Reviews

Child Safeguarding Practice Reviews and Safeguarding Adults Reviews are a statutory requirement for Safeguarding Partnerships.

A review may be commissioned when a child or adult with needs for care and support has either died or suffered serious harm and there are concerns about how partner organisations worked together to safeguard the individual. 

The purpose of a review is to promote learning throughout the partnership and to improve practice.  

December 2021

The below communication from the Child Safeguarding Practice Review Panel and DfE highlights the current position on serious incident notifications and child safeguarding practice reviews.

Communication from Child Safeguarding Practice Review Panel [PDF Document]

Darlington Safeguarding Partnership is the key statutory mechanism for agreeing how relevant organisations in Darlington will co-operate to safeguard and promote the welfare of children in its area.

A key function is to undertake reviews of serious cases.  

Any professionals or agency may refer a case to the Statutory Safeguarding Partners if they believe that there are important lessons to be learned from the case.

The purpose of a Child Safeguarding Practice Review is to:

  • Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children
  • Identify clearly what those lessons are both within and between agencies, how they will be acted on, and what is expected to change as a result
  • Improve intra and inter-agency working to ensure better safeguards and promote the welfare of children.

Working Together to Safeguard Children 2018 [PDF Document] sets out the statutory process to be followed. 

Details of the local process for undertaking a child safeguarding practice review is outlined in the Child Safeguarding Practice Review and Serious Child Safeguarding Incident Procedures [PDF Document]

Notifiable (Serious) Incident Referral Form [Word Document]

NSPCC - Child Safeguarding Practice Review Quality Markers [External Link]

Published Child Safeguarding Practice Reviews

Statutory guidance Working Together 2018 states ‘Reviews are about promoting and sharing information about improvements, both within the area and potentially beyond, so safeguarding partners must publish the report, unless they consider it inappropriate to do so. In such a circumstance, they must publish any information about the improvements that should be made following the review that they consider it appropriate to publish. The name of the reviewer(s) should be included. Published reports or information must be publicly available for at least one year.’

There are currently no Child Safeguarding Practice Reviews published in the past 12 months.

You will find additional information on SCR's on the NSPCC website.  A full list of all published serious case reviews [External Link] can be searched. 

The Statutory Safeguarding Partners must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if:

  • There is reasonable cause for concern about how the Safeguarding Partners, members of the Darlington Safeguarding Partnership or other persons with relevant functions worked together to safeguard the adult AND:

EITHER

  • the adult has died, and the Statutory Safeguarding Partners know or suspect that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died). OR
  • the adult is still alive and the Statutory Safeguarding Partners know or suspect that the adult has experienced serious abuse or neglect.

The Statutory Safeguarding Partners may also arrange for there to be a review of any other case. 

The process for undertaking a Safeguarding Adult review is outlined in the Protocol. 

Safeguarding Adults Review (SAR) Protocol [PDF Document]

Safeguarding Adults Review (SAR) Referral Form [Word Document]

please click here to view the North East SAR Quality Marker checklist and guidance [pdf document].

SAR leaflet for families

A leaflet has been provided to explain what a Safeguarding Adult Review is about. 

Safeguarding Adult Review Leaflet [PDF Document]

Published Safeguarding Adult Reviews

There are currently no Safeguarding Adult Reviews published in the past 12 months.

Domestic Homicide Reviews

Domestic Homicide Reviews (DHR) were established on a statutory basis under section 9(3) of the Domestic Violence, Crime and Victims act (2004). Responsibility for establishing a DHR is clearly placed with the Chair of the local Community Safety Partnership (CSP) in consultation with multi agency partners. CSP’s are viewed to be ideally placed to conduct DHRs because of their multi-agency design. Within Darlington this partnership is referred to as the Darlington Community Safety Partnership (CSP).

Definition of a DHR

A DHR should be carried out to ensure that lessons are learnt when a person has been killed as a result of domestic violence. The guidance states: ‘domestic homicide review’ means a review of the circumstances in which the death of a person aged 16 or over has, or appears to have resulted from violence, abuse or neglect by:

  • a person to whom he/she was related or with whom he/she had been in an intimate personal relationship, or
  • a member of the same household

Where a victim took their own life and the circumstances give rise to concern (e.g. it emerges that there was coercive controlling behaviour in the relationship) a DHR should be undertaken, even if a subject is not charged with an offence or is tried and acquitted.

Purpose of a DHR

The purpose of a DHR is to:

  • establish what lessons are to be learned from the domestic homicide regarding the
    way in which local professionals and organisations work individually and together to safeguard victims;
  • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
  • apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate;
  • prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to
    effectively at the earliest opportunity;
  • contribute to a better understanding of the nature of domestic violence and abuse;
    and highlight good practice

The DHR should describe the history of abuse, identifying which agencies had contact with the victim, perpetrator and family and describing contact between agencies. The DHR should tell this story through the eyes of the victim and their children by talking to those around the victim including his or her family, friends, neighbours, community members and
professionals. This will help the DHR panel understand the victim’s reality, identifying any barriers the victim faced in reporting abuse and why interventions did not work. It will also help the DHR panel understand the context and environment in which professionals made decisions and acted.

The DHR should be inquisitive and professionally curious. It should not simply examine the conduct and actions of professionals and agencies but should consider organisational culture, training, supervision and leadership. The DHR should evaluate whether procedures and policies were sound, whether they supported the best interests of victims and whether changes to processes and policies could have secured a better outcome.

The procedure for undertaking DHR's in Darlington is set out in the procedure below.

Procedure for the conduct of Domestic Homicide Reviews within Darlington Jan 2020 [PDF Document]

Home Office Statutory Guidance for DHR's - Home Office Guidance 2016 [external link]

Lessons Learnt Research Digest

Darlington Safeguarding Partnership has produced a Lessons Learnt Research Digest bulletin to share messages from recently published Serious Case Reviews, Safeguarding Adult Reviews and local lessons learnt. The cases identify lessons to be learnt to improve learning and develop practice across multi-agencies to safeguard children and young people, and adults with need for care and support. 

DSP Learning Research Digest issue 1 (Nov 2019)

DSP Learning Research Digest issue 2 (June 2020)

DSP Learning Research Digest issue 3 (March 2021)

DSP Learning Research Digest issue 4 (November 2021)

You will find additional information on SCR's on the NSPCC website.  A full list of all published serious case reviews [External Link] can be searched. 

Learning from National reviews

The Child Safeguarding Practice Review Panel have published three National Reviews, click on the links below to review full published report: 

Safeguarding Children at Risk from Criminal Exploitation (March 2020)

Sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm (July 2020)

Safeguarding children under 1 year old from non-accidental injury (Sept 2021)