The Government announced in 1999 that it would commission overview reports of serious case reviews on a biennial basis to draw out key findings from the local reviews and identify their implications for policy and practice.

Specific objectives of this study were: to identify the key themes common to the recommendations; to ascertain whether case review reports resulted in action plans derived from the findings; to consider what helped or hindered their implementation; and to ascertain if review processes led to any changes in policy or practice at a local level. Finally an important objective was to identify from the reviews any lessons for policy and practice at a national level.

There were 45 children in this study whose deaths or injuries became the subject of 40 serious case reviews between April 2001 and March 2003. Most of the incidents (73%) involved the death of a child, and a further 23% involved serious injury.

This study aims to reflect some of the new challenges being faced by those who carry responsibility for establishing and undertaking serious case reviews, and to encourage increased openness and dialogue about contemporary experiences.


  • Introduction
  • Children in the study
  • Children experiencing harm in the context of neglect and domestic violence
  • Changing context of serious case reviews
  • Conducting serious case reviews
  • Overview conclusions, recommendations and action plans
  • Learning lessons from serious case reviews
  • Making a difference: reflections and conclusions
  • Appendices