Learning from Serious Case Reviews

Learning that lasts

As we all know, the main reason for conducting a serious case review is to learn lessons and improve practice. But disseminating the learning and making sure it is not lost is often problematic. Although excellent workshops can be run, they only work for the staff who attend. After a period of time learning is lost as those staff who attended the workshops leave.

Baby P

The OFSTED interim report on serious case reviews published in April 2010 indicated 'The majority of the children (65 out of 106) had no contact with social care services at the time of the incident under review' (p10). It is therefore crucial that the learning from reviews reaches the widest range of the children's workforce possible so that recurrences of serious incidents are avoided. Our package allows our customers free access to one another's serious case review library, enabling learning from a range of real-life incidents.

Typically, the courses introduce the family and take participants through a 'storyboard' that sets out the information available to the agencies at each step, usually based around the review’s executive summary. Participants form their own judgements on this information at various stages, and the lessons learned will be introduced gradually in the real life context of the case. They then develop the learning by thinking about their own work context and how they can take action to protect children and ensure they communicate concerns promptly and, above all, effectively.

Agencies or Local Safeguarding Children's Boards receive detailed information on who has taken the course, broken down by agency or other specified factors.


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