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Serious Case Review


In relation to children:

A Serious Case Review must always be initiated when:

  1. Abuse or Neglect of a child is known or suspected; AND
  2. Either:
    1. The child has died; OR
    2. The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

Thus cases meeting either of these criteria must always trigger a Serious Case Review:

  1. Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
  2. Abuse or Neglect of a child is known or suspected AND the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. In this situation, unless it is clear that there are no concerns about inter-agency working, a Serious Case Review must be commissioned.

Additionally, even if these criteria are not met a Serious Case Review should always be carried out when:

  • A child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children's home or where the child was detained under the Mental Health Act 2005. 

The purpose of the Review is to establish whether there are lessons to be learned from the case, identify what those lessons are and how they will be acted upon and improve inter-agency working as a result.

In relation to adults:

A Serious Case Review is a process for all partner agencies to identify the lessons that can be learned from particularly complex or serious Safeguarding Adults case, where an Adult at Risk (Vulnerable Adult) has died or been seriously injured and abuse or Neglect has been suspected. The panel recommends changes to improve practice and services in the light of these lessons.

The Safeguarding adults reviews (SARs) should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.

Its purpose is not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.

For further information:

Care Act 2014 – Safeguarding adults reviews (Safeguarding adults at risk of abuse or neglect)

Care and Support Statutory Guidance – Safeguarding


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