Serious Case Reviews

Learning from National Serious Case Reviews

For a list of all National Serious Case Review Publications, please visit the NSPCC National repository of case reviews. The NSPCC thematic briefings highlight the learning from case reviews that are conducted when a child dies or is seriously injured and abuse or neglect are suspected. Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews.


Serious Case Review Harry – published 29th November 2019

Today North Tyneside Safeguarding Children Board (NTSCB) is publishing a Serious Case Review (SCR) that was commissioned by the Board in October 2018. The SCR is about Harry, a 14 year old who sadly took his own life in the summer of 2018. Harry moved to the UK from Hungary in 2016 with his mother and younger brother. He was described as a quiet, polite and thoughtful young person. He attended school regularly, where he settled well and made friends. His death came as a shock to all who knew him and a tragedy for his family and friends.

The purpose of a SCR is to undertake a rigorous analysis of the contact Harry and his family had with services to try and understand what happened and why. The organisations responsible for services can then identify any lessons to be learnt which could be used to improve services and reduce any future risk of harm to children and young people.

The report, carried out by an independent reviewer, does not identify any single factor that could have prevented Harry taking his own life. It demonstrates that the schools he and his brother attended and other services who became involved did their best to support them and their mother. 

The review identifies that statutory and voluntary agencies will need to continue to improve how they recognise and share some of the key indicators of when children and their families are struggling and take into account the impact of moving to a new country. Also, to strengthen our understanding of how parental mental ill health can place significant pressures on their children.

The Board and its partners are resolved to act on the learning and have commissioned a detailed action plan which identifies achievable and measurable actions to act on the learning identified in the Review.

This work will be reviewed by the new Multi – Agency Safeguarding Arrangements, which came into operation from 29 September 2019. These new arrangements replace the role of Local Safeguarding Children Boards, and are known as the North Tyneside Safeguarding Children Partnership.

Richard Burrows Chair of the NTSCB said “Harry’s death was a tragedy for his family, and I would like to offer my sincere condolences to them.  We know that nationally the numbers of young people who take their own lives is higher than it should be. The review offers partner organisations a real opportunity to strengthen the local response to children in need and who may need help. It can be difficult to identify when a person is thinking about suicide, and the learning from this review will help strengthen the local response”.

If you are worried about someone you know, the following services can offer support:

In North Tyneside young people aged 11-18 can access for support on any issues or concerns they may have. Kooth provides an anonymous and confidential service using a mix of counselling, support and advice on a drop in, out of hours and structured sessions.

You can access a copy of the SCR report here

Richard Burrows
Independent Chair

North Tyneside Safeguarding Children Board


Serious Case Review – Child T

North Tyneside Safeguarding Children Board (NTSCB) commissioned a Serious Case Review into the case of Child T to identify any significant learning, so as to be assured that all partner agencies can continue to learn from joint working practice and that this supports continuous improvement. A copy of the case briefing note which gives the background information to the case can be found here and a copy of the executive summary of the case can be found here.