The national Child Safeguarding Practice Review Panel, set up to commission reviews of serious child safeguarding cases, has consistently highlighted cases in which poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around cases, were a contributing factor.40 The Department for Education told us that the Panel publish the findings from its review of individual incidents, as well as lesson learnt from the findings of multiple reviews. We asked the Department for Education how these lessons get disseminated and acted on.41 It highlighted that this is a challenge as it only takes one person to miss a lesson learnt for there to be a risk of serious failure. However, it recognised that it currently relies on local authorities building lessons into local practice and that it could do more to incorporate lessons into national care standards to make it easier for people to act on lessons learnt. The Department will reflect on this as it considers its response to the Independent Review of Children’s Social Care.42 34 C&AG’s report, para 1.10 35 Qq 23–25 36 C&AG’s report para 1.7 37 Q 23 38 Qq 24, 25 39 Q 29 40 C&AG’s report, para 2.12 41 Qq 98, 99 42 Q 99 14 Support for vulnerable adolescents Adolescents’ mental health services