A serious case review takes place after a child dies or is seriously injured and abuse or neglect is thought to be involved. It looks at lessons than can help prevent similar incidents from happening in the future.

A serious case review should take place if abuse or neglect is known, or suspected, to have been involved and the following has happened:

  • A child has died.
  • A child has been seriously harmed and there is cause for concern about how organisations or professionals work together to safeguard the child.
  • The child dies in custody.
  • A child has died by suspected suicide.

What is seriously harmed and how it is determined?

The definition of 'seriously harmed' includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • a potentially life-threatening injury;
  • serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. Local Safeguarding Children Boards should use available research evidence when considering whether serious harm has occurred.

Source: HM Government (2015) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). [London]: Department for Education (DfE).

What is the purpose of a Serious Case Review?

The purpose of a serious case review is to establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children. Dudley Safeguarding People Partnership Board has also been committed to undertaking smaller scale partnership reviews for instances where the case does not meet the criteria for a serious case review but it is considered that there are lessons for multi-agency working to be learnt.

The Dudley Safeguarding People Partnership Board will determine the terms of reference; appoint an independent reviewer; involve the young people and their families, as well as practitioners; agree recommendations, action plans and the final report. Each agency contributing to a case review is required to produce an action plan to ensure they meet the recommendations made for their agency. Progress on these actions is monitored and reported to the Dudley Safeguarding People Partnership Board serious case review subgroup with oversight of quality assurance.

The Dudley Safeguarding People Partnership Board values the perspective of families involved.

For any professionals a referral should come to the Serious Case Review Sub-group. For information please contact the Dudley Safeguarding People Partnership Business Unit on 01384 813780 or

Child Safeguarding Practice Reviews

For information on Child Safeguarding Practice Reviews (CSPRs) please visit our CSPR page