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Key SCR themes

Key SCR Themes


The Child Safeguarding Toolkit has been developed to raise awareness about the key risk factors identified in the analysis of Serious Case Reviews and the Child Safeguarding Practice Reviews (local and national) since they were introduced under Working Together 2018. 

The risk factors apply to all contexts of child and family practice; mental ill health, domestic abuse, alcohol or substance misuse, and parental criminal records as well as other adverse childhood experiences featured strongly as contributing factors in these reviews. Domestic abuse and violence was a common finding and the levels of criminal activity and the violence witnessed or experienced by children was highlighted as a major concern.


The Child Safeguarding Practice Review Panel's first annual report 2018-19 shares information about the children who died or were seriously harmed.

Age of children for serious child safeguarding notifications to the national panel:

  • Almost a third were for children under the age of 1;
  • 7% of the notifications related to 6 to 10 years olds;
  • Over 20% of the notifications related to 11 to 15-year-olds;
  • Over 18% of the notifications were for 16 to 17-year-olds.

Key features

  • 27% of the rapid reviews involved the death or serious harm of a child under 1- year-old due to non-accidental injury;
  • In 54% of the cases children’s social care services were working with children and families at the time of the incident;
  • In 13% of cases children were on a child protection plan;
  • 15% of cases children were in care at the time of the incident;
  • 46% of children who died or were seriously harmed were not known to children’s social care.

The Panel identified 21 adolescents from 17 localities who died or were seriously harmed within a context of criminal exploitation.


The following key practice improvement themes were highlighted:

  1. Optimism bias, in 32% of the rapid reviews, the Panel identified overly optimistic practice decisions. In 36 cases, children had been permanently removed from their parents, but their subsequent siblings were not returned to court for protection because professionals thought parents had changed;
  2. Weak risk assessment and poor decision making were identified as an area of concern in 41% of the rapid reviews received;
  3. Poor information exchange at critical points between agencies was present in 40% of rapid reviews;
  4. Children returned home post court proceedings, in 49 rapid reviews children had previously been subject to public care proceedings because of concerns about significant harm;
  5. Adults with a history of offending, people with a history of child abuse, including some who had been convicted, were not tracked sufficiently well;
  6. New relationships were not explored properly to establish whether someone with a history of child abuse was in a relationship and/or living with children;
  7. A lack of professional curiosity about fathers and partners, the primary focus continues to be on the needs, circumstances and perspectives of the mother. This is the case even in relationships where the mother’s partner has a major role in looking after the children, leaving some fathers feeling alienated and forgotten, and dismisses their role in bringing up the children;
  8. Children not brought to appointments needs to inform risk assessments about the impact when parents disengage or respond inconsistently to a child’s health needs. This is particularly the case with children who are already known to be vulnerable;
  9. Children educated at home, a small number of the rapid reviews received by the panel involved children educated at home, of whom four died and seven suffered serious harm through neglect and is an area which will be subject to further reviews;
  10. Written agreements, there was widespread use of written agreements, for example to prevent contact where there is a risk of sexual abuse or to clarify expectations between children’s social care and a family. At best these had little or no protective effect, and at worst they created a false reassurance that they would keep children safe.


 Brain Injury

The 2016 report entitled Sudden Unexpected Death in Infancy and Childhood: the Report of a Working Group, convened by The Royal College of Pathologists and The Royal College of Paediatrics and Child health, identified a list of non-exhaustive factors that could suggest a death was suspicious and could provide supporting evidence of Non-Accidential Head Injury (NAHI):

  • Previous on-going child safeguarding concerns;
  • Previous sibling deaths;
  • Delay in seeking help;
  • Inconsistent explanations;
  • Unexplained injury, either present or previously;
  • Evidence of past or present drug and/or alcohol abuse;
  • Neglect;
  • Previous convictions of parents or partners, in particular violence towards children.

All of the surrounding evidence must be fully considered by a prosecutor before a decision can be made on the evidential sufficiency of any case in accordance with the Full Code test in the Code for Crown Prosecutors. Further details are available on this link.


NSPCC SCR summary identified the following risk factors and learning for improved practice:

1. Risks associated with premature births

  • Premature babies may be more vulnerable to abuse and neglect;
  • Caring for a premature baby can be very difficult for parents and families to cope with. If the family is already experiencing problems, and/or if the parents have premature twins/a multiple birth, the risks to the baby/babies may increase;
  • Premature babies may be born with disabilities or chronic health conditions which can be challenging for parents and carers to manage. Children with disabilities are more vulnerable to abuse and neglect;
  • Professionals aren’t always aware of signs that a parent is struggling to meet their premature baby’s needs; for example if parents don’t regularly visit the baby in hospital or bring the baby to medical appointments;
  • Sometimes professionals use generic tools to assess whether a premature baby is thriving, rather than using tools which were specifically designed for premature babies. This can give an unrealistic view of a baby’s progress and may mask areas of concern.

2. Professional optimism may lead to risks being underestimated

  • There can be a tendency to see the birth of a new baby as an opportunity for a fresh start. Sometimes this may hinder professionals from recognising pre-existing patterns in parents’ behaviour which pose a risk to the baby;
  • Sometimes professionals may be reluctant to raise safeguarding concerns about families who have a new baby because they empathise with the parents and think they are doing their best;
  • Some professionals may underestimate the impact of abuse and neglect on a baby. They may not understand how a child’s experiences during their first few months of life can affect their future development.

3. Poor risk assesments

  • Sometimes professionals do not understand that levels of abuse and neglect can fluctuate. They may focus on small improvements rather than looking for recurring patterns;
  • It can be challenging for professionals to find a balance between taking the time to build up a trusting relationship with parents and acting quickly to minimise potential harm to a baby. This is particularly the case with pre-birth assessments, when support needs to be put in place before the baby is born;
  • Sometimes professionals are unable to see the parents interacting with their baby; for example if the baby is asleep during visits. This may lead to professionals accepting what parents tell them without evidence. Professionals need to engage with all the adults in a baby’s life;
  • If professionals don’t understand the role of all significant adults in a baby’s life, they may make assumptions about how the baby is being cared for and by whom;
  • If professionals aren’t engaged with all the adults in a baby’s life, they may be less able to identify patterns of behaviour that could pose a risk to the baby’s wellbeing.


The following key points were identified in the most recent Triennial Analysis of SCRs:

  • Rather than concentrating just on the ‘here and now’, the implementation of multiagency pre-birth planning guidance should ensure a good assessment including family history, relationships and roles within the family, and known risk factors, concluding in a strong plan and appropriate level of intervention;
  • Risk factors are cumulative - the presence of more than one increases the likelihood that the problems experienced and the impact on the (unborn) child and parent will be more serious;
  • Professionals must consider the significance of spiralling risks and analyse the potential impact they might have on the parents’ ability to care;
  • During the antenatal and postnatal period there is still a culture among professionals that the primary focus is on the needs and circumstances of mothers. This needs to be addressed so that father figures are included and that the contribution they make, the stress they experience and the risks they present are properly understood and addressed;
  • When treating a child who may have sustained non-accidental injuries, it’s important to make enquiries about any other children who may be at risk.


Using research to benefit children

An animation, guidebook and set of videos about childhood trauma and brain development have been created by University College London (UCL) in a project funded by the Economic and Social Research Council (ESRC). The resources, which are freely available, can be accessed here.


There was evidence of neglect in nearly three-quarters (208 of the 278, 74.8%) of the reports examined in the most recent Triennial Analysis of SCRs. Features of neglect were apparent in 112 out of 165 (68%) fatal cases and 96 out of 113 (83%) non-fatal serious harm cases. 


Categories of neglect featuring in SCRs

The following categories of neglect featured in the Triennial Analysis of SCRs:

  1. Severe deprivational neglect: where neglect was the primary cause of death or serious harm; neglect of the child’s basic needs leads to impairments in health, growth and development; severe illness or death may result from malnutrition, sepsis, or hypothermia among others;
  2. Medical neglect: failure to respond to a child’s medical needs (acute or chronic) and necessary medication; such failure may lead to acute or chronic worsening of a child’s health;
  3. Accidents which occur in a context of neglect and an unsafe environment: hazards in the home environment and poor supervision may contribute;
  4. Sudden unexplained death in infancy (SUDI) within a context of neglectful care and a hazardous home environment: deaths may occur in dangerous co-sleeping contexts, or where other recognised risk factors are prominent and not addressed;
  5. Physical abuse occurring in a context of chronic, neglectful care: the primary cause of serious harm or death may be a physical assault, but this occurs within a wider context of neglect.

The following reasons for undertaking SCRs into the serious harm of death of adolescents were associated with early or continuing physical and emotional neglect: 

  • Suicides and self-harm in vulnerable adolescents with mental health problems;
  • Vulnerable adolescents harmed through risk-taking behaviours and those harmed through criminal exploitation.


Professional challenge

Published case reviews highlight that professionals face a big challenge in identifying and taking timely action on neglect. The learning from these reviews highlights that professionals from all agencies must be able to:

  • Recognise physical and emotional neglect;
  • Understand the impact of cumulative and long-term effects of neglect;
  • Take timely action to safeguard children.


Learning related to neglect as a key factor

The NSPCC case summary review of key factors found that in the case reviews where neglect was a key factor children died or suffered serious harm in the following ways:

  • Chronic neglect over a long period sometimes co-existing with physical, emotional and sexual abuse;
  • Death or serious harm from physical or sexual abuse where neglect was a feature or preceded the abuse;

It was also found that:

  • Sudden Unexpected Death in Infancy (SUDI) related to neglect risk factors such as malnutrition, poor social circumstances or parental substance misuse;
  • Accidents, sometimes with an element of forewarning when long-term neglect in a family resulted in an unsafe environment;
  • Attempted suicide of a young person as a result of the effect of long term neglect on mental health.


Risk factors for neglect in case reviews highlighted

  • The impact on the parents’ ability to provide safe and appropriate care and to meet their children’s needs;
  • Living with domestic abuse, drug and alcohol misuse, and parents with mental health problems;
  • Young parents;
  • Postnatal depression, and maternal depression was also linked to social isolation;
  • Patterns of improvement in parental care, followed by deterioration;
  • Financial problems including housing problems, homelessness, poverty and unemployment;
  • Lack of resources.


Learning for improved practice 

  • Be aware of children who are more vulnerable to neglect, e.g. newborn babies, premature babies and babies with ongoing health needs are particularly vulnerable. Neonatal professionals have a key role in identifying neglect;
  • Teenagers' needs can be missed, especially where there are youger siblings, professionals should understand the impact of long term neglect on a teenager's emotional wellbeing and consider the risk of self-harm or suicide;
  • Tooth decay may indicate neglect. Dental services should consider initiating further enquiries or making a safeguarding referral;
  • Professionals in all agencies should understand the significance of missed appointments for children. In one case the only indication of a sudden change in parenting capability was an emerging pattern of non-attendance at appointments. 


Elective Home Education

The first annual report of the Child Safeguarding Practice Review, highlighted that a small number involved children who were educated at home. Four of those children died, and seven children suffered serious harm through neglect. 

There is a consensus that attending school is a protective factor. School is a place where children are seen every day and by many different professionals and by peer groups and other families. It is a place where early indications of concern can build into decisive action because the concerns are in plain sight. When a child is educated at home, they become separated from the protective mechanisms which school provides. In these circumstances, it becomes even more critical that other indicators of concern from other agencies are properly connected.


Poverty and Economic Deprivation

The most recent Triennial Analysis of SCRs concluded that:

“Of particular note in this analysis were indicators of poverty or economic deprivation as a feature of the case. The detailed examination of neglect cases revealed the complex ways in which the links between domestic abuse, substance misuse and poverty are 17 often inter-dependent, so that addressing a single issue does not deal with the underlying causes or other issues present. Complexity and cumulative harm was almost invariably a feature of families where children experience neglect."


The Important Role of Fathers

The analysis of neglect cases underlined the importance of understanding the experiences of parents and the perspectives and role of fathers, as distinct from mothers, and other kin caring for the child.

 Physical injury

Phyiscal abuse is defined as:

  • A form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.


The classification of child deaths in the Triennial Analysis of SCRs uses a ‘best fit’ assignment of where the information is pointing towards the following types of fatal physical violence against children and makes a distinction of whether there was ‘intent’ or not and follows a severe or fatal physical assault, whether intra-familial or extra-familial harm, and whether ‘overtly’ or ‘less overtly’ violent means were used.


Categories of physical abuse and violence featuring in SCRs

  • Fatal Physical Abuse includes deaths following severe physical assaults (non-accidental injuries) where the suspected perpetrator is a parent or parent figure, and where there is no clear intent to kill or harm the child. Includes deaths from non-accidental head injuries (shaking or shaking-impact injuries), abdominal injuries, and multiple injuries. May include deaths where an implement has been used, but without evidence of intent to kill or harm the child.
  • Overt Filicide Deaths where a child is killed by a parent or parent figure using overtly violent means, or with no attempt to conceal the fact of homicide, and where there appears to have been some intent to kill or harm the child. This includes multiple or extended familicide, or where the suspected perpetrator takes or attempts to take his/her own life. Includes deaths in fires with suspicion of arson and the suspected perpetrator is a parent/parent figure. Includes deaths from stabbings and firearms, or severe assaults with evidence of intent to kill the child.
  • Covert Filicide Deaths where a child is killed by a parent or parent figure but using less overtly violent means, and with some apparent attempt to conceal the fact of homicide, and where there appears to have been some intent to kill or harm the child. Includes deaths from abandonment, poisoning, drowning, suffocation or asphyxiation. Includes deaths of newborn babies following concealed pregnancies and deliveries.
  • Child Homicide Deaths where a child is killed by someone other than a parent or parent figure using overtly violent means, or with no attempt to conceal the fact of homicide, and where there appears to have been some intent to kill or harm the child. Includes deaths in fires with suspicion of arson and the suspected perpetrator is someone other than a parent/parent figure. Includes deaths from stabbings and firearms, or severe assaults with evidence of intent to kill or harm the child. Includes deaths following sexual assaults by a non-parent perpetrator. May include gang-related violence where there appears to have been intent to kill the specific victim, but excludes more general gang-related violence.
  • Fatal Assaults Deaths following severe physical assaults where the suspected perpetrator is someone other than a parent or parent figure, and where there is no clear intent to kill or harm the child. Includes peer-on-peer violence without evidence of intent to kill. Includes gang-related violence without evidence of intent to kill the victim.

 Complex health needs

Challenging parents and hearing the child’s voice

Although it is very rare, parents can sometimes be deceptive or manipulative when reporting children’s health problems.

Children rely on their parents and carers to take them to medical appointments so missed appointments are always a cause for further action. From a child protection perspective, it is no longer felt that it is appropriate to use the term ‘Did Not Attend’ (DNA) when describing a child’s non-attendance to an appointment. Because it is not a child’s responsibility to attend clinic (it is their parent’s responsibility to take them), it would be more appropriate to say that the child was not brought to the appointment.

  • Failure to attend medical appointments is recognised as a child protection issue within statutory definitions of neglect. Missed appointments may also suggest that services are difficult for vulnerable families to access;
  • In some case reviews professionals were relying too much on parents’ reports and not examining the child or observing their behaviour;
  • Repeat prescriptions were also issued by administrative staff over a long period without the doctor seeing the child;
  • It is important to gather the views of children and other family members, particularly if one parent is dominant or assertive;
  • Case reviews also highlighted professionals’ reluctance to challenge parents’ views or probe for further information for fear of provoking a confrontation;
  • When practitioners have to deal with parents who are hostile and aggressive they focus too much on the parents and not enough on the impact this behaviour will be having on their children;
  • Following up missed appointments and linking incidents;
  • Case reviews have noted a tendency to record missed appointments but no collation of information or questioning its significance. Reviews criticised the system of flagging non-attendance at medical appointments as Was Not Brought which in some cases led to a withdrawal of services;
  • Dealing with incidents in isolation is especially common in A&E where there is a high turnover of patients and a focus on the immediate issue. Considering previous hospital admissions as well as the child and family’s history and background can help professionals distinguish non-accidental injuries (NAI) from other medical conditions. It can also be vital in spotting patterns which indicate child neglect.


Case example from the NSPCC SCR repository

"Death of an 11-year-old boy in May 2017. Parents called an ambulance because Child X was suffering with a chest infection. Paramedics attempted to take him to the nearest hospital but parents refused and he was taken to a hospital further away. Child X suffered cardiac arrest en route and died. Child X had complex health needs since birth including cerebral palsy and epilepsy. His parents cared for him full time. He was admitted to hospital twice in May 2015 and Father questioned treatment. A Section 17 assessment was triggered in July 2015. Section 47 enquiries were initiated in January 2016 which led to Child X being made subject of a Child Protection Plan for neglect, later stepped down to a Child in Need plan. Several professionals reported aggressive behaviour by Father and parents were difficult to contact and displayed challenging behaviour. Family are Black/African Caribbean and Jehovah's Witnesses.

Lessons learned include

  • The threshold for intervention due to neglect was too high;
  • Emergency contingency planning should be given more attention when working with families with children with life limiting conditions; and
  • Professionals would have benefited from a unified approach to working with a family they found hard to engage.

Recommendations include

  • There should be clear guidance for staff where parents are reluctant to engage;
  • Ensure a system for identifying a Lead Professional for all children with complex needs is in place; and
  • The ambulance service should review guidance on how police assistance can be used to ensure the welfare of patients.


The NSPCC summarised the following SCR learning to improve practice with the overriding principle of GPs and other health professionals having a family focus: 

  • Find out each patient’s family details and their links to children. Record these and tell other agencies when this information is relevant to an assessment of need or provision of services;
  • When working with mothers make regular enquiries about male partners who may have access to her children;
  • When seeing parents and carers of children make routine enquiries about drug and alcohol use and domestic abuse;
  • Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant child care responsibilities;
  • Consider their capacity to care for children safely. Record this information in medical notes and emphasise it in referrals and correspondence about patients;
  • GPs who work with different members of the same family need to share information with each other on a regular basis;
  • Explore how continuity of care can be improved by individual patients and members of the same family seeing fewer GPs and healthcare professionals;
  • Develop documentation which prompts an assessment of the social history and background of the child and their family. Train staff in how to ask these questions. The use of genograms may be helpful;
  • Do not automatically accept a parent’s or carer’s report without talking to the child and, if possible, other family members and close friends. If the child is very young observe and analyse their presentation and behaviour;
  • When referring children, highlight anything that has only been reported by adults or has not been observed by professionals;
  • Be alert to patterns in parents’ and children’s behaviour over time which may indicate the child is at risk of abuse or neglect;
  • Do not administer repeat prescriptions to children without a GP regularly examining the child. Consider implementing an alert system to identify the over-prescription of drugs to a child;
  • Be prepared to challenge parents and carers in order to gather as much information about a child’s wellbeing as necessary;
  • Provide training for staff which models how to challenge parents and carers effectively and gives staff the confidence to inquire into potential abuse.
  • Responding to missed appointments: Always follow up a child’s missed appointments. Consider changing the nonattendance code from DNA (Did Not Attend) to WBA (Was Not Brought) which should prompt more positive intervention to safeguard the child and support their wellbeing. Watch Nottingham Local Safeguarding Children Board’s short animation "Rethinking 'Did Not Attend'" on YouTube;
  • Liaise with health, police and social care about arrangements for hospital discharge and the after-care of vulnerable children. Involve parents in these discussions;
  • Recognising child abuse: Always be aware of the significance of bruising on non-mobile babies. Refer these cases to children’s social care with full and accurate information which includes a medical and social history, the child’s developmental stage and the explanation given by the parent;
  • Look for signs of trauma in seriously ill babies when there is no clear cause of illness such as an infection;
  • Take clinical photos as near to the time of injury as possible to record the greatest detail and include the photos in all formal child protection reports;
  • Make all necessary diagnostic tools available to children whenever required, including during the evening and at weekends;
  • During post-natal checks, remove a baby’s nappy before weighing. Plot the baby’s weight on the growth centile chart and analyse information and data gathered during the checks for potential safeguarding risks;
  • Professionals should document they have read and understood the nature of safeguarding concerns about the child they are treating. 


 Fatal stabbing

The British Youth Council Youth Select Committee 2019 Our Generation’s Epidemic: Knife Crime found that:

"Knife crime affects people of all ages and backgrounds across the country, and all too often both perpetrator and victim are young people. However, throughout our inquiry we heard evidence that a young person’s risk of getting involved in knife crime is dramatically different between different groups of young people. Young people who for example experience mental health issues, adverse childhood experiences, have learning difficulties, live in poverty or are excluded from school are more likely to be vulnerable to involvement in knife crime."

"Education has a major role to play in tackling knife crime. Not only through teaching the dangers, risks and consequences of involvement in knife crime but also to facilitate contact with the local police and through safeguarding a child who may be at risk".


Key learning points

  • Young people with insecure immigration status require the same support, at the very least, as any other young person particularly when they are victims as well as perpetrators of crime;
  • Long delays in the criminal justice system are not helpful for young people. They create uncertainty about the seriousness of an incident for young people and practitioners. When there are no criminal justice consequences, it is necessary to provide other support to divert young people from criminal activity;
  • Practitioners must consider contextual safeguarding when working with young people to keep them safe, which involves assessing and intervening in the spaces beyond the home;
  • Communication across local authorities is vital when safeguarding young people who move between addresses;
  • Going missing can be a powerful signal that all is not well in the adolescent’s life and it is therefore not enough to find them and bring them home. A timely multiagency safeguarding response is required for all adolescents who go missing and should not depend on where they go missing from or to (for example, abroad);
  • When a child is found or returns, they should have a prevention interview by police and the local authority should offer an independent return home interview within 72 hours. The child’s individual needs identified within return home interviews should be shared with relevant agencies to enable a holistic safeguarding intervention to be developed;
  • Knowledge of hotspots of activity in local areas combined with the specific concerns for individual children can encourage a contextual safeguarding response. 


The NSPCC case repository include the following recent cases:  

Death of an adolescent boy due to a fatal stabbing.

  • Child Y's murder believed to be linked to a feud between local gangs;
  • Emotional and learning needs highlighted when Child Y began secondary school. He was excluded twice and had several managed school moves, including one to a Pupil Referral Unit;
  • Moved in with aunt after physical punishment by father; Children's Services involved, and Interim Supervision Order made;
  • Allocated support worker from Safer London Gang Exit Service (SLGE).

Learning includes

  • Early help and prevention is critical;
  • Schools should be at the heart of multi-agency intervention;
  • Disproportionality, linked to ethnicity, gender and deprivation, requires attention and action;
  • An integrated, whole systems approach is needed across agencies, communities and families.


Death of a 15-year-old boy in May 2019 as a result of being stabbed.

  • A 15-year-old boy was found guilty of Child C's murder, and a 16-year-old boy and 18-year-old male were convicted of manslaughter;
  • Child C had been permanently excluded from school, and had been injured in another stabbing three months before his death;
  • Increasing police contacts and concerns about behaviour and escalating risk prior to incident;
  • Child C was going missing with concerns about criminal exploitation and county lines involvement;
  • Parents had separated and Mother lived with new partner;
  • Two referrals to children's services and concerns over Child C's cannabis use.

Findings include

  • Exclusion from mainstream school can heighten risk;
  • Education settings need access to local intelligence;
  • Clarity is needed about interventions to mitigate extra-familial risk;
  • Involving and supporting parents is essential to effective safety planning; inconsistent judgements about risk creates uncertainty;
  • Poor case recording can directly impact on practice.

Recommendations include

  • Review processes that involve the application of risk gradings for young people at risk of serious youth violence;
  • Exhaust all kinship options as part of a safety plan for children who are at risk of serious youth violence;
  • Schools ensure they have a detailed understanding of the potential safeguarding needs of any child at risk of permanent exclusion;
  • Ensure that policy, procedure and guidance is sufficient to ensure the active consideration of racial and cultural identity as part of the safety planning process involving extra familial risks. 

 Self-harm and attempted suicide

Case reviews highlight that the warning signs of teenage suicide are often overlooked as typical adolescent behaviour. This means that young people are not always receiving the help that they need. The learning from these reviews highlights that professionals should take young people talks about suicide seriously and work hard to engage with and support young people.

Suicide is rarely triggered by a single event. It is the result of an accumulation of adversities over time. Issues often referred to in cases included:

  • Bereavement, including family history of suicide;
  • History of abuse;
  • Exposure to domestic violence;
  • Parental mental health problems;
  • Parental alcohol or substance misuse;
  • Breakdown of relationships with family or boy/girlfriend;
  • Lack of stable accommodation or consistent source of care;
  • Copycat suicides;
  • Social isolation;
  • Bullying;
  • Mental health problems including depression;
  • Behaviour disorders including attention deficit hyperactivity disorder (ADHD);
  • Risk taking including drug or alcohol misuse, criminal behaviour and underage sexual activity;
  • Lack of parental control and boundaries;
  • Perceived or actual pressure to achieve;
  • Financial worries.


Case reviews involving suicide nearly all related to adolescents, and the majority related to boys.


The case reviews identified a number of warning signs that a young person was considering suicide. These included:

  • Disclosures of suicidal feelings – often verbal, but also letters, suicide pacts or pieces of creative writing;
  • Change in sleep patterns – sleeping more or less than usual;
  • Change in appetite – eating more or less than usual;
  • Sudden mood swings – in some cases a notable uplift in mood preceded a suicide attempt;
  • Feelings of hopelessness, rejection or being a burden to others;
  • Self neglect – often signalled by a decline in personal hygiene and appearance;
  • Self harm – often through deliberate cutting, but also aggressive acts such as hitting walls;
  • Withdrawing from family and friends and stopping engagement with support services.


Every warning sign of suicide should be taken seriously and acted on accordingly. 


The first annual report of the Child Safeguarding Practice Review panel highlighted the following learning from Rapid Reviews:

  • Extremely vulnerable young people with a history of self-harm, overdoses or other longstanding or historical mental ill health. Sometimes this was exacerbated by a history of abuse; other young people also had a diagnosis of autism;
  • Many were in the care system at the time of the incident. Frequently we have heard about these young lives characterised by multiple placements during periods of being looked after, lives becoming increasingly chaotic, with frequent periods of going missing and mental health deterioration;
  • Professionals seemed on some occasions not to be able to hear what the young person was saying, even when it was quite specifically suicide ideation, in any practical or emotionally intuitive way. This was the situation for some young people who then went on to kill themselves;
  • Where these high-level health and social care needs were in the context of a specific form of abuse, like child sexual exploitation, there was also some suggestion that the narrowness of focus led to the wider social needs being forgotten.


The triennial analysis of SCR highlighted that: 

"One example of neglect and subsequent suicide included in the reviews is that of an adolescent who took a fatal dose of opiates aged 15 years. Born with serious narcotic withdrawal symptoms into a family with a long history of substance misuse, sex work, alcohol-fuelled violence and domestic abuse, the harmful influence of the family shaped this child’s life. Signs of distress and self-harm were first identified by a schoolteacher when the child was 12 years old. When asked about the cuts on her arms the teacher reported being told ‘when I am feeling this pain, I am not feeling anything else’. Examples of self-harm escalated to the extent that prior to the fatal overdose, 32 episodes had been recorded. Although all the professionals working with this child were aware of her extreme vulnerability, there was little recorded of what life was like for her or her perspective, views and wishes, in the SCR."

 Injury in pre-mobile baby

The vulnerability of babies and the significance of injuries to this age group was listed as key learning in numerous survey responses and interviews with professionals involved in the management of serious child safeguarding incidents, and examples to address this were:

  • The promotion of awareness among parents and professionals of the ‘crying curve’ (also known as ‘purple crying’) and the impact on parents of coping with inconsolable crying;
  • Strengthened guidance about injuries to non-mobile babies and extended this to non-mobile children of all ages as a recognition of the vulnerability of children with complex health needs and disabilities.


The Royal College of Paediatrics and Child Health (RCPCH) refers to the systematic review on abusive and non-abusive bruising in children (2016), and findings included:

  • On single inspection 93.3 percent of pre-mobile infants do not have a bruise rising to 97.8% in pre-rolling infants, indicating that bruising in children not independently mobile is rare;
  • A bruise must never be interpreted in isolation and must always be assessed in the context of the medical and social history, developmental stage, explanation given, full examination and relevant investigations’.


RCPH expects designated and named professionals to be key partners in formulating local safeguarding procedures on the issue of management of bruising in pre-mobile infants, and suitably qualified healthcare professionals to be present at all strategy discussions/meetings about potential inflicted injury.

The consultant paediatricians’ role in contributing to the assessment of potential inflicted injury in pre-mobile infants is an essential one, bringing to bear their clinical knowledge and experience of accidental injury as well as inflicted injury, along with a knowledge of potential underlying medical causes which may require further intervention.


The NSPCC case review repository abstracts summaries the following SCR key learning for practice improvements:

  • Where there is suspicion of a potential non-accidental injury a formal Child Protection Medical should be undertaken to assess risk and inform decision-making;
  • The effectiveness of assessments; consideration and management of risk e.g. neglect where a baby's weight is varying;
  • The needs of fathers must be properly assessed, and to involve and support fathers as appropriate;
  • The need to share information to allow robust discussion of concerns;
  • To ensure that procedures on pre-birth assessments are consistent, contain guidance on timescales and ensure sufficient challenge;
  • To ensure that all agencies understand legal orders and their implications;
  • That child protection plans are SMART using tools to measure progress;
  • That the hierarchical approach in the working environment leads to professional deference and makes challenging medical professionals and decisions difficult;
  • Child protection practice requires collaborative work and professional respect;
  • Service thresholds were applied that did not correspond to the needs described;
  • A review of internal and inter-agency information sharing systems including use of electronic recording, flagging and coding systems;
  • The safeguarding partnership to develop and agree a multi-agency protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate;
  • The disability needs were a distraction leading to a lack of focus on the vulnerabilities/risks to the child following domestic abuse incidents;
  • The safeguarding partnership to assure itself that the daily lived experience of children is central and captured in all the work partners undertake to promote their health and wellbeing.

 Child Sexual Abuse

Summary of risk factors and learning for improved practice around child sexual abuse

The learning from the NSPCC case reviews briefing looks at case reviews published since 2017, where children experienced sexual abuse. The reviews suggest that professionals are sometimes slow to identify sexual abuse as an explanation for a child's behaviour or medical presentations – particularly when other explanations are offered. The learning highlights the importance of:

  • Professionals ability to recognise and respond to sexual abuse;
  • Displaying professional curiosity and challenge with families, carers and other agencies.


Case study from the Triennnial Analysis of SCRs (2014-2017):

Stacey is a White British girl aged 15. She lived with her mother and stepfather who was a known and convicted sex offender. The stepfather was involved with the family for 10 years and sexually assaulted Stacey on two occasions. She had poor school attendance from the age of 5 years (at times as low as 50%), unspecified behaviour issues and experienced bullying at school and in the community. The GP saw Stacey for a number of minor illnesses and her school mistakenly believed that her poor attendance was because of various illnesses. There was no school/doctor liaison.

The mother suffered from a chronic but manageable illness, which she exaggerated, and Stacey worried about her dying. Both the mother and maternal grandmother had experienced sexual abuse. Children’s social care were involved with the family for eight years during which time they drew up four written agreements: 1. After stepfather indecently assaulted a child related to Stacey, the mother had to promise she would not allow unsupervised contact between Stacey and her stepfather (they all lived in the same home). 

Mother physically assaulted Stacey and she had to promise not to use physical punishment.  Stacey had an unexplained bruised eye and a third agreement specified similar actions to the ones above. The fourth written agreement was drafted without regard to the knowledge that all previous agreements had been breached. Stacey was assumed to be safe staying with her maternal grandmother who undertook not to allow stepfather contact with Stacey.

Life for Stacey continued to be the same despite written agreements and agencies being aware that agreements were not adhered to. CSC closed her case, preventing effective monitoring of agreements whereas the intended consequence of non-compliance with the agreements was that an initial child protection conference would be convened.

Other agencies were reassured by a written agreement and saw it as evidence of parental commitment to keep the child safe. The mother and stepfather later said that they did not understand the agreements as they were not explained in terms they could understand.

Key learning points:

  • Written agreements need to be explained clearly to parents/carers and non-compliance must be acted upon and challenged by other agencies if necessary;
  • The repeat use of written agreements and case closure can serve to wrongly reassure other agencies that the risk to a child is low;
  • Practitioners cannot assume that a mother or grandmother will have an understanding of sexual abuse and the ability to protect her child because of their own experiences of sexual abuse;
  • When there is a focus on parental illness and other difficulties, the voice and lived experience of the child can easily be overlooked.


 Useful Resources

Between 29 June 2018 and 30 June 2020, the Child Safeguarding Practive Review panel received 757 rapid reviews relating to child abuse and neglect. Of these:

  • 198 (26%) involved the death or serious harm of babies and young children due to non-accidental injury;
  • 62 (8%) involved the death of a child under one year old due to SUDI.

 This lead to a national review of Safeguarding children at risk from sudden expected infant death, which is available here.


The Royal College of Pathologists SUDIC multi-agency guidance for care and investigation is here


The Safeguarding children at risk from criminal exploination

The national review sets out recommendations and findings from government and local safeguarding partners to protection children at risk of criminal exploitation. It involved 21 cases from 17 local areas regarding children who died or experienced serious harm where criminal exploiation was a factor.

The national Panel's Safeguarding children at risk from criminal exploitation report can be accessed here.


The NSPCC summary report can be accessed here.