In some circumstances following the death or serious injury of a child, the Local Safeguarding Children’s Board (LSCB), a multi-agency body with an independent chair, is required to consider carrying out a review into the events surrounding the death or injury and consider what, if any, lessons need to be learned.
Following the death of a baby in 2007 from Sudden Unexpected Death in Infancy, such a review was carried out by the LSCB.
That review was judged inadequate by Ofsted on January 30th 2009 and the LSCB, as required, then commissioned a new independent review process.
The executive summary of this review can now be viewed in full on this link.