Case Review Notification Form

Please send the completed form securely to:

Email:

By post:Bolton Safeguarding Children Board

3rd Floor

Paderborn House

Bolton BL1 1UA

Enquiries:01204 337479

REFERRER DETAILS

NAME / AGENCY & DESIGNATION / CONTACT DETAILS – Address, telephone number and e-mail address

Date of referral:

Cases which meet one or more of the following criteria should be referred for consideration to the Learning and Improvement group:-

  1. A child has died (including death by suicide) and abuse or neglect are known or suspected to be a factor in the death
  2. A child has sustained a potentially life-threatening injury through abuse or neglect, serious sexual abuse, or sustained serious and permanent impairment of health or development through abuse or neglect
  3. A child has attempted suicide/self-harm to the point where there is a likelihood they could have died or have suffered serious long-term emotional or physical injuries as a consequence
  4. A parent/carer has been murdered and they have caring responsibilities for a child under 18
  5. A child has committed a serious physical or sexual assault
  6. A child has been a victim of a serious physical or sexual assault, including organised sexual abuse, grooming or trafficking
  7. A child subject to a Child Protection Plan or Looked After has been abducted, i.e. taken abroad, taken from contact etc and there is cause for concern as to the way services have worked together to safeguard the child
  8. A child has been abused or neglected within an institutional setting, e.g. school, nursery, Young Offenders Institution, children’s home, foster care etc
  9. A coroner’s inquest has highlighted new issues with the child’s death that warrant further consideration
  10. An emerging pattern or theme of abuse or neglect in a particular age group

CHILDS DETAILS – this relates to the child who is the subject of the serious incident

Name of Child
Date of Birth
Date of Death or Serious Incident
Home address
Gender
Ethnic Origin
Faith/Religion
Disability/Special Education Needs (SEN)
Level of involvement at time of Incident:-
(please select one option) /
  • Single Agency
  • Multi-agency Early Help
  • Child in Need (S17)
  • Child Protection Plan
  • Looked After Child

Location of incident if different from Home Address
Are there any adult safeguarding concerns and have these been shared with and with whom?

FAMILY DETAILS

Name / Relationship to child / Date of Birth / Legal status / Ethnic Origin / Please indicate of the level of involvement with the child to:-
  • Single Agency
  • Multi-agency Early Help
  • Child in Need (S17)
  • Child Protection Plan
  • Looked After Child

3. Agencies known to be involved with the case (please tick)
Childrens Services / Probation
Police / YOT
Health Services / Housing
Education Welfare Service / CAMHS
Others (please specify)
4. Reason for notification (more than one box may be ticked)
A child has died (including death by suicide) and abuse or neglect are known or suspected to be a factor in the death
A child has sustained a potentially life-threatening injury through abuse or neglect, serious sexual abuse, self-harm or attempted suicide or sustained serious and permanent impairment of health or development through abuse or neglect
A parent/carer has been murdered and they have caring responsibilities for a child under 18
A child has committed a serious physical or sexual assault
A child has been a victim of a serious physical or sexual assault, including organised sexual abuse, grooming or trafficking
A child subject to a Child Protection Plan or Looked After has been abducted, i.e. taken abroad, taken from contact etc and there is cause for concern as to the way services have worked together to safeguard the child
A child has been abused or neglected within an institutional setting, e.g. school, nursery, Young Offenders Institution, children’s home, foster care etc
A coroner’s inquest has highlighted new issues with the child’s death that warrant further consideration
A child death where the Sudden Unexpected Death of a Child (SUDC) process identifies a concern either relating to the cause of death or the quality of multi-agency working to safeguard the child
A child death reviewed by Bolton, Salford and Wigan Child Death Overview Panel that identifies a concern either relating to the cause of death or the quality of multi-agency working to safeguard the child
An agency, through the course of any internal child death review process identifies a concern either relating to the factors contributing to a child’s death or the quality of multi-agency working to safeguard the child
An emerging pattern or theme of abuse or neglect in a particular age group is identified
5. Characteristics of Case (Please tick all applicable factors)
Domestic abuse / Alcohol abuse / Drug abuse
Parental mental health / Fabricated illness / Shaken baby syndrome
Sexual abuse / Parent in care / More than one child abused
Child of teenage pregnancy / Parent is care leaver / Serious illness
Emotional abuse / Recent neglect / Long standing neglect
Physical abuse / Non Accidental Injury
6. Case Outline
Please give a summary of the circumstances of this case and explain why you feel this case should be considered for a Serious Case Review, Single Agency Review or Partnership Review:

For Office Use:

This section will be used to record BSCB’s screening decision of BSCB

INITIAL CASE SCREENING OUTCOME
Serious Case Review criteria highly likely to be met
Serious Case Review criteria possibly met
Serious Case Review criteria not met but possibility of further review
Serious Case Review criteria not met and no requirement for further action
CASE TRACKING INFORMATION
Date of Screening
Child identifier
Date form completed
Date submitted to BSCB Chair

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