Serious Case Reviews and Learning and Improvement Reviews

There are different types of reviews a LSCB undertakes in order to further learning and improve safeguarding in the borough.

Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect is known or suspected to be a factor. They are carried out by Local Safeguarding Children Boards so that lessons can be learned.

A Learning and Improvement Review may be undertaken when there has been a child protection incident but the criteria or threshold for a Serious Case Review has not been met however it is believed that the case does provide lessons of broader relevance.

For more information please see the document below.

Lambeth Serious Case Reviews

The most recent published Serious Case Review (SCR) was into the death of Child J (LSCB Publication 7th March 2016). Please find the SCR report and the Briefing slides to cascade the learning from this tragic death below.

Prior to the SCR into the death of Child J, there were Child H and I. Please find their reports below.


Learning and Improvement Reviews

Aravindan Balakrishnan - Lambeth Response

Following the trial and sentencing of Mr Aravindan Balakrishnan, Lambeth Council and the Lambeth Safeguarding Board are in a position to publish two reports on the case. Lambeth council and the Lambeth Safeguarding Children Board welcomed the lengthy sentence handed down by Judge Deborah Taylor. A council spokesman said: "We are appalled by the abuse Aravindan Balakrishnan committed against members of his own household. Since 2013 when Balakrishnan was arrested we have assisted the police in building their prosecution in what has proved to be a very complex case". "At the same time both Lambeth council and the Lambeth Safeguarding Children Board (LSCB) have been reviewing our records. The council review examined the authority's involvement with the adults in the home before 2013. It found there were no opportunities missed to uncover the offending taking place. Independent scrutiny of the council review has been provided by the Chair of Lambeth Safeguarding Adults Board. The second report, by the LSCB, also found there was no indication of any opportunity missed to identify anything untoward occurring. It must be noted that the court found Balakrishnan was an extremely controlling presence in an unconventional household and took steps to conceal his offending. The youngest victim of his abuse was found to have been born outside the borough and following her birth was in effect hidden from service providers."

Given the serious nature of the offending the LSCB has referred its findings to the National Serious Case Review Board for scrutiny. The LSCB will also hold a review to assess if such a circumstance could arise today given the changes in legislation and systems.

Please see below the report from the Hidden Child Learning Review which was undertaken in September 2016 and approved by the LSCB in July 2017; it provided invaluable learning.