Learning from reviews

What is a Child Safeguarding Practice Review?

Child Safeguarding Practice Reviews (CSPRs) are systematic reviews of serious child safeguarding cases at both a local and national level. They are used to investigate the causes of cases of abuse or neglect to identify whether there are changes that should be made at a local or national level to stop these kinds of cases from happening again.

Serious child safeguarding cases are defined as cases in which abuse or neglect of a child is known or suspected, and the child has died or been seriously harmed as a result of this abuse. Serious harm is defined as serious immediate harm or injury or any longer-term impairments, including conditions that affect physical, mental, intellectual, emotional, social and behavioural development.

The overall purpose of a Child Safeguarding Practice Review is to identify steps that various organisations and professionals should have taken to prevent harm, and reduce or remove the likelihood of another situation happening so severely again.

Some of the other aims of the CSPRs are:

Enfield Child Safeguarding Practice Reviews and Serious Incident Reviews

Local Child Safeguarding Practice Reviews (LCSPR)

Emily LCSPR February 2024

Emily has been a ‘looked-after’ child to Enfield since she was 4 years old, due to chronic neglect and parental substance use. She is subject to a full Care Order (CA 1989). Emily has a diagnosis of autism, global developmental delay, and ADHD. Her placement had been established to meet her needs.  There were Deprivation of Liberties Safeguards (DoLS) in place for Emily and she had 2:1 support at all times. On the day after her 16th birthday, Emily went missing and was found at a central London underground station the next morning. She said that she had been raped and injected with cocaine by a person who she had met online in an interactive game. The circumstances as to how Emily was groomed and how this could have been prevented is explored within the LCSPR.

Nadya LCSPR May 2023

Nadya moved with her family to live in the UK early in 2017 and had been known to multi agency child protection services since November 2019 when concerns were investigated that she had been ‘promised’ in marriage to an 18-year-old male when she was then aged just 13 years. The circumstances around these enquiries are reviewed in this report.

Please see some additional resources on the key topic of Forced Marriage.

Andre LCSPR - May 2022

Andre passed away shortly after completing school. Andre was well- liked by those who knew him, with professionals talking about him favourably stating that he was a pleasure to work with.

Josef LCSPR - August 2021

Josef was a looked after young person from January 2019 and was 17 when he died in February 2020. Josef was known to various agencies at the time of his death, and the last few months of his life were particularly troubled, however those who worked with him remember him as being good fun, witty, funny with a great smile.

The report highlights the improvements that were implemented during the period between Josef’s death and the report being published. Updates on improvements made from our reviews are reported in the Safeguarding Enfield annual reports.

Child Serious Case Reviews

Statistics on case reviews - useful statistics and information on case reviews can be found on the NSPCC website.

‘YT’ Case Review - October 2017

On the 27 October 2017 we published the Serious Case Review (SCR) report for ‘YT’ covering the tragic case of a young man who took his own life just hours after arriving in this country. It is unlikely that anyone will ever know what led him to make that decision and the review concludes that his death could not have been predicted.

It is important however, that those involved in the care of young people in similar circumstances learn as much as possible from such a tragic event and the ESCB has published a response document detailing the local activity that has already taken place in response to the review.

‘AX’ Case Review - January 2016

On the 11 January 2016 we published the Serious Case Review (SCR) report for ‘AX’ which involved the death of a 17 year old male at the end of 2013.

The events covered by the report took place over two years ago. Agencies have not awaited the completion and publication of this review before tackling the issues arising from these events and many of these recommendations have been identified and addressed already.

The report concludes that the circumstances and timing of AX’s death could not have been directly predicted by any of the agencies with which he had been in contact. However, possible opportunities for changing the outcome or influencing elements in this and future cases have been explored thoroughly.

‘CH’ Case Review - May 2015

On 27 May 2015 Enfield and Haringey Safeguarding Children Boards jointly published the Overview Report of a Serious Case Review (SCR) for ‘CH’ undertaken in 2012/13 and completed in 2014.

The Serious Case Review concerns the murder of a young man by ‘CH’. The Overview Report states that the circumstance of the death could not have been predicted. However, through looking at the work of all agencies involved with CH and his family, the report does recognise that there are a number of areas of learning and improvement for partner agencies as well as evidence of good and effective practice. Agencies could, and should, have responded differently at key points.

Local and National Practice Reviews

See information on all National Child Practice Reviews.

Summary of Arthur Labinjo-Hughes and Star Hobson review

NSPCC have helpfully summarised key points within the review which can be found on their website here NSPCC: Summary of the national review into the murders of Arthur Labinjo-Hughes and Star Hobson.

In the foreword it is noted that when completing the review, it was felt that the experiences of Arthur, 6 and Star, 16 months were not unusual. Arthur and Star were both murdered in 2020 because of sustained abuse and neglect from their caregivers. Wider family members voiced multiple concerns and shared evidence of physical abuse with professionals prior to their deaths. There was also a history of domestic abuse in both cases.

The findings are important to read along with the recommendations. Findings were that information sharing between agencies was not good enough, alerting significant weaknesses and that there was a lack of critical thinking and challenge between agencies, to name a few.

The National Review have published a recording of their presentation for frontline practitioners which is available on their YouTube channel. The video outlines findings and recommendations that were found within the review.

In addition they have also created a short briefing on the review for practitioners (PDF, 229.91 KB). Please watch and review the information provided for additional learning.

Local Practice Review - Child Q

Enfield Safeguarding Partnership acknowledge that the treatment to Child Q was unacceptable and demoralising. It is important that we read the review and pay particular attention to the recommendations outlined in order to ensure that practice across the partnership can be scrutinised to prevent another child being treated in this way.

Safeguarding Adults Reviews

For all Safeguarding Adults Reviews, visit MyLife Enfield.