Learning from reviews

We are committed to supporting practitioners and organisations to improve practice and achieve the best outcomes for children and young people.

Reviewing professional practice, alongside personal reflection, allows for the identification of learning and best practice. Reviews can range from case audits and best practice reviews, through to lessons learnt and serious case reviews (SCRs) and can be undertaken using a range of methodology. However the purpose is the same, to identify how to achieve the best outcomes for children and young people.

The following information provides a summary of learning from reviews undertaken by the LSCP. The learning highlights specific themes and identifies how practitioners can implement the learning to improve practice. 

Child B Serious Case Review




Child B was a 14 year old child looked after by the local authority who lived in a children’s home in Leeds. Tragically, he died in August 2015 after climbing a tree, where he got his neck caught in a rope that was hanging from the tree. An inquest was held in November 2016 which arrived at a narrative verdict.

Although the exact circumstances of Child B’s death were unknown, Leeds Safeguarding Children Board commissioned a Serious Case Review (SCR). The undertaking, management and implementation of risk assessments was a key theme addressed by this SCR.

Key learning and practice improvements

Risk assessments:

  • Involve children and young people in the development and monitoring of risk assessments.
  • Remember that risk is dynamic and changeable and assessments should be reviewed at an agreed frequency, be relevant and kept up to date.
  • Share risk assessments (and on-going updates) widely with other relevant agencies and in any review processes.
  • Ensure risk assessments include details of the action to be taken if a young person is in a risky situation and the carer(s) present cannot resolve the situation safely.
  • Managers should ensure that practitioners comply with a young person’s risk assessment.
  • Practitioners should know how to deal with emergency and be aware of their agency's procedures.


Attendance at meetings:

  • Agencies and practitioners should take responsibility for knowing the date, time and venue of the next review meeting and ensure attendance.


Positive relationships:

  • Create a safe environment to allow the identification of, and response to concerns.
  • Provide space and time for the child or young person to talk.
  • Reassure the child or young person that they can talk to staff.

Your next steps

  1. Circulate and discuss the issues of this bulletin within your team.
  2. Review and ensure that your risk assessment practice for children and young people is effective, timely and relevant.
  3. Make sure you are proactive in knowing when review meetings are taking place and ensuring attendance.  
  4. Build positive relationships with children and young people, providing time and space to talk.


Click the image below to download a printable version of this review




Thematic Learning from Leeds Safeguarding Reviews


This brief is based on the findings from 4 safeguarding reviews undertaken by Safer Leeds and LSCP, to learn lessons and improve future responses to safeguarding incidents.

These reviews (some of which will be published) all focused on incidents whereby a level of domestic violence and abuse was evident. Click on the image to expand the view to a printable version.


LSCP Learning Lessons Review