Learning from Practice
This section holds links to Domestic Homicide Reviews, Child Serious Case Reviews, Local Child Safeguarding Practice Reviews, Safeguarding Adult Reviews and other Learning Reviews
The Boards have a duty under Working Together and the Care Act to “learn from practice” where something has happened which they feel show the partners of the Board have not worked together to effectively safeguard people which they need to learn from and improve practice so that similar issues do not occur in the future.
Alternatively the Boards may feel they need to learn from incidents where the partners have worked particularly well together to ensure continuous improvement.
There are legal instructions as to when and how a Local Child Safeguarding Practice Review or cases relating to children and young people and a Safeguarding Adults Review (SAR) for adults at risk should be carried out.
Where it is decided by that the criteria are not met, the subgroups in charge of screening the cases will usually prescribe another course of action to ensure any learning is not lost. These might be a single agency review, critical incident review or other multi-agency review.
The Boards have a duty to ensure that there is continual learning and improving in safeguarding through single agency and multi-agency case audits, case reviews and (when necessary) Safeguarding Reviews.
The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children.
Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and policymakers. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.
Reviews should seek to prevent or reduce the risk of recurrence of similar
incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage.
(See documents on right for further details)
A Safeguarding Adults Review is carried out when an adult at risk dies or has experienced serious neglect or abuse, and there is concern that agencies could have worked more effectively to protect the adult.
A Safeguarding Adults Review is a multi-agency learning process. It aims to:
- identify and promote good practice
- encourage effective learning
- make recommendations for future practice so that deaths or serious harm can be prevented from happening again
Domestic Homicide Reviews (DHRs) were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Victims Act (2004).
This provision came into force on 13 April 2011. A DHR is a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by:
- A person to whom they were related or with whom they had been in an intimate personal relationship
- A member of the same household as themselves.
The purpose of a DHR is to:
- establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
- identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
- apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate;
- prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity;
- contribute to a better understanding of the nature of domestic violence and abuse; and
- highlight good practice.