A Serious Case Review (SCR) is undertaken when abuse or neglect of a child is known or suspected; and either the child has died; or the child has been seriously harmed and there is cause for concern as to the way organisations worked together.

The CSCB has a sub-group which oversees and quality assures all the SCRs undertaken by the Board, and provides advice on whether the criteria for conducting a review have been met. The sub-group has developed local procedures for Serious Case Reviews in conjunction with Chapter 4 of Working Together to Safeguard Children 2015.   Any partner agency may refer a case to the CSCB if they consider the criteria is met for a SCR. The Independent Chair makes the decision of whether to instigate a SCR following discussion with the sub-group representatives.

The prime purpose of a SCR is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children.  After the completion of each review the CSCB will publish an anonymised Final Report.

All reviews of cases meeting the SCR criteria will be accessible on the CSCB’s website for a minimum of 12 months. Thereafter the report will be available on request.  See below for the most recent local SCRs.

National Learning from Serious Case Reviews is a site dedicated to providing materials to support learning in practice for LSCBs, social work and early help, police and criminal justice, health and education practitioners.

Pathways to harm, pathways to protection (July 2016) analyses 293 Serious Case Reviews (SCRs) relating to incidents which occurred between 1 April 2011-31 March 2014. This is the fifth consecutive analysis of SCRs by this research team, whatever the structural arrangements in future, the significant body of learning contained in this Triennial Analysis and the previous reports will remain an essential resource for everyone concerned to prevent and protect against the maltreatment of infants, children and young people.

In 2013 the NSPCC launched the national case review repository, in collaboration with the Association of Independent LSCB Chairs.  The repository has over 600 case reviews and inquiry reports dating back to 1945.  It provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level.

The NSPCC has also produced thematic briefings highlighting the learning from serious case reviews. 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.  See detailed list of NSPCC Thematic Briefings posted on their website.

The national panel of independent experts on serious case reviews published their second annual report in November 2015 and their first annual report in July 2014.


Serious Case Reviews published by Croydon Safeguarding Children Board


Child ‘L’ – SCR published 22nd August 2018

Croydon and Lambeth Local Safeguarding Children Boards (LSCBs) have published the Serious Case Review (SCR) of Child L which was jointly commissioned by both LSCBs in September 2016 and led by Croydon LSCB. The link to the full report is below.

L was the subject of a Child Protection (CP) Plan in Lambeth since before his birth in July 2015. He remained on a child protection plan and the family received support from Lambeth agencies until May 2016, when the case was transferred to Croydon where he was living with his mother.

In July 2016, aged 11 months old, L was taken to hospital by his parents. He was in cardiac arrest as a result of cocaine ingestion.  Child L survived the incident, he was made the subject of care proceedings and is now safe.

The publication of this report was delayed in order to avoid any conflict with the criminal proceedings brought against both parents in June 2018. Both parents were found Not Guilty.

Di Smith, Interim Independent Chair of Croydon LSCB, said:

“Child L was made subject to a Child Protection Plan in Lambeth from before his birth.  His parents had a volatile relationship with allegations and counter-allegations of domestic abuse, assault and apparent mental ill-health. He lived with his mother who was from Croydon, and housed in homeless accommodation across Lambeth and Camden before returning to live in Croydon. His father often stayed with the family.

In May 2016 the family moved to Croydon who took over responsibility for his Child Protection Plan. In July 2016, at the age of 11 months Child L was taken to hospital by his parents as he was in cardiac arrest having ingested cocaine which was said to have been hidden in his cot. Thanks to speedy and intensive medical attention he survived the incident and is living permanently with other family members.

His father was known to have used drugs in the past. The risk that Child L was exposed to from parental drug misuse was not fully recognised in his child protection plan.

We always carefully and independently consider all such cases to assess whether more could have been done, and what can be learned.  In this case, the conclusion is that this sad incident could not have been predicted. Nevertheless, this Serious Case Review highlights where more could have been done to promote his safety and wellbeing. The challenge of multi-agency working across three boroughs is recognised in the review as is the finding that some child protection standards were not met.

All agencies in both Croydon and Lambeth LSCBs are fully in agreement and committed to putting into practice the lessons highlighted in the SCR.”

You can read the full Child L report here


Child “Joe”  – SCR Published 26th February 2018

Croydon Safeguarding Children Board has published the Serious Case Review (SCR) of Joe which was commissioned by the CSCB in July 2016.

Joe was known to services in Croydon since before he was born, when he became subject to a Child Protection (CP) Plan. He remained on a CP Plan until January 2016 when he was two years and five months old. Following this he continued to receive support from local services through a Child in Need Plan.

In June 2016, aged two years and 11 months, Joe lived in temporary accommodation with his mother. On the day of the incident he was found home alone and suffering from life-changing burns. On the same day Joe’s mother was sectioned under the Mental Health Act. Subsequently, mother was found to be suffering from drug-induced psychosis. Joe is recovering, although he will need long-term treatment for his injuries.

Di Smith, Interim Independent Chair, said:

“This serious case review makes for difficult reading. We fully recognise that the practice in Joe’s case was not acceptable and the multi-agency processes in place to protect him were not effective. Whilst his injuries could not have been predicted, it is evident that more could and should have been done to protect his safety and wellbeing.”

Agencies in our partnership have cooperated with the SCR and have accepted all of the findings. They are focused on improving child protection practice and are working hard to continue to strengthen our standards and processes in response to the findings of this review. We are determined to address the shortcomings in the child protection system that this sad case has brought to light.”

The report can be read here:


Child J and Child K  – SCR Published 15th February 2018

Croydon Safeguarding Children Board (CSCB) has published a Serious Case Review (SCR) concerning a four year-old child (Child J) and their 16 year-old half-sibling (Child K). In November 2015 Child J was admitted to hospital with serious malnutrition. Child J had a positive response to intensive hospital treatment and now lives in a permanent home away from their family.

The CSCB commissioned an SCR to examine the children’s history and determine what had led to this event.

Di Smith, Chair of CSCB, said: “CSCB has undertaken rigorous examination of the events in this case as this child could have suffered even more serious consequences, were it not for swift medical intervention. It was important for us to be clear how this situation had come about and to identify what could be done differently in future. The SCR was robust in establishing how agencies had worked together and CSCB has implemented the learning immediately, introducing measures across the partnership to improve earlier identification of such cases.

The report can be read here

Child Claire – Published 24 January 2017

This SCR pertains to the case of Claire a child who had been taken into care and placed with foster carers. She was then sexually abused by her foster carer.

Statement from Sarah Baker, CSCB Independent Chair:

When a child is removed into care for their safety, this is done to keep them safe and offer them better life chances.  ‘Claire’s’ foster carer breached the trust placed in him by sexually abusing her. On behalf of the Croydon Safeguarding Children Board I want to express the deep sadness we all feel for the terrible experience Claire and her family subsequently went through.

 This serious case review has been very difficult for the family and I would like to thank them for their openness and cooperation. Their focus on what is best for Claire has been uppermost throughout their engagement with the review.

 Staff have been fully engaged with the Serious Case Review. All, without exception, believed at the time of this incident they were providing Claire with a safe and secure home.

 The review found no evidence that anything at the time could have indicated this foster carer was likely to sexually abuse a child in his care. However there are still lessons to be learned and actions were immediately taken to tighten up a variety of processes. Staff have also received additional training and guidance to increase their awareness and understanding. I will ensure the findings from this review are built into our future action plan.

 Claire is doing well with her new foster carers, despite this horrible experience and continues to enjoy the unconditional support of both them and her family.  On behalf of the Board I wish her all the very best for the future.

This report can be read here


Children R S & W  – jointly published by Croydon and Lewisham Safeguarding Children Boards on 24 January 2017

A Serious Case Review (SCR) jointly commissioned by Croydon Safeguarding Children Board (CSCB) and Lewisham Safeguarding Children Board (LSCB) following the serious injury of Child W, a 6 month old baby girl. In April 2015 Child W was presented to hospital vomiting blood; she had multiple injuries and the appearance of neglect and as a result of her injuries she required specialist neurosurgical intervention. Child W and her siblings were in the care of their mother and her new partner at the time. The injuries remain unexplained, but were suspected to be non-accidental.

Statements from the Independent Chairs of Croydon and Lewisham Safeguarding Children Boards are as follows:

Sarah Baker, Independent Chair, Croydon Safeguarding Children Board:

Everyone involved with this case wants to express their sadness that a young baby sustained such significant injuries. Gladly, she is now fully recovered and safe in a secure, caring home.

 We all know how the impact of neglect and abuse on children can be devastating. At the very least they can be prevented from ever achieving their full potential. At the worst, the outcome can be life-threatening.

 The central findings of our review emphasise the need for real diligence and partnership working, particularly when dealing with families who move from area to area.”


 Nicky Pace, Independent Chair, Lewisham Safeguarding Children Board:

We are very sad to hear about the injuries to this baby and pleased to hear she has recovered fully and making good progress .

The purpose of the review was to examine how we work together and learn from these experiences. This review has enabled us to share information and work closely with colleagues in both our boroughs to promote the welfare of vulnerable children. Both of our boards have already developed comprehensive action plans to address each of the recommendations from this review and all the agencies involved have made changes to improve services.’’

 This report can be found here.


Child P ‘Josh – Published 21st April 2015

The Croydon Safeguarding Children Board commissioned a Serious Case Review into the circumstances surrounding the very tragic death of ‘Josh’ who died with his mother in the path of a train in March 2013.


This report is available on request.


Child M – Published 21st April 2015

In October 2012 the Croydon Safeguarding Children Board commissioned an independent Serious Case Review into the tragic death of Child M, a 14 year old boy who was stabbed by another young person on a bus in September 2012.  He had been missing for 9 weeks at the time of his death.

This report is available on request.

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