Article Text

Download PDFPDF
What do serious case reviews achieve?
  1. Peter Sidebotham
  1. Correspondence to Peter Sidebotham, Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; p.sidebotham{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


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 It also sparked off a long line of public inquiries into serious and fatal maltreatment, more recently superseded by statutory serious case reviews (SCRs) carried out by Local Safeguarding Children Boards (LSCBs).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?

Box 1 Criteria for holding a serious case review

From Working Together to Safeguard Children2

When …

View Full Text


  • Competing interests Dr Sidebotham has received grant income from the Department for Education for research into serious case reviews.

  • Provenance and peer review Commissioned; externally peer reviewed.