Reviews and reports

Safeguarding Adult Reviews (SARs)

The Care Act states that a review must be arranged by the SAB when an adult in the area dies as a result of abuse or neglect (whether known or suspected), and there is concern that partner agencies could have worked more effectively to protect the adult.

A review must also be arranged if the SAB knows or suspects that an adult has not died, but has experienced serious abuse or neglect.

We report on safeguarding adult reviews (previously called serious case reviews) in our SAB annual report. Where we can, and with the consent of family members, we will also make them available here.

SAR Report Mrs X March 2016

SAR Report Ms K Jan 2017

SAR Report P March 2018

SAR Report Mr A February 2019

SAR Report Mr N February 2019

Domestic Abuse and Adults at Risk 2019 (Thematic SAR Report)

SAR Report Ms B June 2021

Child Safeguarding Practice Reviews

Josef case review - August 2021

Josef was a looked after young person from January 2019 and was 17 when he died in February 2020. Josef was known to various agencies at the time of his death, and the last few months of his life were particularly troubled, however those who worked with him remember him as being good fun, witty, funny with a great smile.

The report highlights the improvements that were implemented during the period between Josef’s death and the report being published. Updates on improvements made from our reviews are reported in the Safeguarding Enfield annual reports.

Josef - Case Review - August 21

Child Serious Case Reviews

Statistics on case reviews – useful statistics and information on case reviews can be found on the NSPCC website.

A summary of all national published serious case reviews from 2013 is available at this link.

‘YT’ Case Review – October 2017

On the 27 October 2017 we published the Serious Case Review (SCR) report for ‘YT’ covering the tragic case of a young man who took his own life just hours after arriving in this country. It is unlikely that anyone will ever know what led him to make that decision and the review concludes that his death could not have been predicted.

It is important however, that those involved in the care of young people in similar circumstances learn as much as possible from such a tragic event and the ESCB has published a response document detailing the local activity that has already taken place in response to the review.

For more detailed information please download the following:

YT Overview Report

YT ESCB Response

‘AX’ Case Review – January 2016

On the 11 January 2016 we published the Serious Case Review (SCR) report for ‘AX’ which involved the death of a 17 year old male at the end of 2013.

The events covered by the report took place over two years ago. Agencies have not awaited the completion and publication of this review before tackling the issues arising from these events and many of these recommendations have been identified and addressed already.

The report concludes that the circumstances and timing of AX’s death could not have been directly predicted by any of the agencies with which he had been in contact. However, possible opportunities for changing the outcome or influencing elements in this and future cases have been explored thoroughly.

For more detailed information please download the following:

AX Overview Report

AX Publication Statement

‘CH’ Case Review – May 2015

On 27 May 2015 Enfield and Haringey Safeguarding Children Boards jointly published the Overview Report of a Serious Case Review (SCR) for ‘CH’ undertaken in 2012/13 and completed in 2014.

The Serious Case Review concerns the murder of a young man by ‘CH’. The Overview Report states that the circumstance of the death could not have been predicted. However, through looking at the work of all agencies involved with CH and his family, the report does recognise that there are a number of areas of learning and improvement for partner agencies as well as evidence of good and effective practice. Agencies could, and should, have responded differently at key points.

For more detailed information please download the following:

CH Overview Report

CH Publication Statement