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).

Some cases may not meet the definition of a ‘serious child safeguarding case’, but nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near miss’ events. Safeguarding partners may choose to undertake a local child safeguarding practice review in these or other circumstances.

Any partner agency may refer a case to the CSCP if they consider the criteria is met for a SPR. The partnership Safeguarding Practice Review Group will consider the referral and make a decision as to whether to conduct a Safeguarding Practice Review or Learning Review or a ‘near-miss’ inquiry.

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.


Making a Safeguarding Practice Review referral to the CSCP

A Safeguarding Practice Referral can be from any person or organisation with statutory, or official duties, or responsibilities, relating to children.

If you are aware of a case or situation which you think meets the criteria outlined above, a referral to the CSCP should be made using the following CSCP SPR or Learning Review Referral Form

Meeting the criteria does not mean that a safeguarding practice review must be carried out. Taking into account that the purpose of a review is to identify improvements, safeguarding partners will consider what other current local factors are in place that may also enable learning and improvement– such as if there are similar issues from other local safeguarding practice reviews (current or recent). Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families.


Serious Case Reviews and Thematic Reviews published by Croydon Safeguarding Children Partnership

Croydon SCR Learning – KEY MESSAGES 2018-2019

The summary learning from the most recent SCRs completed during 2018-2019 is summarised in the following:

Croydon SCR Learning Key Messages 2018 -2019

Below, you can access the reports for each of the published SCRs


‘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 note is also 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