Consultation on Learning Lessons Case Reviews

In addition to our scrutiny meetings, from time to time the National Safeguarding Panel meet members of the National Safeguarding Team to take part in consultations on new or revised policies and procedures.

Recently we discussed the draft guidance on Learning Lessons Case Reviews. These reviews are commissioned by the Church, dioceses or nationally, to understand what happened in safeguarding cases in order to learn lessons for the future. This consultation on the revised policy was due to close on 31st October, however, as a number of people have said that they didn’t know about the consultation, the deadline has been extended and further meetings are being arranged to enable more victims and survivors to respond. This was welcomed by the National Safeguarding Panel with Panel members referring to social media messages and emphasising the need to ensure victims and survivors are consulted. 

This is not the first time the Panel has been consulted on this issue. A discussion took place in 2020. The report is available on this blog.

Revising the policy

A member of staff from the National Safeguarding Team, set out the reasons for revising the policy and noted that the previous policy was much shorter. The revised policy is designed both to offer more guidance to those commissioning and undertaking reviews, and to make it clearer to victims, survivors and other interested people the purpose of reviews and what can be expected.

It was outlined that this approach is in line with reviews that are commissioned in the public sector, and ensures it doesn’t just describe what happened but analyses why. The primary purpose is not seeking who may be to blame, but understanding the context in which mistakes were made. This includes organisational culture, resource levels and whether policies are appropriate. The aim is to identify these issues to prevent similar failures in the future.

Members of the National Safeguarding Panel reflected that this approach is positive in terms of encouraging learning, however, victims and survivors rightly expect there to be accountability for mistakes. There are complex structures within the Church of England with many legally separate entities meaning the processes for holding people to account are often not straight forward. The Clergy Discipline Measure can be the only route for accountability for clergy and this has not been seen as effective by many victims and survivors. It was noted that the Clergy Discipline Measure is due to be replaced by a new measure known as the Clergy Conduct Measure.

Six month target for completion

Panel members sought to understand whether the expected timescale of six months to complete a review is realistic. It was agreed that such a timescale is desirable in ensuring that those concerned learn promptly from any mistakes. It was clarified that this is guidance and should be the aspiration but that it will not always be achievable. Complex cases will take significantly longer and this is entirely appropriate.

Panel members highlighted that the complexities around publication can take considerable time. This can include gaining agreement from a number of different organisations as well as the need to ensure the anonymity of those affected. It is unlikely that a review and publication could happen within six months.  

It was agreed that rapid reviews could be particularly beneficial where the  issues are less complex. Rapid reviews are part of the guidance issued by the national Child Safeguarding Review Panel (an independent panel, set up by Government, commissioning reviews of serious child safeguarding cases). This guidance includes how to conduct a rapid review and how to capture themes. It was recognised that it could be more difficult to engage survivors in a rapid review and this needs to be a consideration.

Report format

Panel members suggested that in addition to guidance a template would be helpful and encourage a standard approach and also make it simpler to collate information nationally. It was suggested that there should be a cover sheet with key details as is done for some reports in the statutory sector.

Panel members asked whether there would be a quality assurance process to check that reviews are being properly carried out. It was agreed that this is important and should include checking that thresholds are being met with the aim of achieving consistency across the country.


The revised policy includes two examples of methodologies that could be used to undertake the review. This was questioned, with suggestions that it would be better to set out the expected outcomes and not be so specific as to the methodology to be used. Specifying particular ones could limit the choice of reviewer to those familiar with those methodologies.

Panel members identified that reviews often find the same errors have been made, suggesting that previous lessons have not been learned by organisations. These matters could perhaps best be dealt with through rapid reviews.

Panel members suggested that in addition to Terms of Reference there need to be agreed lines of inquiry. A chronology is important but it should be concise and proportionate. Too much emphasis on the chronology leads to a tendency to describe in detail what happened without sufficient attention to analysing why things were done.


The Panel urged the National Safeguarding Team to avoid using jargon, to review the guidance to ensure that it is in plain English and to avoid the frequent use of acronyms. It was also suggested that a glossary of terms and acronyms be included at the beginning of the document to provide an easy point of reference.

The use of the term vulnerable adult was queried. Statutory organisations have moved away from this term, but it is used within the Church within other policy and procedures and there should be consistency. At times within the draft revised policy the term “adult” is used on its own. Panel members felt that this could be appropriate. All adults have vulnerabilities at particular times in life and this is particularly true in relationship to involvement with the Church. It is often a place that people go to for support during particular times of vulnerability such as bereavement.

Good practice

Panel members endorsed the need to identify good practice through reviews as well as things that have not gone well. Good practice needs to be shared as well as lessons to be learned.  


Panel members raised the issue of governance. It was recognised that governance arrangements depend on whether the review is undertaken within a local diocese or nationally.

Within dioceses, Diocesan Safeguarding Advisory Panels have a very important role. It was agreed that there needs to be greater contact between the Panels and the National Safeguarding Team and more work done to encourage consistency across dioceses.

It was suggested that regardless of whether a review was undertaken at national or local level that there should be a central repository of reviews that is accessible. This would assist in ensuring that learning can be shared and that issues that are common to a number of reviews are more easily identifiable.


The Panel asked to be kept up to date on the further consultations that will be taking place and to see a copy of the final draft in due course.