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:
- to examine how local professionals and organisations worked together to safeguard who was harmed
- to consider what happened and where local services failed that meant a child or young person experienced abuse or neglect unnoticed
- to assist organisations in improving safeguarding practice and policy to improve the effectiveness of child protection systems
- to understand what practices were already in place from the perspective of the individuals and organisations involved at the time, and why these were deemed to be sufficient to keep the child safe
- to focus on learning and improving safeguarding practices, rather than holding individuals, organisations and agencies accountable and passing blame
- to translate findings into actions that support and underpin sustainable change and improvement, in order to prevent or reduce the risk of recurrence of similar incidents of abuse
Enfield Child Safeguarding Practice Reviews and Serious Incident Reviews
Local Child Safeguarding Practice Reviews (LCSPR)
Keiron LCSPR – February 2025
Kieron was a 16-year-old boy of dual heritage from the London Borough of Enfield who died from a stab wound. Kieron lived with his mother and younger brother. Described as polite, well-mannered, and intelligent young person.
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.
- Forced Marriage Best Practice Guide (PDF, 99.08 KB)
- Further information about Forced Marriage (PDF, 70.52 KB)
Child Serious Case Reviews
Statistics on case reviews - useful statistics and information on case reviews can be found on the NSPCC website.
‘‘Local and National Practice Reviews
See information on all National Child Practice Reviews.
Summary of Sara Sharif Safeguarding Practice Review
The Surrey Safeguarding Childrens Partnership has produced a helpful summary of the key learning from the Sara Sharif Safeguarding Practice Review, which can be accessed via the briefing link below. The review was commissioned following the death of Sara Sharif, aged 10, in 2023, and examines agency involvement with Sara and her family over several years.
The review identifies several missed opportunities to recognise and respond to risk, concluding that Sara's death was preventable. Key themes include the importance of robust safeguarding decision-making, effective information sharing, professional curiosity, responses to domestic abuse, oversight of elective home education, and ensuring children's experiences remain central to safeguarding practice.
The findings and recommendations provide important learning for all agencies working with children and families. Practitioners are encouraged to read the briefing and consider how the learning can be applied to strengthen local safeguarding practice.
SS-CSPR-SSCP-Executive-summary-for-publication-13.11.25.pdf
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.
Safeguarding Adults Reviews
For all Safeguarding Adults Reviews, visit Safeguarding Adults Board | MyLife.