Local Safeguarding Practice Reviews

A child safeguarding practice review is a process that aims to identify and learn from the factors that contributed to a serious incident involving a child. The review is led by an independent practitioner who has expertise in child protection and relevant fields. The purpose of the review is to improve the quality and effectiveness of the services that support children and families and to prevent similar incidents from happening in the future.

The responsibility for the lessons learned from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel and at the local level with the Croydon Safeguarding Children Partnership (CSCP). 

Child safeguarding practice reviews are considered when:

  • abuse or neglect of a child is known or suspected 
  • the child has died or been seriously harmed 
  • a child who is looked after dies (whether abuse or neglect is suspected)

How to use a 7-minute briefing.

A 7-minute briefing summarises the main points of a full safeguarding practice review. It is a valuable tool for communicating key information concisely and clearly and should be used to share good practices, raise awareness, or provide updates on a topic. This is a free resource that you can download and share. It has helpful information and tips on the topic. You can also contact the CSCP if you have questions or feedback.

Child Safeguarding Practice Reviews 


Baby Eva (published April 2024)

Baby Eva, just four months old, entered the hospital with a fracture, but X-rays unveiled multiple fractures of varying ages. Her family history, overlooked until then, hinted at preventable risks. This echoes similar cases, prompting a deeper examination of past learnings. This review aims to explore Baby Eva's journey, highlighting the urgent need for proactive risk assessment in pre-and post-birth.

Serious Youth Violence Thematic Review (Published February 2024)

The CSCP publishes a thematic review that sets out key principles to reduce the risk of children and young people becoming involved with serious youth violence. 

Chloe (Published October 2023)

'Chloe' was 17 when she took her own life, the inquest verdict was ‘accident’; that she did not freely intend to take her own life. 'Chloe' was a child who experienced early trauma and who came into statutory care just before her teenage years. Her story illustrates the appalling legacy of sexual abuse, exploitation, trauma and re-traumatisation. When she carried out the fatal act she was in a state of mental crisis, this review examines 'Chloe’s' story and the services that were provided.

Jake (Published May 2023)

This Child Safeguarding Practice Review (CSPR) looks into the tragic case of 'Jake', a 17-year-old child who took his life just before he turned 18. Examining his needs and the involvement of various services, it reflects on legal, policy, and research aspects, drawing from the expertise of multi-agency safeguarding professionals.

Carl and Max (Published March 2022)

This review examines the case of 'Carl', who was 16 when he was fatally stabbed. It revealed how he faced homelessness, unstable housing, and 2 years of no schooling. The family's forced moves disrupted support services, pushing Carl towards criminal activities and gang-related dangers.

Ben (Published March 2022)

This review highlights lessons in engaging vulnerable young parents, particularly when domestic abuse is a concern. The missed opportunities to support the mother and her child, 'Ben', led to tragic outcomes. The importance of a multi-agency child protection approach and identifying potential risks is also emphasised.

Emily and Jack (Published October 2020)

Following a tragic incident where a three-month-old baby girl, referred to as 'Emily', was killed by her mother, a serious case review was conducted by the Croydon Safeguarding Children Board. The review identified the need for improvements in local agency information sharing.

Vulnerable Adolescents (Published February 2019)

In the summer of 2017, three Croydon teenage boys known to social services lost their lives. The CSCP agreed to conduct a thematic review that would determine whether there were any patterns in the children’s experiences. The intention was to learn from the children’s experiences to inform future service provisions.