Learning from case reviews

Serious Case Reviews (SCR's)


Working Together 2015 sets out the purpose and process of Serious Case Reviews (SCR's). SCR's are undertaken when a child dies (including suicide) or is seriously injured, and abuse or neglect is known or suspected to be a factor.

The purposes of SCRs carried out under this guidance are to:

  • Identify and establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;
  • Identify clearly within what timescales any improvement and learning will be acted upon, and what is expected to change as a result; and
  • Improve single agency and partnership working to better safeguard and promote the welfare of children.
  • Southwark Safeguarding Children Board has a sub group of the Board that considers whether cases referred to it meet the criteria for a SCR or smaller scale review.

The previous SCR’s were Child G a baby who died in 2007, Child H a baby who died in 2008 and Child I – a baby who was seriously injured in 2009.

Child U- SCR


A Serious Case Review was conducted by Southwark Safeguarding Children's Board (SSCB) following the fatal stabbing of a young person in September 2015. The SSCB chose to use the 'Welsh Model' to conduct the SCR. There is an action plan to respond to the learning identified in this review. Find the full report here.

Child R- SCR


This Serious Case Review conducted by Southwark Safeguarding Children Board took place between April 2014 and February 2015. The SSCB has set out a response to the Serious Case Review and there is an action plan to respond to the learning identified in this review. The action plan will be monitored by the SSCB, in order to further improve services to young people.

Serious Adults Reviews (SAR's)

Southwark Safeguarding Adults Board (SSAB) has a statutory duty to conduct a review when a person with care and support needs has died or experienced serious harm from abuse and / or neglect and there are concerns about how agencies have worked together. This is set out in the Care Act 2014 and is called a Safeguarding Adults Review (SAR). It is focused on learning and improving safeguarding responses, not on blame.

Adult A- SAR

A Serious Adults Case Review was conducted by Southwark Safeguarding Adults Board (SSAB) following concerns being raised by the Coroner back in 2014 as to the care and safeguarding of an adult.

Find full report and learning summary here.

Adult B- SAR

A Serious Adults Case Review was commissioned by Southwark Safeguarding Adult's Board to investigate the events leading to Adult B's death following a fire at her home in October 2016.

Find full report here.

Archive Policy


Working Together 2013 requires that all serious case review of cases meeting the SCR criteria should result in a report which is published and readily accessible on the Board’s website for a minimum of 12 months.

Learning from National Serious Case Reviews


The Research In Practice mini-site (hosted by the DoE) includes materials to support learning in practice for LSCBs, social work and early help, police and criminal justice, health and education practitioners.


The NSPCC provides a series of at-a-glance briefings highlighting the learning from national case reviews that are conducted when a child dies or is seriously injured, and abuse or neglect are suspected.


Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews.