. 

Tackling some common obstacles

  • Strong leadership by the LSCB chair about the full range of factors that need to be taken into account helps avoid some being disproportionately prioritised more than others.
  • Up-to-date knowledge about the availability of suitable lead reviewers will make their identification easier.
  • Having someone within the LSCB team with specific responsibility for SCRs in the context of the learning and improvement framework makes this easier.
  • A detailed understanding of what constitutes an effective investigation by relevant LSCB personnel will support the discussions and decision-making.
  • Some of the factors relevant to deciding what proportionate looks like in a particular review are local factors, but some emanate from outside the area, and many are beyond an LSCB’s power to control. In this context transparent decision-making that has taken account of the above factors can help anticipate challenges for the review and can help focus and manage expectations.
  • Cases that cross single or multiple borders add considerable complexity to commissioning considerations and need to be discussed early on. Involving all relevant LSCBs helps foster collective ownership of decision-making. Consideration of a cross-LSCB governance body can be useful.