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Learning from Cafcass submissions to Serious Case Reviews

This version of the report has been adapted for sharing with external agencies, and case examples have been anonymised to protect identities (November 2017)

This is the fifth study into the learning derived from Cafcass submissions to Serious Case Reviews (SCRs). This report presents data in relation to:

  • The 15 most recent SCRs between December 2015 and December 2016 (referred to as ‘the 2017 study’);
  • The 97 SCRs to which Cafcass has contributed since 2009, taken from the five studies.

The caveats we have expressed in previous studies bear repetition. Firstly, 97 cases represent a tiny fraction of the total number of cases that Cafcass has worked with between 2009 and 2016: approximately one case per 4000 or 0.025% of our total caseload. Tragic outcomes are extremely rare.

Secondly, SCRs have added to our understanding of risk and of our practice strengths and weaknesses, but they have no predictive value. They do not tell us which children are going to die, how, or when. We cite examples in this report of cases where the overt risk was derived from one adult but the fatal or serious harm was perpetrated by somebody else. We also provide data showing that the ‘index incidents’ (the fatal/serious abuse that triggered the SCR) took place during proceedings in just over a third of cases.


Section 1 provides a description of the context in which this study is published, notably the passing of the Children and Social Work Act in April 2017 which sets out new arrangements that will replace SCRs. We expect that SCRs will continue to be convened until the new arrangements are implemented, at a date to be confirmed.

Under the new arrangements there will be two different types of multi-agency reviews, one national and the other local. At a national level a Child Safeguarding Practice Review Panel will be established to identify cases that are complex or of national importance and arrange to have these reviewed under its supervision. Cases that do not meet these criteria will be subject to a Local Child Safeguarding Practice Review. These will be the responsibility of the safeguarding partners – the local authority, police and health – who will be responsible for setting up the arrangements that currently fall to Local Safeguarding Children Boards (LSCBs). Further details will be set out in regulations and Working Together.