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Learning reviews

What are Learning Reviews?

Learning reviews are undertaken when there has been a death or a serious injury has occurred to an adult or child caused by abuse or neglect.

Prior to the introduction of Working Together to Safeguard Children 2018, CSPRs were known as Serious Case Reviews (SCRs), but SCRs are no longer a part of current practice. 

Child Safeguarding Practice Reviews (CSPR)

All partner agencies have a responsibility to inform the Telford and Wrekin Safeguarding Partnership of any serious incident which they think should be considered for either a national or local CSPR. The cases are discussed at the CSPR Panel, and the Rapid Review Process instigated.

There are two types of review:

  • local reviews: where safeguarding partners consider a case raises issues of importance within their area; and
  • national reviews: where the CSPR Panel consider a case that raises issues which are complex or of national importance. 

Published reviews

March 2024

CSPR 14 and 15 - Neglect Thematic Review

CSPR 18 - Neglect Revisted


May 2024

CSPR 10 - Non-accidental Injuries



Download our Rapid Review Referral Form

Rethinking 'Did Not Attend' - take a look at the short video below, created by Nottingham City Council, NHS Nottingham City ICS and the Nottingham City Safeguarding Children Board which highlights the importantance of considering the individuals circumstances as to why an appiontment may have been missed. Although it features a child the same message is appropriate for adults who may have care and support needs or in a domestically abusive relationship and rely on others for support.


Safeguarding Adult Reviews (SAR)

A Safeguarding Adult Review (SAR) is a statutory duty of the Telford and Wrekin Safeguarding Partnership (TWSP) under Section 44 of the Care Act 2014, and must be undertaken when:

  • An adult or adults with care and support needs die as a result of abuse or neglect and there is a concern that partnership agencies could have worked more effectively to protect the adult(s); OR

  • An adult or adults with care and support needs has not died, but the TWSP knows or suspects that the adult has experienced serious abuse or neglect with a concern that partnership agencies could have worked more effectively to protect the adult.

SARs are not enquiries into how an adult died and who is responsible. That is a matter for the Coroner or criminal courts.


Who can refer a case for a SAR, and how?

Anyone can refer a case for a SAR, where is fits the above criteria, by making contact with Family Connect to raise your concern:

  • Family Connect (Option 3)
    Telephone: 01952 385385 (when prompted please select option 3)
    Monday to Friday from 9am - 5pm
  • Emergency Duty team
    Telephone: 01952 676500
    Monday to Sunday after 5pm


What is the purpose of a SAR?

The purpose of a SAR is to:

  • Learn from cases where agencies could have worked together more effectively;

  • Consider whether serious harm could or could not have been predicted or prevented, and develop learning that enables the partnership to improve its services, and prevent abuse and neglect in the future;

  • Identify any issues in multi or single agency policies and procedures;

  • Agree on how the learning will be acted on, and what is expected to change; and

  • Publish a summary report, which is available to the public.

SARs help to improve services, multi-agency working, share best practice and lessons learnt, and to better safeguard adults from risk of abuse and neglect


What happens when I refer a case for a SAR?

  • Information will be requested from agencies known to be or have been involved in the case, as part of the initial scoping exercise;

  •  The SAR Review Panel will meet to discuss the referral, and consider whether the case meets the SAR criteria;

  • The SAR Review Panel will make a recommendation to the TWSP Safeguarding Adults Board;

  • Where the criteria is met, the individual or organisation that requested the SAR will be notified and engage in the proceedings of the review. Families will also be invited to contribute to the review; and

  • If the criteria is not met, the individual or organisation will be notified, and the SAR Review Panel will ensure that any learning from the scoping exercise is retained by TWSP for future reference.


The SAR library

This is a library that holds all published SARs in one place and allows practitioners to search all SARs that have been published nationally. You can access the national SAR library here.


Download our published SARs


Domestic Homicide Reviews (DHRs)

The purpose of a Domestic Homicide Review (DHR) is to establish the lessons that can be learned from the homicide, apply these lessons to inform local and national policies and procedures, as appropriate, and to highlight evidence of best practice. The cases are referred to the Community Safety Partnership (CSP) - known locally as the Safer Telford and Wrekin Partnership - and although the progress of the review is managed through the CSP, learning dissemination is also shared with our Domestic Abuse Local Partnership Board.

Further information on Domestic Homicide Reviews, including the DHR referral form, can be found on the Safer Telford and Wrekin Partnership website.

Download our DHR Referral Form