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Child and Vulnerable Adult Case Reviews

Updated: 26 November 2019|Legal Guidance, Domestic abuse , Violent crime


Serious Case Reviews (SCRs) were previously held for cases involving children, and occasionally vulnerable adults, but they have now been replaced with new regimes in England and Wales. These apply to cases involving death or serious harm to a child and Safeguarding Adults Reviews are now used for cases where a vulnerable adult has died. There is separate section for Domestic Homicide Reviews contained within Inquiries and Reviews legal guidance.


On 29 June 2018, local areas began their transition from Local Children's Safeguarding Boards (LSCBs) to the local safeguarding partner arrangements set out in Working Together to Safeguard Children 2018 (Department for Education, 2018a).

This transition period ended on 29 September 2019.

Within 15 days of notification of a "serious child safeguarding case" the local Panel must hold a Rapid Review involving the partner agencies: local authority, Police, Health, Education, Social Care. The purpose of the Rapid Review is to:

  • Gather facts
  • Discuss any immediate safeguarding issues
  • Examine the potential for identifying improvements
  • Promote the welfare of children
  • Identify the next steps.

The Rapid Review has three possible outcomes, although the National Panel can challenge these decisions if it considers it appropriate to do so:

  • Decide the case does not meet the criteria for a further review and no further action is taken
  • Proceed to a Local Review
  • Decide that the case also raises national issues and refer to the national Panel for a National Review.

Local reviews: where safeguarding partners consider that a case raise issues of importance in relation to their area.

National reviews: where the Child Safeguarding Practice Review Panel considers that a case raises issues which are complex or of national importance. The Panel may also commission reviews on any incident(s) or theme they think relevant.

Any Local or National Review must normally take place within six months.

The reviews are known as:

  • Child Safeguarding Practice Reviews in England
  • Child Practice Reviews in Wales.

Section 16N Children Act 2004 sets out the ability of a Review to request any body or person to provide information to the Review. The body/person must comply with that request.


In England, Child Safeguarding Practice reviews should be considered for serious child safeguarding cases where:

  • abuse or neglect of a child is known or suspected and
  • a child has died or been seriously harmed.

This may include cases where a child has caused serious harm to someone else.

Serious harm includes, but is not limited to serious and/or long-term impairment of a child's mental or physical health or intellectual, emotional, social or behavioural development. This should include cases where impairment is likely to be long-term, even if this is not immediately certain.

In England, the key guidance for safeguarding practice reviews is Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (Department for Education, 2018a).

At a local level, the safeguarding partners must make arrangements to:

  • Identify and consider serious child safeguarding cases which raise issues of importance in relation to their area
  • Commission and oversee child safeguarding practice reviews of those cases, where they consider it to be appropriate.

The Guidance points out that meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families.

Safeguarding partners are responsible for:

  • Commissioning and supervising reviewers for local reviews and agreeing the methodology to be used
  • Ensuring that practitioners, families and surviving children are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith.

At a national level, the Child Safeguarding Practice Review Panel is responsible for:

  • Identifying serious child safeguarding cases which raise issues that are complex or of national importance
  • Overseeing the review of these cases
  • Setting up a pool of potential reviewers who can undertake national reviews, a list of whom must be publicly available
  • Agreeing the potential scope and methodology of the review with the local safeguarding partners and engaging with them and others involved in the case.

All child safeguarding practice reviews should:

  • Reflect the child's perspective and the family context
  • Be proportionate to the circumstances of the case
  • Focus on potential learning
  • Establish and explain the reasons why the events occurred as they did.

The final report should include:

  • A summary of recommended improvements to safeguard and promote the welfare of children
  • An analysis of any systemic or underlying reasons why actions were taken or not taken.


In Wales, the key guidance for conducting child practice reviews is Working together to safeguard people: volume 2: child practice reviews (Welsh Government, 2016).

The purpose of a child practice review is to generate professional and organisational learning and promote improvement in future inter-agency child protection practice. The review should focus on current practice, so should normally consider a timeline of up to 12 months preceding the incident.

A child practice review (CPR) should take place if child abuse is known or suspected and a child has:

  • Died
  • Sustained potentially life threatening injury
  • Sustained serious and permanent impairment of health or development.

There are two types of CPR, a concise and extended review:

  • A concise review should take place if the child was not on the child protection register or in care at any point in the six months running up to the incident. The review is managed by a review panel and a reviewer is appointed to work with the panel.
  • An extended review must take place if the child was on the child protection register and/or was in care at any point during the six months running up to the incident. An extended review is undertaken by two reviewers working closely together, appointed by the review panel.

Both concise and extended reviews must include an action plan.

Vulnerable Adults

The Care Act 2014 sets out a legal framework for how local authorities and other parts of the system should protect adults at risk of abuse or neglect. One of the duties of local authorities is to carry out Safeguarding Adults Reviews (SARs) when someone with care and support needs dies as a result of neglect or abuse and there is a concern that the local authority or its partners could have done more to protect them.

Any relevant person or organisation must provide information to Safeguarding Adults Boards as requested (section 45 Care Act 2014).

The purpose of SARs is described in the statutory guidance as to 'promote effective learning and improvement action to prevent future deaths or serious harm occurring again'. The aim is that lessons can be learned from the case and for those lessons to be applied to future cases to prevent similar harm re-occurring. The purpose of a SAR is not to hold any individual or organisation to account. Other processes exist for that purpose, including criminal proceedings.

SARs are expected to explore:

  1. What happened
  2. Any errors or problematic practice and/or what could have been done differently
  3. Why those errors or problematic practice occurred and/or why things weren't done differently
  4. Which of those explanations are unique to this case and context, and what can be extrapolated for future cases so become findings.
  5. What remedial action needs to be taken in relation to the findings to help prevent similar harm in future cases

CPS Participation in a Review

An invitation to participate in a Review will come from the Chair of the relevant review panel addressed to the CPS Area. The invitation may be to invite a senior member of the CPS Area:

  • to be a member of the Review Panel; or
  • to contribute to the review process, e.g. by the submission of an Individual Management Review (IMR), which is an account of an agencies' involvement in the case. IMRs are covered in the Domestic Homicide Review section within Inquiries and Reviews Legal Guidance

Upon receipt of an invitation to participate, Areas should contact the Chair of the Review Panel and request details of the terms of reference for the Review, so that an assessment can be made about the extent of participation.

Requests to participate as a Review panel member should be considered positively where there is a specific reason associated with the case which requires a response from the CPS (for example, where a homicide occurred whilst the defendant was on bail, or if there had been a previous decision to not charge a defendant). It is likely that panel members will be required to attend a number of meetings and such invitations should be assessed on a case by case basis. Alternatively, participation by the CPS may be required as an opportunity to explain our role and decision making process in a particular case.

Once informed of a Review, the relevant CPS Area should ensure that steps are taken to secure any records relating to the current case and any previous related cases. Where files have been destroyed due to passage of time or a decision not to charge, the police should be contacted for any records they may have.

The CPS should usually agree to participate in the Review process, particularly where it appears that the CPS role may have been misunderstood and to avoid erroneous conclusions being reached. Where the CPS has had previous involvement in the case in under review, Areas should consider participating in the Review in order to  explain  the role of the CPS and the application of the Code for Crown Prosecutors in the decision making process. The CPS representative attending a Review must have full knowledge of the case and be prepared to explain the actions and role of the CPS in the case under review.

The following issues need to be considered prior to participation:

  • the fact that a case may be sub judice (see later in this guidance about simultaneous criminal proceedings);
  • the need to  prevent  the disclosure of confidential information;
  • the importance of the independence of the Prosecutor;
  • potential criticism of decisions made by the CPS.;
  • the Panel may ask the CPS representative to comment on issues beyond the circumstances of the case under review. It is not the role of the CPS to comment upon prevention and protection issues, unless the death case under review has had criminal justice input prior to the offence, e.g. where a defendant was on bail when the homicide occurred.

There may be cases where the CPS is not invited to be part of the Review process but is then referred to within the Review by another agency. In these cases the CPS should make enquiries of the panel and either offer to be involved, or request a copy of the report for accuracy before it is published and suggest amendments where appropriate.

Simultaneous Review and criminal proceedings

If a prosecutor is approached for early investigative advice or charging advice regarding the death or serious harm of a child or vulnerable adult where abuse is suspected, they should ensure the SIO is aware of the outcome of the Rapid Review and that they are kept informed of any ensuing review process.

The Review panels are independent from the criminal justice process and it is not possible to enforce demands that the timescales or methodology of the Review is altered. The subject matter of each Review, the identity of the agencies contributing to it, and the disclosure issues to which it gives rise will differ considerably from case to case. If there is concern that the Review will jeopardise ongoing criminal investigations or proceedings, there should be discussion and agreement reached with the Panel chair on the way forward.

The CPS has liaised with the panel in England and the NPCC and produced a protocol for information sharing. The panel in Wales is still considering reforms to its review system.

Disclosure of Unused Material

During the process of a Review, material will be generated (e.g. minutes of meetings) and gathered (e.g. IMRs from contributing agencies and notes of interviews). Reasonable lines of enquiry must be followed by the police to establish what material exists, and whether it may be relevant to the criminal investigation/criminal prosecution. If material relevant to the criminal prosecution exists, the police must alert the CPS to its existence. Relevant material should be scheduled in the normal way and reviewed by the prosecutor to assess whether or not the material is disclosable with respect to the disclosure test.

Further reading

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