Strategic Partnership Boards

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’.  

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

Under Working Together to Safeguard Children 2023, 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.

Thematic Review: Violence Affecting Black Boys

How can we work better together to keep our children safe from harm outside their homes? 

30 October 2025 

This thematic review explores the common themes in 11 incidents of violence that led to 14 children, mainly Black boys, tragically coming to serious and / or fatal harm between March 2023 and July 2024. 

It serves as the local child safeguarding practice review (LCSPR) for those children whose circumstances met LCSPR criteria. Much of the learning gathered throughout was applied to practice as it developed and informed the Serious Violence Strategy, which has a focus on reducing knife crime injuries among children and young people under 25 years of age.

Insights came from direct engagement with children, case records, and feedback from professionals gathered through learning events / rapid reviews and helped with understanding the circumstances and factors that led to these incidents and to identify lessons to prevent future occurrences. 

The Community Safety and Safeguarding Partnerships will remain accountable for how this learning is embedded into practice. The review will be used to ensure that the protection of young people from knife crime and risks outside their homes is placed at the heart of the partnerships’ efforts. We are committed to working collaboratively to tackle the underlying issues and protect our children. We will continue to listen, learn, and act, ensuring our strategies focus on delivering real change, fostering anti-racist practice, and improving safety for all children.

• Thematic Review: Violence Affecting Black Boys (PDF)
• Community Safety and Safeguarding Partnerships’ Response to Thematic Review (PDF)
• 7 Minute Briefing – Violence Affecting Black Boys (PDF)

LCSPR for Children M 

28 October 2025

The circumstances of Children M mirror patterns of neglect and the perplexing presentations highlighted for Children L, detailed below. Building upon those insights, this review highlights persistent challenges within the national elective home education (EHE) framework and explores the difficulties agencies encounter in balancing children's rights, parental responsibilities, and effective inter-agency information sharing. Children M’s experiences demonstrate how EHE, when coupled with parental avoidance of services, can result in children's isolation and invisibility, ultimately causing considerable harm. 

Each child is doing remarkably well and continues to make promising progress as their day-to-day needs are now consistently met.

• LCSPR Children M
• Local Safeguarding Partners’ Response to LCSPR for Children M
• 5 Minute Briefing – Children M

LCSPR for Children L

23 April 2025

This LCSPR concerns a large white British sibling group, known as Children L. Despite being loved by their parents, the children experienced persistent neglect, with their basic needs not being met, ultimately leading to their removal into care. Professionals faced challenges in identifying the neglect due to 'perplexing presentations'.

All the children showed similar developmental concerns from infancy, including feeding issues, mobility problems, speech and language delays, and potential learning difficulties. Numerous professionals were involved, but the parents' descriptions of symptoms often didn't match clinical findings. Missed appointments and poor school attendance further complicated the situation, causing delays in intervention. Now in foster care, the siblings are thriving, with all their needs met and each child making significant progress.

• CSPR for Children L
• Local Safeguarding Partners' Response to CSPR for Children L
• 7 min briefing_Children L

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.

• SAR Jodie: full report
• Waltham Forest Safeguarding Adults Board response to SAR Jodie
• SAR Jodie: 7 minute briefing 

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.

• SAR Ivan: full report
• Waltham Forest Safeguarding Adults Board response to SAR Ivan
• SAR Ivan: 7 minute briefing

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.

• SAR Harry: full report
• Waltham Forest Safeguarding Adults Board response to SAR Harry
• SAR Harry: 7 minute briefing