The Safeguarding Practice Review Process
SPRG Purpose & Accountability
Safeguarding Practice Reviews (SPRs) are commissioned when a child dies or is seriously harmed, to identify how safeguarding practices can be strengthened. While the learning is rooted in local experience, it often has wider significance for professionals working with children and families, as well as for government and policy development. Understanding systemic issues—and identifying where practice or policy needs to adapt—is vital to creating a responsive, learning-led safeguarding system.
This work is led by the Review Group, which reports to the CSCP Executive Group through quarterly updates and Review Summaries.
Roles & Responsibilities
The Safeguarding Practice Review Group is tasked to:
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Identify serious child safeguarding incidents where a review would raise issues of importance in Croydon
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Commission an oversee reviews for those cases they consider it appropriate
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Ensure that action plans are drawn up in response to reviews, and that reviews are diligently followed to enhance processes and improve outcomes for children and young people.
Each SPRG member is tasked to:
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Take responsibility for the timely completion of the Rapid Review Information Request/IMRs/other documents required by the review coordinator. The forms may be completed by a relevant professional from their organisation, but the SPRG member is responsible for making contact with that professional as well as the quality and standard of the report.
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Liaising with the professionals from their organisation, who had contact with the child or family subject to the review, to ensure feedback about the purpose and outcomes of any review.
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Liaising with relevant professionals within their organisation, to determine whether they should attend SPRG Panels or other meetings (agreement from the Chair of these meetings will need to be sought by the coordinator)
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Informing their organisation’s press office and ensuring any communication about publication of any review is shared with their organisation.
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Prepare for all meetings by reading papers in advance and, by sending papers or reports in accordance with deadlines set by the coordinators. Attend SPRG/RR meetings or ensure a proxy of similar seniority attends in their place.
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Follow up actions arising from meetings to be addressed between meetings and in accordance with deadlines set by coordinators.
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Be involved in safeguarding learning and practice improvement,
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Take responsibility to influence their own agency/service safeguarding learning approach and implementation
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To report on the sharing of/impact of learning in their organisation
Membership & Quoracy
Membership will be formed of representatives of the three statutory safeguarding partners plus representation from other relevant agencies as follows:
Rotating Chair from CSC/Police/Health
Rotating Deputy Chair from CSC/Police/Health
Independent Scrutineer
CSCP Business Team
- CSCP Project Officer
- Administrator
CAMHS / South London and Maudsley (SLAM)
- Associate Director Safeguarding Lead
Croydon Council: Children, Young People & Education
- Head of Service Early Help & Children's Social Care
- QA/Performance Improvement Manager
- Youth Justice Service
- Director of Education
- Service Manager Early Years/PAIRS
Croydon Health Services (CHS)
- Named Nurse
Croydon Integrated Care Board (ICB)
- Designated Doctor Child Protection
- Designated Nurse Safeguarding Children
Croydon Council: Housing Safeguarding
- Safeguarding lead (post currently vacant)
Croydon Council: Public Health
- Public Health Principle
Metropolitan Police
- Detective Inspector
Quoracy is achieved by the attendance of: Croydon Children’s Social Care, Croydon Health (ICB), & the Police.
Frequency & Standing Items
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Frequency - The Safeguarding Practice Review Group will meet six times a year / bi-monthly.
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Standing Items include:
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Summary of Reviews
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Partnership updates
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Confirmation of previous minutes & actions.
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The Meeting Schedule (circulated with papers)
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The Chair is rotated, agreed in advance as per the Meeting Schedule
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These terms of reference should be updated every 2 years.
Review Oversight
The Review Group has oversight of:
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Stage 3 and above Escalations
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Case of Concerns (CoC)
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Rapid Reviews (RR)
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Safeguarding Practice Reviews (SPR)
The L&D Project Officer produces a bi-monthly report which summarises all reviews, the current progress as well as provides data to support greater understanding of the themes and features of safeguarding reviews. This oversight will influence the training offered by the CSCP.
The Review Group will agree the methodology to be used for each review; this decision may be influenced by:
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Known areas of improvement needed, including where those improvements have been previously identified.
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Re-occurring themes in safeguarding and promotion of the welfare of children.
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Concerns regarding effectiveness of agencies working together and associated procedures.
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Concern about the actions of a single agency and relevant procedures.
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Where there has been no agency involvement, and this gives safeguarding partners cause for concern.
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Where more than one local authority, police area, or ICB is involved, particularly where families have moved around.
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Recommendations from the National Child Safeguarding Practice Review Panel to undertake a review.
The CSCP conduct statutory and non-statutory reviews depending on the severity of harm and the likelihood of eliciting new learning to support better practice and outcomes for children.
Escalation Policy
The Escalation Policy is designed to help professionals who encounter disagreements about a course of action. It provides a framework for managing necessary conversations and escalating unresolved issues.
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You can find the full policy here: CSCP Escalation and Resolution Policy
The CSCP tracks all escalations that reach Stage 3. Whether the matter is resolved at this stage or not, it is essential that a copy of the escalation is sent to CSCP@croydon.gov.uk.
Review Types
This section outlines the steps for managing a Case of Concern, including how agencies can initiate the process by completing the relevant referral form and the potential actions that follow. Additionally, this section covers the procedures for SINs, Rapid Reviews (RRs), and SPRs, providing guidance for professionals involved in child safeguarding reviews.
Case of Concern (COC)
A Case of Concern is identified when a case does not meet the threshold for a Significant Incident Notification (SIN) or a Safeguarding Practice Review (SPR) but still presents valuable opportunities for multi-agency learning. These cases typically involve near-miss safeguarding incidents where serious practice issues are identified, though the matter is not considered time-critical.
The Review Group will assess each COC and decide the most appropriate method for extracting learning—often through a short, focused review or discussion.
How to submit a Case of Concern:
Download the Case of Concern report form, any agency can complete the form and submit it via email to: CSCP@croydon.gov.uk
Upon receipt, the form will be reviewed by the CSCP Business Manager, who may consult with partner agencies and the Independent Scrutineer. Based on the review, one of the following actions will be taken:
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Advice offered on how the matter should be addressed outside of the CSCP Review Process, or
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Scheduled for discussion at the next suitable subgroup meeting.
If accepted as a CoC, the Review Group will:
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Determine the most effective method to capture learning (e.g., case file review, multi-agency discussion, appreciative inquiry, or policy review)
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Identify relevant agencies to be involved
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Share findings and learning outcomes with the SPRG and the CSCP Learning Group
This process helps to ensure that even lower-threshold cases contribute to continuous learning and improvement across the safeguarding system.
Serious Incident Notification (SIN)
A SIN is a statutory duty on the local authority when certain criteria are met:
16C (1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) states:
Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if:
(a) the child dies or is seriously harmed in the local authority's area
(b) while normally resident in the local authority's area, the child dies or is seriously harmed outside England
The death of a Care leavers under the age of 25 must also be notified, this notification does not automatically trigger a Rapid Review and may require liaison with the Croydon Adult Safeguarding Board (CSAB). Though the responsibility to notify rests on the local authority, it is for all three safeguarding partners to agree which incidents should be notified in their local area.
SINs should be notified to the National Panel within 5 days of the LA becoming aware of the incident that led to the child death or serious harm.
Rapid Review (RR)
If a SIN is reported for a child under 18, there must be a Rapid Review within 15 working days. A SIN always results in Rapid Review.
The purpose of the Rapid Review is to:
a) gather the facts about the case, as far as they can be readily established
b) discuss whether any immediate action is needed to ensure children’s safety and share any learning appropriately
c) consider the potential for identifying improvements to safeguard and promote the welfare of children
d) decide what steps they should take next, including whether to undertake a child safeguarding practice review (SPR)
Even if the criteria for a SPR are met, commissioning one is not mandatory. The Rapid Review Process is coordinated by the CSCP Business Team. Professionals are expected to complete the required template within the specified timescales, attend the Rapid Review meeting, and ensure the learning is shared with their respective agencies.
Local Safeguarding Children Practice Review (LSCPR)
LSCPRs are about promoting and sharing information about improvements, both within the area and potentially beyond, so the safeguarding partners must publish the report, unless they consider it inappropriate to do so.
The CSCP Business Team will co-ordinate the SPR process. Professionals will be required to complete relevant templates, attend panel meetings specific to the review and share the learning with their agencies.