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Serious Case Reviews

Serious cases

A serious case is one where:

(a) abuse or neglect of a child is known or suspected; and

(b) either — (i) the child has died; or (ii) 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.

Undertaking a serious case review

LSCBs must always undertake a review of these serious cases. The chair of the LSCB will make the decision as to whether the statutory criteria above have been met. There are different approaches to serious case reviews including Social Care Institute for Excellence (SCIE) and Significant Incident Learning Process (SILP). OSCB is trialling the SCIE model in 2015.

Case Review (SCR) is to establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children. OSCB has also been committed to undertaking smaller scale partnership reviews for instances where the case does not meet the criteria for a serious case review but it is considered that there are lessons for multi-agency working to be learnt.

The LSCB will determine the terms of reference; appoint an independent reviewer; involve the young people and their families as well as practitioners; agree recommendations, action plans and the final report. Each agency contributing to a case review is required to produce an action plan to ensure they meet the recommendations made for their agency. Progress on these actions is monitored and reported to the OSCB subgroup with oversight of quality assurance.

In May 2019 Oxfordshire adopted new multi-agency safeguarding arrangements. As a result new arrangements have come in to effect for commissioning and publishing ‘child safeguarding practice reviews’ in line with Working Together 2018.

Oxfordshire Case Reviews

The OSCB has produced a summary document for older Serious Case Reviews (pdf format, 3.82 MB). The summaries include the key facts of the case, a brief analysis of what agencies did and the main learning points for professionals.

Serious Case Review Reports

Child M – OSCB Overview Report – September 2019

Child M – OSCB Executive Summary – September 2019

Child M – OSCB Learning Summary – September 2019

Child M – OSCB Press Statement – September 2019


Child A and Child B – OSCB Overview Report – March 2017

Child A and Child B – OSCB Executive Summary – March 2017

Child A and Child B – OSCB Learning Summary – March 2017

Child A and Child B – OSCB Press Statement – March 2017


Child Q – OSCB Overview Report – January 2017

Child Q – OSCB Press Statement – January 2017

Child Q – OSCB Progress Report – January 2017


Baby L – OSCB Overview Report – September 2016

Baby L – OSCB Press Statement – September 2016


Child J – OSCB Overview Report  – February 2016

Child J – OSCB Executive Summary – February 2016

Child J – OSCB Press Statement – February 2016

Child J – OSCB Progress Report – February 2016


Children A-F – Overview Report – March 2015  – Updated 14.03.15 with clarification around gender of children identified at risk of child sexual exploitation.

Children A-F – Overview Report Accessible Summary – March 2015

Children A-F – Case Review Summary for Children & Young People – March 2015

Children A-F – OSCB Recommendations – March 2015

Children A-F – OSCB Media Statement – March 2015

Children A-F – Agency Responses since 2011

Children A-F – Opening Statement from Press Conference – March 2015

Partnership Review Reports

There are no partnership review reports at this time.

Learning from Case Reviews

For OSCB Learning Summaries from Case Reviews please visit the Learning from Case Reviews page

The NSPCC have created the Learning from Serious Case Reviews Document, this includes:

  • Case reviews published in 2015
  • Enablers to Learning from SCRs
  • Barriers to Learning from SCRs.