Clarity of purpose

Serious Case Review Quality Markers 

Quality statement

The Local Safeguarding Children Board (LSCB) is clear and transparent, from the outset, that the purpose of the Serious Case Review (SCR) is organisational learning and improvement, and acknowledges any factors that complicate this goal.


SCRs often provoke fear, for individuals and agencies, that the process involves looking for someone to blame for the incident or outcome of the case. In contrast, the purpose of SCRs should be organisational learning and improvement and, where relevant, the prevention of the reoccurrence of similar incidents. This framework accepts that errors are inevitable and, where they are identified, they become the starting point of an investigation. Individual and organisational accountability is manifest through being open and transparent about any problems identified in the way the case was handled, and demonstrating a commitment to seek to address the causes. In many SCRs this is what the LSCB wants the SCR to achieve. It is as simple as that. Communicating with clarity the learning and improvement purpose helps address fears and uncertainties over the function of the SCR. It also helps reduce defensiveness on the part of those affected.

In some cases, the situation is not as straightforward. Certain cases and/or local circumstances can trigger government and/or media expectations about individual(s) and/or agencies being held to account by disciplinary means. The need to identify someone to blame can also become a driving factor for senior managers. Alternatively, there is often an expectation that any practice identified through the SCR as falling below expected standards is reported to the agency concerned, so they can consider the need for disciplinary or capability processes. These different agendas can create significant challenges to the learning and improvement goal of the SCR. On the one hand, they can create false expectations that the SCR itself will ascribe individual or corporate blame. On the other hand, such circumstances can muddy the waters about the purpose of the SCR because while the SCR is not designed to apportion blame, it can provide information that feeds into individual or corporate discipline processes, or clarify the grounds for needing to initiate them. As a result, claims that the purpose of the SCR is learning can ring hollow for those involved. An honest articulation of any tensions and contradictions that exist in relation to the goal of learning in an SCR is therefore recommended.

How might you know if you are meeting this quality marker?

  1. Has there been communication with all the necessary parties about the purpose of the review (e.g. LSCB members, involved agency leaders and practitioners directly involved as well as those conducting the review)?
  2. Has this communication been articulated in a strong and positive fashion, underlining the learning and improvement purpose of the SCR?
  3. Have any complicating circumstances been honestly acknowledged?

Knowledge base

Link to statutory guidance & inspection criteria

Tackling some common obstacles