Special report on the recent Sheffield serious case review


Important lessons about the value of integrated working by professionals to protect children emerged in a serious case review into severe child neglect published by Sheffield Council last month.

As closer working between children’s social services, health and education develops, the report shows why momentum must not falter.

Five children were severely neglected by their parents. For two of the children the neglect was life-threatening. Although the children’s father, David Askew, was known to social services as he had been in care, the family as a whole was not. Askew had also been on probation and referred to mental health services for anxiety attacks.

Hanvey, Chirs
Mistakes made by professionals involved with the Sheffield case are depressingly familiar.  Yet again lack of communication between agencies is blamed. From the 1974 inquiry into the death of Maria Colwell to the Victoria Climbie inquiry in 2003, the absence of a holistic approach by professionals failed to protect children.

Chris Hanvey, UK director of operations at children’s charity Barnardo’s, talks of a “sadness that this consistent issue in child protection inquiries remains uppermost”.

The need for improved communication between care agencies was a key impetus behind Lord Laming’s recommendations following the Climbie inquiry, that led to the wholesale changes in children’s services now being implemented.

The question now is will the push to get agencies working more closely together work?

One crucial passage in the Sheffield serious case review says: “The provision of universal services for children and families must be seen not as separate from, but a part of, a spectrum of care that includes child protection.”

Limited involvement

This is vital because education and health professionals had most contact with the family involved.

Sheffield social services had limited involvement with the family and only two areas for improvement are identified in the report. These are failure to assess Askew’s parenting skills when the first child was born; and the lack of follow-up when the same child was referred to social services by her school.

Child protection work only began when two of the children were taken to hospital in June 2004.

But there were clues that the family “was vulnerable and had many needs,” that agencies including education, health, early years and the police failed to pick up on, says the report.

These included both parents being 16 when the first child was born, their background, the number of children, frequent changes of address and “intermittent engagement” with health and education by the family, including many missed appointments and absences from nursery and school.


Facts causing concern “were known singly and sometimes collectively to most of the services that knew the family but their total impact on the welfare of the children was not thoroughly assessed or communicated between agencies,” the report notes.

The agencies involved assessed the children in “silos”, said report author independent expert Pat Cantrill, when she spoke to Community Care.

When the oldest child’s school contacted social services, this did not trigger intervention, says Cantrill. The school saw the child’s non-attendance as a school problem, instead of a possible indicator that all was not well at home and the issue was not fully assessed and followed up, she adds.

Cantrill calls for a review of the “pace” of implementation of the framework of assessment for children in need, and the common assessment framework in Sheffield and nationally.


She is optimistic about the value of these tools for assessing children in need and believes the changes happening in children’s services are a “golden opportunity.” She believes the “post-Climbie” commitment to change and working together is unprecedented.

But is structural change enough?

“Structures are changing in social services but the standard of day to day work with children is not being fundamentally addressed,” says Barnardo’s Hanvey.

Shaun Kelly, safeguarding manager at children’s charity NCH, agrees that standards of practice by individuals are key.

“Policies and new structures can be in place, including information sharing and multi-agency working, but staff need support and good supervision and management to work within them,” he says.

Kelly also calls for more support for teachers, if the system expects them to identify children in need.


Hanvey is concerned about the growing split between children’s and adult social services.

“Can the new structures make supporting the whole family easier?” he asks.

In the Sheffield case, the father was referred to mental health services but his assessment did not identify any possible child protection issues. Hanvey wonders if the new structures could make this failure to address the needs of the whole family more likely in future.

Basic information about every child in England is to be recorded on an electronic database by 2008. But how useful will this be?

 “Information sharing, however good the system, won’t prevent child deaths.
But the modest aspirations of the new index will make it easier for agencies to know when other professionals are working with a child, concludes Hanvey.

Executive summary of Sheffield serious case review at:- http://www.sheffield.gov.uk/safe–sound/protection-from-abuse/sscb/serious-case-reviews

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