This study offers an analysis, for the first time, of a near-total sample of 161 serious case reviews undertaken during the two-year period from April 2003 to March 2005.

Serious case reviews are carried out when abuse and neglect are known or suspected factors when a child dies (or is seriously injured or harmed), and there are lessons to be learnt about inter-agency working to protect children.

At least every two years, an overview analysis of serious case reviews in England is conducted to draw out themes and trends, so that lessons learnt from these cases as a whole can inform both policy and practice. This is the third such overview analysis and involved a near-total sample of 161 cases.


  • Introduction
  • Literature review
  • Findings and descriptive statistics
  • Assessment and analysis: an ecological-transactional perspective
  • Key themes, understanding the cases from an interacting risk perspective: children and families
  • Implications for safer practice
  • Bibliography