Child B

Child B Serious Case Review


  • Risk assessments
  • Attendance at meetings
  • Positive relationships


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

Share and discuss the identified good practice and learning points with colleagues, and ensure the following is embedded in your practice:

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

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