Report: Learning from Significant Case Reviews – March 2015 to April 2018 – Care Inspectorate

This report presents the findings of a retrospective review by the Care Inspectorate of 25 significant case reviews (SCR) conducted in Scotland over the three years from April 2015 to March 2018.

It follows their previous report Learning from Significant Case Reviews in Scotland: A retrospective review of relevant reports completed in the period between 1 April 2012 and 31 March 2015.

A significant case review is a multi-agency process for establishing the facts of, and learning lessons from, a situation where a child has died or been significantly harmed. Significant case reviews should focus on learning and reflect on day-to-day practices and the systems within which those practices operate.

The overarching objectives of significant case reviews are outlined in National Guidance for Child Protection Committees Conducting a Significant Case Review, published by the Scottish Government in 2015. They are fundamentally to establish whether there are lessons to be learned about how better to protect children and young people and help ensure they get the help they need when they need it in the future.

This review of significant case review reports reflects a number of familiar themes from earlier reviews that remain areas for learning and development for child protection committees and children’s service staff across agencies. These include information sharing, thresholds for intervening with families, particularly in relation to neglect, and working with resistance and disguised compliance.

This report presents the findings from their analyses of 25 significant case reviews that concerned 44 children and young people, carried out by child protection committees in Scotland between 1 April 2015 and 31 March 2018.

Twenty-two out of the 25 SCRs related to incidences of child abuse and/or neglect, of which 19 related specifically to children under 5 years old. Three of these SCRs were also affected by Sudden and Unexplained Death in Infancy (SUDI). A further three concerned teenage suicide.

Download the report here.