The lessons from previous inquiries

To the media, which only focuses on child protection when a
catastrophe occurs, it appears that the same things keep going
wrong. Child protection is by no means alone in hitting the
headlines only in times of crisis; that is how news works. But the
fact that this blame culture spreads far beyond children’s
services is no consolation for the damage it causes,
writes Polly Neate.

The perception that the lessons of past inquiries have not been
learned is not accurate. In fact, child protection has a complex
relationship with inquiries, and the publicity and government
activity that surround them. For a start, our child protection
system is founded on inquiries. The Maria Colwell report in 1974
led to the creation of the three pillars of today’s system:
area child protection committees, inter-agency child protection
conferences to consider specific cases, and child protection
registers to identify children at risk. This system was further
formalised after the Jasmine Beckford inquiry in 1986.

By 1989 the blame pattern social workers call “damned if
you do, damned if you don’t” had established itself.
The Cleveland inquiry and other cases had led the media, the public
and ministers to identify an over-zealous trend. Of course, it is
quite reasonable to criticise professionals for erring from good
practice, whichever direction they err in. What is not reasonable
is to allow policy, guidance and management to swing reactively
between extremes, leaving little room for professional judgement.
If the risks to individuals and agencies are too grave – and the
tabloids treated some social workers as if they were directly
responsible for children’s deaths – their influence on
practice can threaten to outweigh the risk to the child.

The introduction to Messages from Research1, the most
authoritative guide to what works in child protection, points to
four factors that have influenced policy, and explains the fine
balance that should exist between them – but doesn’t. The
four are: the legal and moral framework; pragmatic considerations;
the evidence; and the views of those who receive services.

The first factor tends to dominate after specific events, and
drives change in which pragmatism (what is actually possible), the
evidence, and the needs and wishes of children can all too easily
be ignored. Professor Roger Bullock of the Dartington Social
Research Unit, warns that the Victoria Climbié Inquiry could
herald one such phase. “What we are coming into is a major
report phase, which we haven’t had for some time,” he
says. “It will shake up the system. It could have the level
of impact of Cleveland. The danger is that policies based on
extreme cases don’t always make good policies for everyone
else. And they can consume huge resources.”

Despite the undeniable professional and agency failings in the
Victoria Climbié case, many managers and practitioners agree
that the protection of the children at greatest risk is not the
weak point in the system.

The most damaging error for Victoria was that she was classified
as a child in need and, as Association of Directors of Social
Services spokesperson on children Jane Held says, was therefore
shut out of the child protection system that could have ensured
resources were there to protect her.

Under the Children Act 1989, reinforced by Messages from
Research, Bullock says: “All children in need should get a
service.” But when children’s needs and research have
been marginalised by moral panic and an understandable haste to
ensure tragedy cannot be repeated, resources inevitably focus on
the most dangerous cases. When resources are severely limited, that
doesn’t leave much room for anyone else.

In the mid-1990s, there was a strong line from the Department of
Health, of which the commissioning of Messages from Research was a
part, that social services departments should “refocus”
child protection towards preventive efforts, working in partnership
with families. But the government’s resistance to a
transitional period in which protection services and new preventive
work would be funded simultaneously meant “refocusing”
never happened, as both Held and Bullock agree. In fact, as they
both say, the intentions of the Children Act have never been put
into practice.

Since the death of Rikki Neave in Cambridgeshire in 1994,
followed by a critical social services inspectorate report three
years later, most child deaths have been followed by case reviews
with unpublished findings, rather than by inquiries. The NSPCC has
criticised this trend, but it has led to a calmer period, allowing
practice to develop out of the media spotlight. It has also,
however, coincided with the New Labour government’s focus on
targets and performance indicators, which have concentrated on
children at risk rather than following the spirit of the Children

The calm has now given way to the storm. The horrific death of
Victoria Climbié, followed by the tragedies of Lauren Wright
and Ainlee Lebonté, has forced the child protection system
back into the public eye. But it would be ironic indeed if the
death of a child who was overlooked partly because services are not
available for children in need, led to an even greater
concentration on the smaller number of children at risk, and proved
the final nail in the coffin of preventive social work with
children and families.

The question is whether this inquiry will push the system in the
right direction. Practitioners are increasingly alarmed at the
rigorous criteria of entry into the child protection system, saying
that inter-agency relationships suffer as a result, with referrals
from schools, for example, drying up once it is known that social
services will only deal with children in danger.

Moira Vangrove was principal officer in a local authority child
protection unit until becoming an independent social worker two and
a half years ago. She still works with social services departments.
She says: “I am becoming increasingly concerned about the
lack of provision for children in need. I was optimistic, if a
little naïve, when the Framework for the Assessment of
Children in Need and their Families2 was introduced. But
I have become alarmed to find an increasing number of social
services departments introducing eligibility criteria, especially
when band one – the greatest need – who are probably the only ones
to receive a service, are clearly children in need of

Vangrove describes “a horrendously high threshold of entry
into the child protection system”. She also describes cases
being dropped once a child is removed from the register, but
argues: “You don’t go from significant harm to needing
nothing. The departments say that if they have enough resources to
meet all the need in level one, they would then meet level two. But
they haven’t got the resources. Meanwhile, they only have to
meet targets on the length of time on the register and on
re-registration. And inspections praise them for being clear about
what they don’t do as well as what they do.”

Jane Held agrees: “Prevention hasn’t
happened.” Under the Children Act, she says, the whole
council is responsible for children in need. But it is left to
social services, and “social services have no power to change
their partners’ priorities. We end up with all of the
responsibility and none of the power.” Section 27 of the
Children Act is clear that other agencies have a duty to work with
children in need, but this is another element of it that has not
been implemented, Held argues. “Other agencies know when it
goes wrong social services pick up the problem, and get the blame
if a tragedy occurs.”

The introduction of Sure Start has made the problem even more
obvious, says Held, because Sure Start uncovers unmet need that
social services cannot deal with. Although significant funding is
being targeted on children at risk of social exclusion, there is
still a gap when it comes to those who are in greater need but not
(yet) at risk.

It’s never going to be a popular solution with government,
but Held argues more resources is an obvious answer – “ask
any social work manager”. But resources is one area in the
findings of inquiries that has consistently been overlooked.

UK operations director at Barnardo’s Chris Hanvey has been
re-reading inquiry reports from the Maria Colwell report to the
present day. He says there are three consistent themes: “A
plea for better training across agencies, better co-ordination and
co-operation between agencies, and resources.” He adds that
the need for more resources always gets dropped.

Yet the pressures on front-line practitioners caused by
inadequate resources and staffing have become worse. The Kimberley
Carlile report of 1987 says of Kimberley’s social worker,
Martin Ruddock: “Given that there was an acute problem of
under-staffing around that time, we are not surprised that Mr
Ruddock’s work suffered as a result.”3 The
Doreen Ashton report, published in 1989, says: “The Southwark
social worker’s ability to respond positively at this time
was seriously impeded by other crises which had arisen in her
caseload … She had been carrying six child abuse cases with 16
children on the child abuse register… We record this as a
reminder of the pressure to which inner city social workers are

In 1989, the Liam Johnson report described social workers mired
in administrative work, and the negative impact on their
practice.5 And in 1990, the Stephanie Fox report
criticised the long delay in passing the case from one area office
to another but – while not excusing it – clearly places this
failing in the context of resource constraints: “We find it
unacceptable that staffing levels should be such that there should
be a lengthy delay in finding the new worker and handing over. …
It is all too easy to deflect attention from resource issues by
personalising the criticism, by focusing exclusively on the work of

Evidence to the Victoria Climbié Inquiry has shown that
staff face even worse pressures more than a decade later.
It seems we have failed to learn key lessons from inquiries, but
perhaps not the lessons that social services are most criticised
for ignoring. In 2000, Christine Walby wrote about the two-year
implementation initiative which she chaired following the National
Commission of Inquiry into the Prevention of Child Abuse
established by the NSPCC.7 She said: “There are
three outstanding issues that would be most likely to produce
enduring change for the better in the war against the abuses that
stifle life chances and cause actual harm to so many children. They
are finance, organisation and information, and social values and

Chris Hanvey says that the last of these – social values and
attitudes – has if anything seen society as a whole become more
distanced from child protection since the mid-1970s. “The
Maria Colwell report was very straight about the responsibility
that we all have for child protection, the whole of society, and I
think it’s more honest about that than we are now. Since then
the expectations have grown that professionals will take on this
responsibility and discharge it on behalf of society.” Those
expectations have become unrealistic.

Jane Held says: “It would be a brave person to say we have
to accept that we can’t protect all children. We have to say
it. We cannot eliminate risk altogether.”

But isn’t that what the inquiry-driven model of
policy-making strives for? The evidence-base of policy-making is
dominated by the type of evidence heard by inquiries – what went
wrong in particular difficult cases and why. Before systems are
changed, filters are applied to the evidence – primarily to resist
pressure to remedy inadequate resources, staff shortages and heavy
workloads. More widely applicable evidence, such as that from
research, is brought to bear on the system but cannot hold its own
against the calls for action that follow the sadistic murder of a

So the fact that inquiries have pointed to similar weaknesses in
services does not mean inquiries have failed to influence policy
and practice. In fact they are fundamental to the way child
protection operates. Whether they have so far influenced it to the
good – as measured by the ideals of the Children Act, Working
Together and research findings – is another question.

1 Dartington Social Research Unit, Child Protection:
Messages from Research, HMSO, 1995
2 Department of Health, Framework for the Assessment of Children in
Need and their Families, The Stationery Office, 2000
3 A Child in Mind: Protection of Children in a
Responsible Society, London Borough of Greenwich, 1987
4 The Doreen Ashton Report, London Boroughs of Lewisham,
Lambeth and Southwark, 1989
5 Liam Johnson Review: Report of Panel of Inquiry,
London Borough of Islington, 1989
6 The Report of the Stephanie Fox Practice Review,
Wandsworth Area Child Protection Committee, June 1990
7 Christine Walby, “Betrayal of innocents”,
Community Care, 29 August 2000

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