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What is a Serious Case Review (SCR)?

A Serious Case Review (SCR), is undertaken by the Safeguarding Children Partnership Board when;

  • Abuse or neglect of a child is known or suspected; and
  • Either – the child has died; or the child has been seriously harmed and there is cause for concern as to the way the authority, their board partners or other relevant persons have worked together to safeguard the child.

Professionals from a wide range of agencies working with a child and family contribute their experiences and perspectives in an effort to; learn and explore what could have been done differently to improve the outcomes for the child and to provide future guidance for professional practice.

This SCR was undertaken on a baby who we shall call Oliver, to respect his anonymity. The SCR was initiated following a referral, for a SCR, to the SCR Sub-group Panel. This review concerns the very serious injuries sustained by a baby of only 15 days old.

In the case of Oliver all agencies were required to provide Independent Management Reviews (IMRs) and a chronology of their involvement with Oliver. In addition, a practitioner’s event took place which explored key episodes and events within the timeframe being reviewed by the SCR enabling professionals to talk through their experiences in a safe and learning environment.

Changes since the SCR for Oliver

The Cambridgeshire and Peterborough Safeguarding Partnership Board have combined a number of resources for safeguarding children and young people around dogs

The Serious Case Review for Oliver


The subject of this review is Oliver, who was 15 days old, when he sustained very serious injuries as a result of being attacked two family pet dogs. Oliver subsequently died of these injuries.

Identification of risk specifically in relation to the family pet dogs

There is guidance on the Safeguarding Children Partnership Board, which was in place and published at the time of the injuries to Oliver. Whilst the guidance states that risk can come from the most trusted pets, the inference is that it is the breeds that are defined dangerous dogs that present the greatest risk.

Key Learning Points for Professionals

A workshop took place with all of the agencies involved with Oliver and his family and the following points were discussed and put forward as areas to focus on for future learning to help prevent a case like this happening again:

  • Where risk factors are identified it is important that they are fully explored, using all available information to challenge and test hypotheses and mitigate the risk.
  • Adherence to the Safeguarding Pre-birth protocol, undertaking a full pre-birth assessment and support from the unborn panel will ensure that there is a coherent multi-agency approach to supporting and protecting the unborn and newly born child.
  • Where actions are set within the child protection framework they should be followed through and evidenced as being completed. If the action becomes unnecessary or irrelevant this should be recorded.
  • Within the partnership there is shared responsibility for safeguarding and the completion of actions, where there is apparent drift, failure to complete this should be appropriately challenged and addressed.
  • Any assessment of risk needs to look at the history of a case as well as the events occurring and being presented at that time. Where there is experience to be drawn on from the past this should be used to assess the present. In this case the parenting experience of the father from having a previous child.
  • Professionals should be open to challenging information or behaviour which appears to be incongruent to information they hold or contrary to their own professional judgement or experience.
  • Professionals should balance the desire to identify and build the strengths of parents with an overly optimistic viewpoint.
  • Professionals should take every opportunity to explore the risks of domestic abuse in a relationship, considering how coercion can be applied. Safe, open conversations about previous domestic abuse should not be avoided. Where there are concerns regarding previous domestic abuse consideration should be given to how much the current partner is aware of and whether consideration of disclosure under Clare’s Law is appropriate.
  • Managers should have oversight on key decisions and plans being made, in particular decisions in this case like the discharge from hospital plan. Staff should also seek formal safeguarding supervision in complex cases where it is available.
  • There is opportunity for non-mental health staff to be made more aware of the mental health diagnosis which would assist in a better understanding of the risks posed by the mental health condition and a better understanding of the pathways to treatment.


  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should seek assurance from all agencies contributing to this review that all single agency recommendations identified in their respective reports have been actioned and progress is being monitored.
  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should be assured that practitioners have a clear understanding of the Safeguarding Partnership Board Procedures for Pre- birth assessments. Quality assurance activity should be undertaken to confirm its effectiveness.
  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should seek assurance that the multi-agency pre-birth panel is functioning effectively. Quality assurance activity should be undertaken to confirm its effectiveness.
  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should continue to deliver multi agency training on parental mental health to assist practitioners to better understand the impact of their conditions on parenting and what the pathways for treatment are.
  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should develop guidance on professional curiosity and disguised compliance and how this can impact on an overly optimistic view on parent’s ability to change.
  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should seek to ensure that agencies take every opportunity to enquire and identify all aspects of domestic abuse, including coercive control.
  • The Cambridgeshire and Peterborough Safeguarding Partnership Board should ensure that agencies are focused on the potential risk presented by dogs, in particular to young children and babies, by reviewing the current policy and linking in with other resources to build on the message ‘never leave a baby or young child unsupervised with a dog, even for a moment, no matter how well you know that dog’.

Further Information:

Safeguarding Partnership Board Website:

Practice Guidance and resources for Safeguarding Children around Dogs:

Safeguarding Training:

Pre-Birth Assessment:

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