Significant case reviews are carried out where a child has died or significantly harmed or where they have been at risk of harm. Signifcant case reviews aim to find out if anything could have been done to prevent harm, and what could be done to stop a similar event happening in the future.

Most children and young people in Scotland grow up safe and healthy and enjoy the best start in life in loving, nurturing environments.  About 15,000 children in Scotland are currently looked after by local authorities and around 2,800 children are on the child protection register. They rely on social work, health, education, police and other professionals to work together to care for them safely, give them the best start in life and enjoy good outcomes.

A great many more children and families also receive valuable shorter-term support from social work services and a range of other agencies.

This is why it is crucial that social workers, police, teachers, health staff and a range of third-sector partners all work together effectively to protect children and young people.

Sadly however, even when staff work tirelessly, often in very challenging circumstances, they cannot always prevent terrible things happening.

Today's report reviews the cases of 23 children in Scotland where something has gone badly wrong. Tragically, 11 of these children and young people died.

Karen Reid, chief executive of the Care Inspectorte said 'Collectively, we owe it to these children to understand what happened and to find out what must be done differently to prevent harm in the future.

'Where harm happens, everyone involved in protecting children must do everything possible to ensure that practice changes, not just in the area where the harm occured, but right across the country. The need to share learning makes this report so important.

'We have examined 20 significant case reviews, involving 23 children and young people commissioned by local child protection committees across Scotland over a 3-year period.

'We comment on their quality and effectiveness, and share key findings. This is not directed to apportioning blame, but to support learning. Some information in this report is distressing to read, but learning from tragedy and mistakes requires, candour and frankness.  They are essential ingrediants in preventing the same things happening again.'

'It is the Care Inspecorates's job to collate and review significant case reviews in order to help child protection committees, and colleagues in local authorities, the Scottish Government, police, health and third sector services across Scotland to reflect on best practice and take action where things are that can be changed now to prevent future harm.

Karen Reid added, Strong local leadership and a clear focus on working together to improve outcomes for every child in Scotland are essential if we are to prevent harm, keep children safe and reduce health and social inequalities.'

The report made several recommendations, including that the Scottish Government and child protection committees work together to support better quality in significant case reviews and greater consistency in approach.  Chief officers and child protection committees should focus on attention on implementing and embedding practice change as a result of learning from significant case reivews, even from ones outwith their area.

Significant case reviews are being considered as part of the child protection improvement programme announced by the Scottish Government earlier this year.

The report is available here