Learning from 97 Serious Case Reviews


The Cafcass Policy Team has produced new research, Learning from Cafcass submissions to Serious Case Reviews, to better understand what can be learnt from Serious Case Reviews (SCRs) in Cafcass. The report analyses data from 15 SCRs to which Cafcass contributed between December 2015 and 2016, and from 97 submissions to SCRs between 2009-2016. It looks into the children and families involved, the serious incident, the risks known at the time the case was open to Cafcass and practice learning.

National Child Care Policy Manager Richard Green says, “This research helps us to learn from our submissions to SCRs and identify the risks that commonly feature in the very small number of cases that have the most tragic outcomes.”

Serious incidents

The study of the 97 cases found:

  • Just over a third of serious incidents occurred while family court proceedings were ongoing.
  • About 60% of cases involved the death of a child and 40% serious harm. 
  • Almost half involved physical abuse or homicides. 
  • A quarter related to neglect or co-sleeping, occurring in both private and public law cases.

Richard comments, “We also looked at who was known or thought to have been the perpetrator of the incident. We found that the vast majority were family members. There were very few exceptions, and these were mostly cases of child sexual exploitation.”

Men and women were suspected perpetrators of a similar number of incidents of homicide. However, in the few cases of homicides, the report notes how fragile the mental health of some of the female perpetrators seems to have been and how the male perpetrators had histories of domestic abuse and control.

Risk factors

The most common risk factors identified within the cases were neglect, present in 60% of cases, and domestic abuse, present in 71% of cases. However, in almost half of cases featuring domestic abuse the person thought to have killed or harmed the child was not the alleged domestic abuse perpetrator. SCR submissions showed that in some cases the risk posed by the violent adult may have masked other less evident risks.

“We found many different contexts in which the incident took place, presenting significant challenges for those charged with safeguarding children,” says Richard. “The suspected perpetrator of the serious incident was not necessarily the person that was thought to pose the greatest risk during proceedings. Some children were harmed or died in an alternative placement, or at the hands of the parent considered to be the ‘safe’ one.”

In other cases, low level risks took on particular significance with hindsight. The report notes that while in some cases it is possible to identify areas where more scrutiny of risks was warranted, it is no coincidence that only a very small minority of SCRs concluded that the fatal or serious harm was predictable or preventable.


While SCRs do not have predictive value, they do add to our understanding of risk and practice strengths. Cafcass ensures that the learning from fatal or serious maltreatment of children is identified and cascaded at an early stage through a review of the file conducted by the National Improvement Service (NIS).

Alexander Kemp, Head of Practice for NIS, says, “Occasionally SCRs break new ground by producing ‘new’ learning. More often they confirm what we already know – which does not make them less valuable. The key learning points in this report reinforce messages from our training, and will be shared with practitioners via a learning module which Practice Supervisors will deliver later this year.”

The report uses case examples to illustrate the importance of attention to: 

  • front-loading of the work
  • planning
  • sound recording
  • systematic attention to the needs of the child
  • a crisp analysis.


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