Child and adult protection Learning Reviews (and their legacy Significant Case Reviews) commissioned by Scotland's Child and Adult Protection Committees where a person died or was seriously harmed.
8 published reviews tracked6 child protection2 adult protection
This collection covers published reports located by the Index. National submitted-review counts include unpublished cases and are shown separately below.
Learning Review (child)Executive summaryCity of Edinburgh5 recommendations
Findings (verbatim excerpt)Learning Arising from the Review Process
This section of the Executive Summary examines each of the elements of the Terms of Reference and highlights any specific learning that arose in relation to each one.
A. Were child protection procedures and other multi-agency guidance/protocols, including infant bruising applied and were risk assessments sufficiently robust in order to effectively protect…
Recommendations (verbatim excerpt)These recommendations should be actioned alongside those from the Learning Review Report for Child E.
Recommendation 1
Getting it Right for Every Child (GIRFEC) is Scotland's consistent framework to ensure joined-up assessment and planning for children, even at the urgent end of the continuum. Therefore, Chief Officers should review the implementation of GIRFEC across all Children's Services in …
Findings (verbatim excerpt)Specific Practice and Organisational Learning and Suggested Strategies for Improvement
In accordance with Learning Review Guidance, we need to agree whether the following identified learning outcomes are unique to this case or have wider system implications.
Effective Practice
In October 2012 North Lanarkshire Council's quality assurance system was able to aggregate concerns from the care review…
Recommendations (verbatim excerpt)Improvement recommendation (Learning Issue 1)
It is recommended that Scottish Government should consider an amendment to planning regulations to ensure that any planning application for a new care home should include consultation with and approach by the local Integrated Joint Board (IJB) and NHS Board. Approval of any application should be dependent on a "developer contribution" to pay for local…
Findings (verbatim excerpt)Section 6 Conclusions
1. While the use of Adult Protection procedures in July 2017 was successful in facilitating David's discharge from hospital, the decision to conclude the investigations and remove the three brothers from the Adult Support and Protection framework was made a week after new allegations about the conduct of the POAs came to light. There is no reference to the new concerns in t…
Recommendations (verbatim excerpt)Five specific recommendations are offered for the Adult Protection Committee to consider:
1. Social work and Police Scotland should jointly offer an apology to the family of the McCulloch brothers for the failure of the August/September 2017 investigation to identify the risk of financial exploitation and for concluding the investigation in a way which left the brothers exposed to continuing har…
Learning Review (child)Executive summaryPerth and Kinross
Findings (verbatim excerpt)Practice and Organisational Learning – Child G
5.1 NHS Tayside Paediatric Medical and Nursing staff did not confidently follow the NHS Tayside Child Protection Policy for Children admitted to Hospital who are on the Child Protection Register (CPR).
There is an alert on NHS Tayside's Health database system that highlights a Child's registration status on the Child Protection Register (CPR) when t…
Learning Review (child)Recommendations logPerth and Kinross22 recommendations
Recommendations (verbatim excerpt)Child G
1. NHS Tayside should review their current wide range of child protection policies, procedures and guidance and where possible, rationalise them, to ensure that it is readily available, accessible and is understood by all staff across all NHS Tayside disciplines and services, including primary and acute services. Regular quality assurance exercises, including staff surveys and audit repo…
SCR (child, legacy)Full reportNorth LanarkshireSCIE Learning Together
Findings (verbatim excerpt)FINDING 1: Some key mechanisms for bringing the right people together to share information and make joint decisions are not working effectively. This results in some children not receiving the right service at the right time. (Management Systems)
SUMMARY
In the context of multiple overlapping changes over the evolution of GIRFEC policy and associated legislation, the fundamental purpose of the m…
SCR (child, legacy)Executive summaryHighlandSCIE Learning Together
Findings (verbatim excerpt)Finding 1
Are there sufficient resources available within the Family Team to provide assurance that risk to children and families is effectively identified and managed?
The Family Team has a pivotal role to play in a multi-agency response to safeguarding vulnerable children and families. The consistent availability of experienced, qualified staff is essential along with the accountability for cas…
Findings (verbatim excerpt)5.0 CONCLUSIONS
5.1 INFORMATION SHARING
5.1.1 There were several occasions over the years before and after the birth of Child R that more direct and timely intervention could have been taken both to protect the children and understand their experiences, and this is true of all agencies.
5.1.2 Significant information was held by Adult Mental Health services where Child R's mother was a long term …
Recommendations (verbatim excerpt)1. All staff who are Named Persons and Lead Professionals for children must be fully aware of the remit and limitations of their role and they must understand how to raise and share concerns appropriately and what actions to take when they have significant child protection concerns.
2. To support recommendation 1, the Highland Practice Model guidance and Child Protection guidelines must be updat…
Publication of a full report is a discretionary, case-by-case decision made by each area's Chief Officer Group; where a report is not published, only an undefined "learning" extract is required. The Care Inspectorate's own national analysis states plainly that it is "not always made aware when learning review reports are published." This registry covers only the published minority that this site has located and hand-verified against the live source document. It is not a complete record of every review that has taken place. The Index checks Child and Adult Protection Committee publications for additional reports.
These are the Care Inspectorate's own submitted-review and notification counts for Scotland as a whole, a different and larger denominator than the 8 individually published reviews tracked below, since most submitted reviews are never published. Source: Learning Reviews National Statistics.
Reviews by Type
Read the chart values
Indexed Scottish Learning Reviews by type · full collection
Review type
Reviews
Learning Review (child)
3
Learning Review (adult)
2
Significant Case Review (child, legacy)
3
Key Insights
8 published Learning Reviews tracked across 4 committee areas.
Reviews are commissioned under the National guidance for child protection committees undertaking learning reviews (2021) or the equivalent adult support and protection guidance (2022); older cases follow the pre-2021 Significant Case Review framework.
Some methodologies (e.g. SCIE Learning Together) produce Findings and Questions for the Committee rather than formal numbered recommendations: a review having no recorded recommendations is expected, not a data gap.