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Decision making

Serious Case Review Quality Markers 

Quality statement

The decision about whether to have a Serious Case Review (SCR), and the nature of the SCR that is required, take into account factors related to the case and the local context. The rationale for these decisions is clear, defensible and reached in a timely fashion.


Following the referral of a case for SCR consideration, there are two purposes for information-gathering. The first is to determine whether the case meets the statutory criteria and if it does not, whether the Local Safeguarding Children Board (LSCB) still wants to commission an SCR. The second is to make an initial determination of the nature of the SCR to be commissioned.

When doing the initial thinking about the size and scope of the SCR, the LSCB chair has to weigh up a wide range of issues including:

  • what useful learning it will enable
  • how it relates to previous learning
  • resource constraints
  • impact on practitioners
  • impact on the family
  • other reviews/investigations being conducted at the same time
  • political and media interest
  • public trust in safeguarding organisations

Therefore it is necessary to gather sufficient and varied information to weigh up these issues.

The reasons for the chair’s decisions need to be explicit and justifiable to member agencies, central government, professionals involved and family members. Drift in decision-making will delay the review and learning being achieved. Decisions on the nature and scope of the review may need to be revisited during the commissioning of independent reviewers and as new information comes to light.

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

  1. Is sufficient information gathered, both about agency contact with the child or young person and a range of contextual information, to inform the decision-making?
  2. Are key agencies being asked to provide at least minimum data about their involvement with the incident and/or family?
  3. Are checks with neighbouring LSCBs being planned if it is apparent that the family has lived outside the LSCB area?
  4. Are there adequate mechanisms to support an informed inter-agency discussion to achieve a recommendation being made to the chair on whether an SCR should be conducted?
  5. Is any delay justified by the circumstances of the case?
  6. Is there consideration of independent challenge to the decision-making such as peer discussion with another LSCB chair?
  7. Is the decision informed by the statutory criteria and was this evidenced in the record of the decision made by the chair?
  8. Is the decision about the nature of the SCR informed by local learning and improvement activity, and outstanding needs?
  9. Do LSCB member agencies have the opportunity to provide input to the chair’s decision?

Knowledge base

  • Practice experience of conducting SCRs suggests the seriousness of the outcome of the case should not dictate the size of the SCR. LSCBs may already know the causes of practice problems evident in a new case, from previous SCRs. However, LSCB chairs often have to consider wider public interest issues in this decision (see QM5).
  • There is a suggestion from the experience in the health field of reviews, that there are benefits from doing fewer reviews of a high quality, rather than many which are less detailed. See for example the rationale for establishing a national investigation branch for NHS patient safety incidents.

Link to statutory guidance & inspection criteria

  • ‘Working Together’ (HM Government 2015) sets out an LSCB’s function in relation to SCRs in Chapter 4, paragraphs 18–20, p 75.
  • The National Panel routinely cross-references notifications of incidents with decisions about SCRs and reported concerns about delays in decision-making in the second annual report.
  • The Office for Standards in Education (Ofsted) is requiring boards to demonstrate that there have been decisions in relation to notified incidents. 

Tackling some common obstacles

  • Where LSCBs have sufficient funds they are more likely to explore broader learning opportunities rather than focusing exclusively on statutory SCR criteria.
  • Where the LSCB business unit has sufficient independence from member agencies this facilitates information-gathering and dispassionate decision-making.