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Previous Serious Case Reviews

When a child dies or is seriously harmed as a result of abuse or neglect, a review is conducted to identify ways that professionals and organisations can improve the way they work together to safeguard children and prevent similar incidents from occurring.

The multi-agency safeguarding partners should ensure that reports for all reviews are written in such a way so that what is published avoids harming the welfare of any children or vulnerable adults involved in the case. Safeguarding partners should set out the justification for any decision not to publish either the full report or information relating to improvements.

Local child safeguarding Serious Case Review reports must be publicly available for at least one year.

If there have been any SCR's within 12 months of publication, you will find the reports below. Otherwise if there are none it means that locally we haven't had a SCR that has been published.

 Serious Case Review (SCR) Baby A - Report Summary

This review concerns Baby A, a new born who died at home where co sleeping was a significant factor in the death. Baby A had been under the parental supervision of her father and mother. Baby A was the youngest of a sibling group of three.

The review considered whether the death of Baby A could have been predicted or prevented. The multi-agency service provision and family experience of services has been appraised to identify if information had been effectively and systematically compiled and shared in the pre-birth or neonatal period. The review also asked: could a prediction of harm have been identified and could any risk be more effectively managed?

‘The review found that there were complex, interacting factors leading up to the death of Baby A, as is frequently documented in infant deaths in similar circumstances. Within the timeline there was not one identifiable factor that led to the death or one point in the timeline at which, had different action been taken, the death could have been prevented. The risk could have been predictable had there been robust multi-agency information sharing to inform the risk assessment, planning and intervention in the antenatal and neonatal periods.’

Click on the link below to read the full report & view the supporting action plan:

adobe pdf Baby A SCR Full Report Dec 2018

adobe pdf Baby A SCR Action Plan


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