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Child Safeguarding Practice Reviews


Why do we do reviews?

Working Together states; “The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children”.



What triggers a review?

 A review is triggered by a Serious Incident or a concerning situation. Serious child safeguarding cases are those in which:

  • abuse or neglect of a child is known or suspected and
  • the child has died or been seriously harmed*

Any serious incident generates a notification to Ofsted and a Rapid Review.

How is the decision made to undertake a review?

Once Ofsted has been notified of the Serious Incident the WSP Joint Case Review and Group then meets to do a Rapid Review and considers if the criteria for a Child Safeguarding Practice Review is met.

This decision must be made within 15 working days of the notification.

*Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health. When safeguarding partnerships are making decisions, judgment should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain.


Announcement: National CSPR for Baby M – May 2024 (TBC)

The Panel’s letter gives details about the review, including:

  • a range of themes including concealed pregnancy, working with those who evade services, working together across different areas and jurisdictions
  • details of panel members carrying it out

The Panel anticipates publishing the national review by the end of May 2024

Read the letters and Terms of Reference 


The NSPCC have published their learning from parental substance misuse related local case reviews.

The report highlighted several failings including lack of understanding of substance misuse and its effect on caring responsibilities, workers not always asking whether drug and alcohol users have children, and lack of information sharing between children’s social care and specialist alcohol and drugs services.


Working with male carers to reduce non-accidental injury to infants under 1 year old – June 2023

This joint briefing from the Child Safeguarding Practice Review Panel (the Panel) and Foundations – What Works Centre for Children & Families shares information arising from work undertaken by the Panel and Foundations with safeguarding partners and those working in child protection.

This paper explores current practice and evidence base relating to working with fathers to reduce non-accidental injury (NAI) in infants under 1 year old. It builds upon work that Foundations were commissioned to carry out by the Department for Education, and the previous work of the Panel.

The aim of this briefing is to support safeguarding partners in reviewing their current policies on working with fathers and to make recommendations on how the evidence base and national guidelines can be further developed.

Read the briefing: Working with male carers to reduce non-accidental injury to infants under 1 year old


In April 2023, the Child Safeguarding Practice Review Panel (the Panel) published their Phase 2 report reviewing safeguarding children with disabilities and complex needs in residential settings. The report set out several recommendations for central and local government for changes to policy and practice to improve the safety, support and outcomes for children with disabilities and complex health needs. We all agree that the abuse and neglect experienced by the children and young people at the three residential settings run by the Hesley Group in Doncaster was appalling. There were a series of failures in the current systems in private providers, children’s social care, SEND, [the then] Clinical Commissioning Groups (CCGs) and education providers that led to the events that occurred in these homes. While no system, however robust, can fully eliminate all risk of harm and abuse, those risks were exacerbated by wider systemic failings arising from inadequate leadership and management, poor quality training, support and supervision of the workforce, weak compliance with legal requirements, and regulatory failings.


The national review into the murders of Arthur Labinjo-Hughes and Star Hobson: Publication date June 2022

In May 2022, the Child Safeguarding Practice Review Panel published a review looking at the circumstances leading up to the deaths of Arthur Labinjo-Hughes and Star Hobson in 2020.

The review explores why the public services and systems designed to protect Arthur and Star were not able to do so. It also looks at wider issues and evidence from serious safeguarding incidents reviewed by the Panel in the last three years.

This review sets out recommendations and findings for national government and local safeguarding partners to protect children at risk of serious harm.

It examines the circumstances leading up to the deaths of Arthur Labinjo-Hughes and Star Hobson and considers whether their murders reflect wider national issues in child protection.

Read the full review on the Government publications website


Nottinghamshire Safeguarding Children Partnership

Child Safeguarding Practice Review for SN20 – December 2020

This review concerns Jean who was 19 months old when she died in 2020. Her mother was subsequently charged and convicted of her murder and received a life sentence. Jean and her mother were involved with a range of children’s social care and health services and Jean’s mother with adult community and mental health service. The focus of concern was Jean’s mother’s vulnerability due to mental health and substance misuse problems and the impact these might have on Jean’s care. At no stage were there concerns about the development or standard of care of Jean. The review concluded that Jean’s death could not have been anticipated or predicted.

The review has highlighted issues in how children and adult health and social services work together. There is a need for better joint working to improve access to the expertise held within each service and to improve the quality of assessments of adults with parental responsibilities. Improved assessment will help the implications of adult issues to be fully considered in relation to an adult’s parental responsibilities and appropriate help provided. The review also highlighted the negative impact of long waiting lists for service in adult mental health service.

Read the full report: child safeguarding practice review


The Black Country Child Death Overview Panel has been set up by Child Death Review partners across the region.

The purpose of the Black Country CDOP is to ensure that a review of all child deaths (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) up to the age of 18 years, normally resident in Black Country, irrespective of the place of their death.