The process and function of serious case review

Serious case review was neither envisaged nor mandated in the original No Secrets (Department of Health, 2000) although individual authorities have issued protocols in the intervening period. Recognising that there would always be a need to look back and to learn from challenging cases, Kent was one of the first authorities to put in place a mechanism for referral and conduct of these reviews. In this paper, I summarise the way this process is set in train, and what we have learned from the reviews we have undertaken to date. I write as the independent chair of the Serious Case Review Panel, and as an occasional chair of one‐off inquiries for other authorities, which I also refer to for comparison.