Introduction

Although there had been some earlier public inquiries, the inquiry into the death of 7-year-old Maria Colwell in 19731 was a critical episode in the history of child protection in the UK. It was this inquiry that led to the formalisation of inter-agency child protection procedures, the establishment of Area Child Protection Committees, and the creation of a child protection register. It also sparked off a long line of public inquiries into serious and fatal maltreatment, more recently superseded by statutory serious case reviews (SCRs) carried out by Local Safeguarding Children Boards (LSCBs). The public outcries over the deaths of Victoria Climbié and Peter Connelly highlighted the fact that, in spite of all the time and resources spent on these reviews, the problems of severe child abuse have not gone away. This begs the question of whether we have truly learnt anything from the reviews and whether anything has changed as a result.

An SCR is mandated in England and Wales whenever a child dies and abuse or neglect are known or suspected to be a factor in the death.2 LSCBs may also carry out an SCR into serious but non-fatal child maltreatment (box 1). The prime purpose of an SCR 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 (box 2). Given this primary purpose and the related aspects of identifying lessons to be learnt and acting on those lessons, evaluating the effectiveness of these reviews should be judged against the following criteria:

• ▶ Are we better safeguarding and promoting the welfare of children?

• ▶ Are we identifying lessons about safeguarding children?

• ▶ Are we implementing actions to safeguard children?