What is a Safeguarding Practice Review?

The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel (the Panel) and at local level with the Croydon Safeguarding Children Partnership (CSCP).

Child Safeguarding Practice Reviews (formerly Serious Case Reviews) and Learning Reviews and  occur when:

  • abuse or neglect of a child is known or suspected and
  • the child has died or been seriously harmed,
  • or the child is looked after (whether or not abuse or neglect is suspected).

When an agency becomes aware of a serious child safeguarding incident which appears to meet the criteria above, a notification should be made to Croydon SPoC and, in the event of a child death to eCDOP

Serious harm includes life-changing or long-term injury or an injury that is clearly life-threatening, serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development and impairment of physical health. A serious child safeguarding case is one in which issues of local importance are raised, including effectiveness of multi-agency safeguarding practice, and in such matters the CSCP will consider if a review is appropriate.

If (a) a child dies or has been seriously harmed, and (b) abuse or neglect is known or suspected – a decision on whether to submit a Serious Incident Notification to the National Child Safeguarding Panel has to be made. If a SIN is made, a Rapid Review will take place and a decision on whether to conduct a local Safeguarding Practice Review.

The prime purpose of a SPR 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 CSCP will publish an anonymised Final Report.

Any professional aware of a serious incident involving a child should notify Croydon Single Point of Contact. And in the event of the death of a child eCDOP should be used.

  • For the full Croydon Child Death and SPR ProcessClick Here
  • For more details on Notifying c Child Deathclick here

Croydon Safeguarding Learning from Reviews

Summary learning from recent SCRs (18-19), Safeguarding Practice Reviews and Rapid Reviews:

Published Reviews

‘Emily’ & ‘Jack’ – SCR published 15th October 2020

Croydon safeguarding Children Partnership have published a SCR concerning a three month old baby, Emily, who died in March 2019, and her older sibling, Jack.

Early on in her first pregnancy, Emily’s mother disclosed that she had a history of mental health issues and had required in-patient treatment in her home country. She was referred for perinatal mental health services, but was not offered a service as she was stable. She received routine ante-natal care and remained well throughout both pregnancies and births.

When Emily was 12 weeks old, her mother was taken by ambulance to Croydon University Hospital after alerting a neighbour that she had taken an overdose.  She was discharged and advised to see the GP. A referral was made to children’s social services, who carried out a home visit and developed a plan, including a referral to the community mental health team.

A few days later, her husband called an ambulance after arriving home and finding Emily unresponsive.  Emily’s mother admitted killing her child and in July 2019, appeared in court and pleaded guilty to infanticide. She was convicted of this offence and given a Hospital Order under Section 37 Mental Health Act 1983.

Di Smith, independent chair of Croydon Safeguarding Children Partnership, said: “This was a tragic case of infanticide by a mother who was suffering from significant mental illness, with devastating consequences for the entire family.”

It is not possible to say whether these tragic events could have been predicted or prevented had more professionals been aware of her mental health history. This review has however, highlighted issues with the way local agencies and health professionals share information; how patients can be enabled to feel safe in disclosing mental health issues and the possible impact of language and cultural barriers. It also raises some questions about the thresholds for perinatal mental health support, when a mother presents as stable but has a significant history of mental illness”

You can download the full report here:

SCR Emily & Jack for publication v2

A single page briefing available here:

Emily and Jack SCR Briefing June 2020 v2

Child Y SCR

Child Q SCR: “Where were you when I was six?”

Vulnerable Adolescents Thematic Review 2019

Child A & Baby N – published 22nd February 2019

Child ‘L’ – SCR published 22nd August 2018

Child “Joe”  – SCR Published 26th February 2018

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

National Learning 

The National Safeguarding Panel has published its first thematic review ‘It was hard to escape – safeguarding children at risk from criminal exploitation’. This review included a local learning review Child B.

The National Safeguarding Panel has published its second thematic review ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’

www.seriouscasereviews.rip.org.uk 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.


Domestic Homicide Reviews

Deaths as a result of domestic violence are thankfully rare, but by their very circumstances the perpetrator will be linked to the victim as a partner, an ex-partner or as a family member.

Since 2011, where there has been a case of a violent death in domestic circumstances, there has been a legal requirement upon community safety partnerships (in this borough the Safer Croydon Partnership) to instigate a Domestic Homicide Review (DHR).

This examines the conduct of professional agencies involved with the case in order to identify what needs to be changed, so that, if similar circumstances arose, the risk of a death happening again is dramatically reduced. You can find out more, or read Croydon published Domestic Homicide Reviews here:



NHS South London
Met Police
NHS Croydon Health Services
NHS Croydon Clinical
Safer London