The government’s forthcoming care review must include a fundamental inquiry into the child protection system to make it better equipped to tackle persistent problems in keeping children safe.
That was the message from a panel of government advisers – including chief social worker for children Isabelle Trowler and former children’s minister Edward Timpson – in a report this week that analysed local reviews of 538 serious child abuse or neglect cases in England from July 2018 to December 2019.
In its first annual report, the Child Safeguarding Practice Review Panel said the cases illustrated how safeguarding was beset by persistent problems – optimism bias, weak risk assessment, poor information sharing – that were rooted in systemic issues including the impact of poverty on families and workload pressures facing practitioners.
Key questions for care review
- How should child protection services be organised on the ground?
- How can we best strengthen information exchange, risk assessment and decision making?
- What is the knowledge and skillset needed to make good protective decisions about children?
- How should that skillset be developed, by whom and to what national standards?
- To what extend are existing child protection procedures the right ones?
- Are there effective checks and balances in the system?
- How can we best use evidence to enhance multi-agency working?
- What should be the focus for building new evidence to support practice?
With the government committed to a review of the care system – which education secretary Gavin Williamson said this week would be independent – the panel said it must consider key questions (see right) about how child protection was organised, practised and governed.
“We think it imperative that the scope of the review is firmly focused, although not exclusively so, on the effectiveness of child protection practice and considers the questions we have set out,” the panel’s report said.
“To our minds, there is no question that there is a need to address these systemic issues, such is the frequency with which we have seen the same practice concerns raised in the serious case reviews and rapid reviews submitted to us.”
In raising these systemic issues, the panel referenced the findings of the latest triennial review of serious case reviews, covering 2014-17, also released this week, in relation to the increasing prevalence of family poverty in serious cases and the impact of high workloads on professional decision making.
In a separate report on safeguarding children at risk from criminal exploitation, the panel called for the Working Together to Safeguard Children guidance and the wider child protection framework to be reviewed specifically to ensure that it was better equipped to tackle harm from outside the home.
‘Weak risk assessment’
In 54% of the cases considered by the panel in its annual review, children’s social care were working with the child at the time of the incident.
“To the lay person and even the experienced professional, it often seems incredible that we couldn’t have done more to protect a child given the known risk factors,” the report said.
The panel acknowledged the extereme difficulty of predicting what will happen to a child in a given set of circumstances, given the number of variables, and that it was not helpful to judge practice in hindsight. However, it found that risk assessment was “weak” in 41% of the cases considered, saying that “in too many of the detailed explorations of practice we have seen, we are sure that different decisions could and should have been made”.
About the panel
The eight-strong panel, which, besides Trowler and Timpson, includes social work, health, police and education experts, is appointed by, and accountable to, the education secretary, though operationally independent. Its role is to learn the lessons from serious child safeguarding incidents.
Where a child dies or is seriously harmed in an area and the relevant local authority suspects they have been abused or neglected, or when this applies to a child who is normally resident in the area and dies or seriously harmed outside of England, the council must notify the panel within five working days. It is expected to submit a rapid review of the case to the panel within 15 working days.
The panel’s annual report is an analysis of all the rapid reviews it received from July 2018 to December 2019.
It raised similar points in relation to optimism bias, a factor in 32% of cases, which linked it linked to high workloads.
“A system that often lacks clarity of purpose, with high workload and conditions of uncertainty, is destined to hope for the best,” the report said. While it said it was not easy to fix, the report said it was “time to do something about it, and at the very least limit the worst outcomes”.
Information sharing was poor in 40% of the cases, which the report said also raised critical systemic issues.
“We need to move beyond the legislative and procedural, to the technological and the behavioural, and forensically explore how we can develop our multi-agency and multi-disciplinary practice in routine ways, and at critical points, which strengthens information sharing, risk assessment and decision making,” it added.
The report was welcomed by Claudia Megele, chair of the Principal Children and Families Social Worker Network, who said its themes “reflect clear opportunities for further improvement in practice and decision making”.
“However, the fact that these have remained as common and consistent themes in serious case reviews over the past four decades calls for reflection and more critical examination of risk management and decision-making processes across safeguarding partnerships and the significant pressures and systemic issues due to continued impact of austerity and lack of due prioritisation of social care services on national agenda,” she added.
Harm outside the home
The separate report on the system’s response to criminal exploitation, which examined the cases of 21 young people, found common predictors of risk were not present in the lives of many affected children – just two of the 21 were looked after – there was little reliable evidence of what worked and practitioners lacked confidence in their practice in this area.
On the basis of its findings, it said the child protection framework, based on tackling harm within the home, needed to be reviewed to make it better equipped to tackle harm from outside the home.
“The formal child protection framework may not always be the best approach to take for children at risk of extra-familial harm,” it said. “While practitioners and managers generally don’t feel that the child protection framework is a barrier in these circumstances, there was an acknowledgement that in some circumstances it didn’t facilitate the best interventions.”
Particular issues included the need for assessments to take into account young people’s relationships with people outside the family, and the need for assessment timescales to provide the time for practitioners to develop the relationships with young people that were critical to good practice. Also, child protection conferences tended to focus on how parents could better keep their children safe which, where most of the risk is extra-familial, could leave parents feeling blamed and unsupported.
The panel said the current narrative and requirements within Working Together were not clear enough about how the guidance could be applied to these cases.
“We recommend that government moves at pace to review Working Together,” it said. “The Department for Education should bring together the relevant stakeholders to explore how best to ensure the narrative and requirements of Working Together reflect the risk of harm from outside the home, with a view to agreeing amendments to the current guidance.”
It also said the DfE should fund and evaluate the trial of a practice framework on criminal exploitation, which would include the development of specialist multi-disciplinary teams in each area, with a dedicated budget and permission to work flexibly, outside routine procedures.
Association of Directors of Children’s Services vice-president Jenny Coles said it would welcome talks with the DfE about the report’s proposals, adding: “National policies and guidance have fallen behind the realities our practitioners now face in working with young people and their families; the child protection system was originally designed to keep younger children safe from harm located in the family home.”