Children’s safeguarding under scrutiny as two Serious Case Reviews published

The Tower Hamlets Local Safeguarding Children Board (LCSB) will publish two Serious Case Reviews tomorrow Thursday 28th February.

One concerns the death of a child in July 2016 (Child Elias) and the second (Baby Adam) examines the care of a child who was made the subject of a court order in May 2015.

Documents published in the last 12 months by the Tower Hamlets Local Safeguarding Children Board (LCSB) are available on their website give some insight into the reasons for the length of time taken for the LSCB to publish these reviews.

One has taken four years since the events in question, the other three years.

A Serious Case Review (SCR) is a locally conducted multi-agency review in circumstances where a child has been abused or neglected, resulting in serious harm or death and there is cause for concern as to the way in which the relevant authority or persons have worked together to safeguard the child. (Source: CPS)

Timeline of Events

(Detailed extracts from relevant LSCB documents can be found at the bottom of this page. )


  • May – Baby Adam made the subject of a court order.


  • July – Child Elias dies.


26th January

  • Two ongoing Serious Case Reviews progressing (Baby Adam and Child Elias).

21st June

  • Draft reports ‘imminent’ on the two current SCRs

13th September

  • Two current SCRS at second draft overview stage

22nd November

  • Final drafts on two cases ready to be reviewed. Action plan to be circulated following drafts reports.


26th February

  • Draft reports of the four current SCRs are ‘in progress’ with aim of being published in early summer 2018.

Two other SCRs at fact-finding stages.

25th September

  • No references to SCRs in minutes of LSCB Development Session


28th February

  • Serious Case Reviews into the deaths of Child Elias and Baby Adam published.

In the case of Baby Adam, four years pass between events taking place and the SCR being made public. The report into the death of Child Elias is published three years after his death.

‘We need transparency’ – Khan

Cllr. Rabina Khan (Shadwell, Lib Dem)
Cllr. Rabina Khan (Shadwell, Lib Dem)

“After the Safeguarding Scandal over two years ago when Ofsted identified children were at risk of harm and the Labour social services chief resigned in disgrace, there is no excuse for these delays,” said Cllr. Rabina Khan (Liberal Democrat, Shadwell).

“We need transparency as to why these Serious Case Reviews have taken so long to be produced. How else can the public have any faith that vulnerable children in the care of Tower Hamlets Council are safe?”

Why the year-long gap?

All SCRs, because of their nature, take time to produce. What is interesting with the two SCRs published today is that on 21st June 2017 draft reports were ‘imminent’, by 13th September they had progressed to ‘second drafts’ to be reviewed and then six months pass before these second drafts become ‘in progress’ in February 2018.

At this point, the LSCB realises it may be criticised for the length of time the reviews have taken to be completed and suggests a ‘Communication Plan’ will be needed when the reports are published.

This makes it even more surprising that a full year then passes before the reports are published.

A possible contributory factor may be found on page 2 of the LCSB Operational Group minutes for Wednesday 22 November 2017. In Section 3 there is this note: “Chair informed the Ops Groups that disagreements within LBTH with regard to the status of SCR authors/reviewers resulted in a lengthy dispute about how they are categorised for tax purposes. This has been escalated to the Chief Executive.”

We have asked the Council for clarification as to if this disagreement about tax delayed the report’s publication, and if so for how long?

LW Comment

When Ofsted condemned Tower Hamlets Children’s Services as ‘inadequate’ in April 2017 the LCSB came in for severe criticism. But then few didn’t.

Who did we blame before Lutfur?

The Labour administration would love it if we all forgot what a train wreck they allowed to happen on their watch, especially when they could not blame it on Lutfur Rahman. Who was the official scapegoat before Mayor Lutfur? Bambi?

Things were so bad that the chief executive, the Director of Children’s Services and politicians (especially then Deputy Mayor Cllr. Rachel Saunders) were completely unaware of the failures that were occurring right under their noses until the Ofsted inspectors told them. You can read that Ofsted report here.

We mention this report because of a single paragraph that caught our eye at the time. Here it is on page 33.

“101. The LSCB website requires significant improvement, as much information is basic and it does not promote the work or function of the board to the wider community. This has long been recognised by the board, and progress has been too slow.’

During the last year that we have been visiting the LSCB website on a regular, sometimes three times a day, basis we know only too well how bad the website is. If the website was a cute cuddly animal (Bambi?) it would be taken to the vet to be euthanised as that would be the only kind thing to do.

Digital media can be incredibly useful, but it can also be used by organisations as an excuse for pretending to be open and transparent while they are anything but. The LSCB site is an example of this approach.

There is lots and lots and lots and lots of text on the site but very little information. Most of the information that is there can be found in the documents section. At the bottom you can find five documents which are the LSCB Operational Group Minutes for the last 12 months.

For anyone who wants to find out what the LSCB actually does these five documents are all there is. Minutes are published every four months. Apart from when they are not. The most recent is dated 18th June 2018. Eight months ago.

What has the LSCB done in those eight months? Only they know. Why has it taken so long to produce these SCRs? There may be a genuine and completely reasonable explanation but this is not apparent from any of the LSCB minutes we have read. Which is odd because the LSCB works on behalf of the residents of Tower Hamlets.

This level of digital opacity in such a fundamental area of a local council’s responsibilities is not acceptable and shows a clear disregard for the needs of borough residents. Because of the nature of the LSCB’s work no outsiders can attend its meetings. So information never escapes.

So when an SCR is published four years after the events it scrutinises, including a year-long gap when no progress is reported, it seems reasonable for residents to ask why did it take so long?

Maybe Ofsted will be able to tell us.

Detailed extracts from LSCB documents

Local Safeguarding Children Board Main Board Minutes

Date: 26 January 2017

3.Serious Case Review Update (standing item) – Judith Lewsey

Judith gave an update from the Case Review Group (CRG) meeting. There are 2 ongoing Serious Case Reviews (SCR) which are progressing, the SCR panel met twice. These relate to two infants one of whom died and the other seriously injured. Staff interviews will be taking place shortly.

[LW Comment: It is presumed that these relate to Child Elias and Baby Adam.]

Local Safeguarding Children Board Operational Group

Date: Wednesday 21st June 2017

Serious Case Review Update (standing item)Judith Lewsey gave details of the two current SCRs: Draft reports imminent; practitioner events to follow, possibly early September. Case Review Group to consider LSCB response.

Local Safeguarding Children Board Operational Group Chair: Steve Ashley

Date: Wednesday 13 September 2017

Serious Case Review UpdateTwo on-going SCRs are at second draft overview report stage

Tower Hamlets Safeguarding Children Board Operational Group Chair: Steve Ashley

Date: Wednesday 22 November 2017

Serious Case Review Update (standing item)Most recent SCR Panel meetings for both AU and RAM were cancelled; however, final drafts are ready to be reviewed. NA and JBK reviews are both moving along. Action plan to be circulated following draft reports.

[LW Comment: It is not clear who AU and RAM refer to, NA and JBK may refer to Child Elias and Baby Adam.]

Tower Hamlets Safeguarding Children Board Operational Group Chair: Steve Ashley

Date: Monday 26th February 2018

Serious Case Review Update (standing item) – Monawara Bakht There are currently four ongoing Serious Case Reviews. Two are in the latter stages and the draft reports are in progress and will hopefully be presented to the next Operational Group on 18th June 2018 with the reports being published in early Summer [2018?]. Steve Ashley said that a Communications Plan will be needed for publishing both reports as there is likely to be criticism due to the length of time the reviews have taken to be completed.[LW Comment: Draft reports are presumed to be those relating to Child Elias and Baby Adam.] 3.1 ACTION: Steve Ashley to update the Operational Board and Debbie Jones about the progress of the SCR reports and the need for a Communications Plan.

The other two Serious Case Reviews are at the fact finding stages and the timeline for completion is Summer.

[LW Comment: Unclear which cases ’other two Serious Case Reviews’ refer to.]

Local Safeguarding Children Board Development Session Notes

Date: 25th September 2018

No reference to any Serious Case Reviews, this may be because this was a LSCB Development Session, not an Operational Group meeting.

Tower Hamlets Safeguarding Children Board Media Event

Date: Thursday 28th February 2019

Serious Case Reviews into the deaths of Child Elias and Baby Adam published.

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