Statutory reviews and One Panel

Statutory reviews

The purpose of a statutory review is to learn lessons from certain serious incidents relating to safeguarding to improve future practice. In Waltham Forest, we take a Think Family and systems approach to learning that happens through our monthly ‘One Panel’.

One Panel

The One Panel is made up of senior officers from different agencies such as health, children’s social care, adults’ social care, community safety and the police. Responsibility has been given to the One Panel by the Safeguarding Adults Board, Waltham Forest Safeguarding Children Board and SafetyNet (our Community Safety Partnership) to consider whether referrals made for safeguarding adult reviews (SAR), child safeguarding practice reviews (CSPR) and domestic homicide reviews (DHR) meet the relevant criteria for a statutory review and / or whether there is any other learning that can be taken forward. The panel discusses the referrals and makes recommendations to the relevant board. A final decision is then made (by the appropriate board / chair) about what type of review will take place.

One Panel referral form (Word)

The most recently published Waltham Forest SARs, CSPRs and DHRs can be found below and will be available for one year from the date of publishing. Should you wish to access any historical statutory reviews, please contact the Strategic Partnerships Team

Child safeguarding practice review for Kubus

Under Working Together to Safeguard Children 2018, local safeguarding partners are required to commission and oversee the review of appropriate serious child safeguarding cases which, in their view, raise issues of importance in relation to their area.

Serious child safeguarding cases are those in which:

abuse or neglect of a child is known or suspected and
the child has died or been seriously harmed

The purpose of reviews of serious child safeguarding cases, at both local and national levels, is to identify improvements to be made to safeguard and promote the welfare of children.

This child safeguarding practice review (CSPR) explores a number of identified impacting factors; Covid-19, pregnancy (antenatal, peri and post-natal), housing, domestic abuse, cultural competence, fathers and documentation.

Kubus was a 15-week-old baby boy who died while sleeping on his stomach on an inflatable mattress with his mother. As per her wishes, he is called Kubus in the review, which explores the services provided to him and his family during his mother’s pregnancy and his short life, in which domestic abuse was a significant feature. The cause of death was recorded as a sudden unexpected death in infancy (SUDI).

Safeguarding adult reviews

The Care Act requires the Safeguarding Adult Board (SAB) to undertake a Safeguarding Adult Review (SAR) when an adult in its area with care and support needs

dies of abuse or neglect, whether known or suspected or the adult has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect and
there is concern that partner agencies could have worked more effectively to protect the adult.

The SARs below have sought to understand why things happened in the way that they did, and what each individual's experiences tell us about how our systems work.

Jodie

18 November 2024

Jodie’s death occurred within a tragic and out of the ordinary set of circumstances. She was a white woman in her early fifties who lived with her mother, with whom she was very close. They had minimal contact with the outside world, including professionals. The review findings emphasize the importance of professional curiosity to ensure comprehensive safeguarding efforts, enhanced communication between agencies, and a 'Think Family' approach that considers all household members.

Ivan

13 March 2024

Ivan was a single 69-year-old white British man who loved the outdoors. He was found deceased in Epping Forest in March 2023 after a brief period of being missing. This review draws out learning relating to how agencies worked together whilst providing care and support under the deprivation of liberty safeguards.

Harry

4 January 2023

Harry, a 68 year old white British man died in a house fire at his home on 25 January 2021. His death was due to inhalation of smoke and combustion products and burns sustained during an accidental fire, the cause of which was the ignition of a towel which had fallen on a fan heater.

This SAR has sought to understand why things happened in the way that they did, and what Harry’s experiences tell us about how systems work.