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Alex Dobson investigates the tendency of staff in health and social work to defer to the judgements of those who are seen as higher up the professional ladder, sometimes unbalancing child protection systems.

The child protection system is only as strong as its weakest link, as witnessed by many inquiries into children's deaths.

In almost all child protection cases, more than one agency holds vital information. Unfortunately, any failure to share information, particularly in a climate where professional relationships are not based on trust and empathy, can result in tragic consequences.

During the Victoria Climbie Inquiry, for example, it became apparent that the lines of communication between health and social services had been far from clear, with discussions between professionals over crucial issues appearing to obscure rather than clarify issues.

An early medical diagnosis by a senior paediatrician that Victoria Climbie had scabies was to have profound implications for the way that the case was subsequently handled. Junior doctors and nurses also came into contact with Victoria during her admissions to hospital, but although they identified child protection concerns, their influence on subsequent events seems to have been marginal.

Janet Foulds is unit manager in the child protection abuse unit of Derby Council and vice chairperson of British Association of Social Workers. She argues that staff from both health and social care need to understand how other professionals arrive at their assessments. Without that understanding, Foulds says that the ability to question and challenge those decisions is lost.

"It is vital to work on trust and communication which in turn works to protect children," she says. "Where you have that trust you don't get the imbalance of power that can sometimes happen, where there are workers who are lacking in confidence and who may defer to someone else because they are from a certain discipline.

"What is important is to work on relationships to the point where everyone has an equal ownership of the duty to protect and an equal ownership of the duty to communicate," Foulds adds. "Practitioners from whatever setting and in whatever job they have, be it ward staff in a hospital or a junior member of social services, must have their views taken into account and given equal weight."

Her own experience working in Derby has been positive, with a successful partnership between health and social services that has worked to protect vulnerable children. She says that good practice means working together but it also involves having the confidence to challenge decisions even when they come from senior practitioners.

"It may mean going to a paediatrician and saying that the decision that he or she has made may not be the right one and then having the confidence to sit down and talk about it. Senior managers and training staff have a responsibility to promote a culture so that new workers or inexperienced workers have the confidence to go and talk with people from other agencies. So that they can say 'I don't agree'. It is far better to lose face in an argument than allow a child to become injured," she adds.

When health professionals first came into contact with Victoria she was diagnosed as suffering from scabies by an experienced paediatrician, Ruby Schwartz. That diagnosis was to be highly influential in the classification of her as a child in need rather than a child at risk, but the contact that she had with other health professionals seems to have either been lost through poor communication or simply not given sufficient weight.

During the time that Victoria spent on the Rainbow Ward of North Middlesex hospital, nurses had the opportunity to spend time with a child who was displaying behaviour consistent with abuse. They noted that she was poorly dressed in stark contrast to Kouao and that at times a master-servant relationship appeared to exist between the two, with Victoria standing rigidly by her bed when her aunt was there.

The child had a voracious appetite, she wet the bed, and although she had been admitted because of the burns to her head, it was observed during bath-times that she had unexplained marks on her body, one of which looked like it had been caused by the buckle of a belt.

The extent to which this crucial information was passed to social services is a matter of debate, but what is striking is that the suspicions of nurses - several of whom were highly experienced - were not taken into account in a way that might have helped to prevent the unfolding tragedy.

Fiona Smith, adviser on paediatric nursing at the Royal College of Nursing, says that paediatricians are by no means the only medical staff that are involved in the assessment of child protection cases. She says that the key issue is one of training in child protection awareness and the setting up of support structures so that staff who may be concerned can take that concern forward and be given a proper hearing.

"Where the practitioner believes that there is a child protection issue involved, then the nurse has a duty to make a referral and that is why it is so important to have a named nurse or designated nurses to support junior nurses. But this can also apply to junior doctors who sometimes need access to a designated doctor for child protection because they may have been the one who assessed the child," says Smith.

She continues: "Junior practitioners need to have access to key individuals both within acute trusts and primary care trusts, to discuss particular cases and to be assisted to follow through the referral process."

According to Smith there are also issues surrounding effective communication between different agencies, as well as ensuring that messages of concern are properly documented and understood by all sides.

She says that health terminology is sometimes unclear in meaning to social services staff. Likewise health professionals occasionally misunderstand what social workers are saying.

In order to counter what can be basic but crucial misunderstandings, she says that some organisations have implemented procedures designed to clarify and simplify discussions between agencies.

Rhian Stone, child protection policy adviser for the NSPCC, says that there are problems of hierarchy and status within the health profession as there are in most professions, and points out that the decisions and judgements of paediatricians hold considerable weight.

"Often that deference can be the right thing as those professionals do have a particular expertise and social services are often reliant on their medical diagnosis of non-accidental injury if they are to have the grounds to pursue an investigation. In the Victoria Climbie case the paediatrician's opinion held a great deal of weight because of the absence of other information," she says.

She adds that the proposals that the NSPCC has put forward to the inquiry include developing a model that would improve collaborative working by putting together teams that would include a health representative. This would have the effect of improving the dialogue and collaboration between social services and health.

She says that the area child protection committee could provide an independent point of consultation and advice for professionals who are concerned about a child. This would allow more junior staff to have access to help and advice, she suggests.

What has emerged from the Victoria Climbie Inquiry is a story of misunderstandings that led to a failure to protect a vulnerable child. But what has also emerged is the importance of giving due weight to the opinions of all those professionals that come into with a child at risk.

Everyone in the team needs to have the ability and confidence to question the decisions of others, whoever they are, consultant or nurse, social worker or junior doctor. It is, after all, far better to lose face than to lose a child.