About Richmond LSCB

Learning & Improvement Case Reviews

The LSCB has a statutory duty to have a learning and improvement framework, which helps all agencies work together in Richmond to look at situations involving children and families where there has been good or concerning practice. This helps us look at our safeguarding learning and systems. You can access Kingston and Richmond's Learning and Improvement Framework here.

Local Learning

Child G Learning Lessons Richmond 2013
This 7 week old baby died as a result of unknown natural causes. A learning lessons review was undertaken.
Key themes: timely pre-birth assessment; planning for looked after young people, who become parents; working across borough borders; the value of reflective supervision for those who work with vulnerable adolescents.

Child F SCR Richmond 2012 
Child F died of an overdose - he was 13 years old. For many years, he thought that his maternal grandparents were his parents.

Key themes: information sharing; risk assessment for adults with substance misuse concerns who have contact with children; recording and analysing family history; pre-birth assessment; young carers; recognition of risks for agencies working with adults; medicalisation of social concerns; escalations of concerns between agencies.

Southbank International School SCR -  Hammersmith & Fulham, Kensington and Chelsea and Westminster LSCB
For more information please click - Summary of the Westminster LSCB Southbank School Serious Case Review January 2016

Family A
Family A Serious Case Review was published in November 2015.  The independent authors were Edina Carmi and Nicki Walker Hall. The mother killed her children in April 2014.

Key themes: neglect; risk assessments; and working with children with complex needs.

Please find for download below, the overview report, LSCB response and SMA Support UK information sheet and press release statement:

Child B
Child B Serious Case Review, independent author Susan Ellery, was published in June 2015. Child B, 15, sadly took his own life in 2014.

Key themes: working with concerns of self harm and suicide; online gaming; and interventions with minority ethnic groups.

  • Child B Serious Case Review in Kingston Executive Summary - 
  • Download
  • Child B Serious Case Review Final 2015 - Download
  • Resources for parents, carers and professionals to support online safety and gaming: what to do if you are worried - Download

Kingston Domestic Homicide Review published November 2014
A woman was stabbed to death by her partner in 2011; she had a young child.

Key themes: risk assessment; information sharing; communication; and child abduction.

For more information please click: Domestic Homicide Review 2011

Tom and Vic SCR Kingston 2013
Tom and Vic were adolescents injured in 2012 and involved in criminal activity.

Key themes: working with vulnerable adolescents; risk assessments; missing children; and evaluation of outcomes when working with children and young people.

For more information please click: Tom and Vic Serious Case Review - October 2013

National learning

Brighton LSCB Serious Case Review - July 2017 

Brighton LSCB published a Serious Case Review in July 2017 regarding the tragic death of two brothers in Syria in 2014. There is learning about radicalisation and the vulnerability of young people to grooming for extremism.  The review is here:


Stanbridge Earls School Hampshire LSCB Serious Case Review 2015. More information can be found here.

Colin - XLSCB 2016 
X Local Safeguarding Children Board (XLSCB) conducted a Serious Case Review into the death of a child “Colin”. Colin died following an incident which took place while he was in the care of professionals during a planned activity.

Full Learnings can be downloaded here

Child CN - Devon LSCB 2014 
In June 2013, the stepfather was convicted and imprisoned for sexual offences against his two stepdaughters. The youngest daughter took part in the serious case review and said it would have made a difference if she had felt that her mother would have listened to, and believed her, so that she could have confided in her. She also said she wished that social workers would have visited the home and so have seen what things were like rather than seeing her at school. There was learning about assessing males in the family home, information sharing, sexual abuse and the rule of optimism.

Further information can be found ont the Devon LSCB website

Daniel Pelka - Coventry LSCB 2013
Daniel, 4, was the middle child in a Polish family of three children. He was the subject of chronic neglect by his mother, torture and physical abuse by his stepfather. There were concerns of domestic abuse between the couple. The school struggled to recognise Daniel’s neglect and his mother explained his hunger and weight loss as a genetic concern, which the school did not question. Few attempts were made to hear Daniel’s voice. He died as the result of a head injury inflicted by his stepfather. He was found to be severely malnourished.

Further information can be found on the Coventry LSCB website

Child G – East Sussex LSCB 2013
This young person was involved in a relationship with her school teacher. Despite concerns from school students, the young person’s family, and staff at the school did not see this as an abusive situation and considered the teacher to be a victim; the LADO involvement was not effective. Child G was taken abroad by her teacher in 2012 leading to high profile media campaign before she was found and returned to the UK. Her teacher was subsequently convicted and imprisoned for child abduction and sexual offences.

Further information can be found on the East Sussex LSCB website

Young people 1, 2,3,4,5 & 6 – Rochdale LSCB 2013
Rochdale Borough Safeguarding Children Board (RBSCB) has published two serious case reviews in to the response of services in Rochdale Borough to the sexual exploitation of 7 young people between 2003 to 2012. Problems identified include: poor front-line understanding and implementation of policy and procedures; an absence of high quality supervision, challenge and line management oversight; failure to intervene early to protect 6 of the 7 exploited young people from damaging experiences including neglect and domestic violence. The reports make a number of recommendations including: RBSCB to map and scrutinise work on practice improvement that has already taken place and identify what further action is now required.

Further information can be found on the Rochdale Borough LSCB

The sexual abuse of children in a foster home - SCR by City and Hackney LSCB 
Between September 2013 and November 2014, the City and Hackney Safeguarding Children Board conducted a Serious Case Review (SCR) about the sexual abuse of a number of children by two men. One was an approved foster carer, the other a member of his family. The abuse of foster children is known to have taken place between 1999 and 2008.

Further information can be found on the City and Hackney LSCB

Two Serious Case Reviews published by Thurrock LSCB - Megan & Julia
Thurrock LSCB has published two helpful Serious Case Reviews. Megan has learning for agencies around early help for an older teenager. Julia's review is around CSE (Child Sexual Exploitation).

Further information can be found on the Thurrock LSCB website


Daniel - A Serious Case Review published by Kent LSCB 
Kent LSCB's review regarding Daniel in 2013 is also about CSE and substance use. 

Further information can be found on the Kent LSCB website 

Child J - A Serious Case Review published by Lambeth LSCB

Lambeth LSCB's Child J Serious Case Review is about a teenage young woman who had mental health concerns and took her own life. 

Further information can be found on the Lambeth LSCB Website

National repository of published case reviews
The NSPCC and Association of Independent LSCB Chairs have been working together to develop a national repository of case reviews that have been published in the UK. This is a resource to access and share learning on a local, regional and national level. Please click here to access the NSPCC repository. 


Bristol Safeguarding Adults' Board

Bristol Safeguarding Adults' Board published this review into a young person, Melissa, who was murdered by another young person  -  both young adults had just transitioned to adults' services. 

Please click here for the Case Review.
Please click here for the Learning Summary.