REFERRAL FORM FOR A REVIEW OF A CASE BY THE SUTTON LSCB CASE REVIEW SUBGROUP
1. / NOTIFIER DETAILS
Notifier’s Name: / Notifier’s Role:
Notifier’s Agency: /

Tel Number:

Date of Notification: /

Linked Cases:

2. / CASE OUTLINE: Please include any critical incident, status of child i.e. Subject of a Child Protection Plan, Looked After Child, disability, etc. Also are there any adult safeguarding concerns and have these been shared with the local authority Adults Social care? (If so who is the key contact?)
3. / CHILD DETAILS
Child’s Last Name/s: / Child’s Date of Birth:
Child’s Forename/s: / Age: [If DOB not known]
Other Names Used: / Date of Death [if applicable] or SI date
Child’s Home Address: / Gender: [Please delete] / Male / Female
Mother’s Name
Mother’s DOB
Mother’s Address
Father’s Name
Father’s DOB
Father’s Address
Sibling’s Name(s)
Sibling’s DOB(s)
Ethnicity: Please specify
4. / REASONS FOR REQUESTING A REVIEW/REFERRAL: Please select all appropriate options:
  • Fits criteria of Notifiable Incident/Serious Case Review
[Please specify appropriate criteria from Working Together to Safeguard Children, Chapter 4]
  • Provides opportunity for learning lessons from Multi-Agency work in this case
[Highlight if either good or poor practice]
  • Case does not reach threshold for a Notifiable Incident/Serious Case Review but will provide the opportunity for learning lessons
  • Other:
[Please specify]
5. / PARTICULAR CONSIDERATIONS: Please specify any considerations for this case, for example; Is there media interest? Are there criminal proceedings? Is the case linked to a complex abuse case?
6. DECISION REQUESTED/REQUIRED BY THE CASE REVIEW GROUP
  • Referral to LSCB forconsideration forSerious Case Review
  • Individual Management Review (single agency)
  • Lessons Learned Review
  • Other review [please specify]
Multi-Agency Case Review
Multi Agency Case File Audit
Multi-Agency Audit
Single Agency Review (IMR)
Single Agency Audit
Peer Review
Alternative Review[please specify]
  • Signposted to other agency [please specify]
  • No further action
  • Other [Please specify]
Has the referrer been informed of the decision [and date]?
If not, why not?
7. SIGN OFF BY LSCB CASE REVIEW CHAIR
Those present who agreed to this decision (list names):
Signed______
Date ______
The completed referral form should be completed and sent by secure email to: Sutton LSCB Administrator
Secure Email:
Tel: 020 8770 5706