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Herefordshire Safeguarding Children Partnership Publish Serious Case Review Louise

Date: Monday, 28th Nov 2022 | Category: HSCP

Monday 28 November 2022

On Monday 28 November 2022, Herefordshire Safeguarding Children Partnership published the Executive Summary for Serious Case Review Louise. The Serious Case Review was commissioned by its predecessor body Herefordshire Safeguarding Children Board, in respect of the circumstances leading to the child Louise* sustaining serious life-changing injuries.

Serious Case Review Louise was undertaken in accordance with the guidance in Working Together 2015, which is the statutory guidance that was in place at the time Louise was harmed. The guidance relates to inter-agency working to safeguard and promote the welfare of children.

Under the statutory guidance in place at the time, Local Safeguarding Children Boards were required to undertake a Serious Case Review when a child died or was seriously injured and abuse or neglect was known or suspected.

The purpose of a Serious Case Review is to establish whether there are any lessons to be learned about the way in which local organisations worked together to safeguard and promote the welfare of children, to make recommendations in response to these findings and, as a result, to improve inter-agency working and the safeguarding of children and young people.

The Serious Case Review was carried out by Jonathan Chapman (Independent Author). It looked into the complex circumstances around Louise’s life and events leading up to the incident, to understand whether there is any learning for the local multi-agency safeguarding children system so we can make changes and improve practice within local services.

There had been significant previous agency involvement with Louise’s family and other prominent adults. A criminal investigation was undertaken and as a result a 32yr old man was convicted of Section 18 GBH and sentenced to 10years.

The three statutory Safeguarding Children Partners of the Herefordshire Safeguarding Children Partnership are Herefordshire Council, West Mercia Police and NHS Herefordshire and Worcestershire, (formerly NHS Herefordshire and Worcestershire Clinical Commissioning Group). The findings and recommendations from the review have been endorsed by Herefordshire Safeguarding Children Partnership.

Following completion of the review, the recommendations were incorporated into the existing workstreams and an action plan was implemented. Most recommendations are completed and any remaining actions are in progress. The action plan is monitored through the Joint Case Review Group which consists of senior representatives from statutory and other agencies from across Herefordshire.

Herefordshire Safeguarding Children Partnership said:

“The partnership is fully committed to keeping children and young people safe and improvements are already underway in our local services for children based on the recommendations within the Serious Case Review Louise report.

We are working together as a partnership and have responded to the lessons learnt from this review and others. We have considered the findings of the review carefully and are working together to ensure that practices are improved to achieve effective safeguarding and improved outcomes for children.”

Link to the report – Serious Case Review Louise, Executive Summary report


Please note:

Louise is not the real name of the child involved, which has been changed to protect their identity.

At the request of the Herefordshire Safeguarding Children Partnership all media enquiries regarding this Serious Case Review will be co-ordinated by Herefordshire Council and should be emailed to