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Serious Case Review Quality Markers 

Quality statement

The Serious Case Review (SCR) achieves the requirement for independence and ownership of the findings by the Local Safeguarding Children Board (LSCB).


Rigorous SCR analysis requires a significant degree of objectivity combined with sufficient understanding of context and organisational arrangements. Subsequently, changing practice is the responsibility of the LSCB and member agencies and they are more likely to be able to achieve this if fully engaged in and supportive of the findings of the SCR. Both these issues create a necessary tension between the independence of lead reviewer(s), on the one hand, and local involvement and ownership of the findings and/or recommendations by LSCB members on the other. Governance arrangements need to manage this tension to best effect.

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

  1. At the start of the review, is there clarity about roles and responsibilities and are there explicitly stated governance arrangements (e.g. are the terms of reference/scoping document clear about who is responsible for what – who conducts the review, who provides quality assurance and challenge and who is ultimately accountable)?
  2. Is the system for quality assurance of the process and sign-off of the report set out clearly from the start?
  3. What are the mechanisms to allow challenge to the information and analysis of the review, so that the findings/recommendations have been thoroughly considered before the report is finalised and taken to the LSCB?
  4. Do the quality assurance mechanisms manage the tension between the independence of the lead reviewer(s) and the ownership of the final report by the LSCB in a fair and balanced fashion?
  5. Is there clarity about what happens when agreement cannot be reached about the analysis and findings/recommendations, and how impasses are handled?

Knowledge base

  • Practice experience of lead reviewers indicates that if governance arrangements are not explicitly stated at the beginning of the SCR there can be complications when the SCR report is to be completed. 

Link to statutory guidance & inspection criteria

  • ‘Working together’ (HM Government, 2015: 78) identifies the need for the independence of the lead reviewer and states that ‘The LSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues’ (para 20, p 76). 

Tackling some common obstacles

  • Clarity about roles and responsibilities can assist in resolving any tensions between independence and ownership.
  • Care needs to be taken that scrutiny and challenge are not personalised and do not become inappropriate pressure.
  • Processes of editorial support or peer review need to be explicit and a part of the formal process, given the sensitive interplay with the meaning being conveyed. This input is best provided at the analysis stage rather than later.
  • Where compromise cannot be reached between the lead reviewer and the LSCB members it is best for this to be acknowledged and addressed in the final report that is presented to the LSCB.
  • Where the analysis is jointly produced by a local group of senior managers and the lead reviewer(s), this can help reduce pressure to make inappropriate amendments. However, increased collaboration also creates challenges for lead reviewer(s) about how they exert and maintain their independence.
  • Keeping senior managers up to date so that there are no surprises about findings at the end of the review helps cultivate ownership of those findings.