Supervision of social workers involved with a family where child sexual abuse was suspected provided “no challenge or direction” during two years of inadequate child protection planning, a serious case review has found.
The highly critical investigation, carried out by Southampton Safeguarding Children Partnership, said the city’s children’s services failed to fulfil their responsibilities to a young boy, ‘Freddie’, after he reported sexually inappropriate behaviour towards him from his parents and exhibited sexualised behaviour himself.
It found children’s social care practice appeared to focus on his mother’s needs, rather than the risk of sexual harm to Freddie, meaning any effective response was lacking, despite a longstanding history of alleged abuse within the family.
Damaging case drift was fuelled by staff changes and absences, poor management oversight, delays in assessments and uncertainty around how to deal with the situation in Freddie’s home, the review found.
It added that there was “strong evidence of the multi-agency machinery around formal child protection processes being ineffective”, with other organisations failing to call out perceived shortcomings of social workers.
While the review period concluded in 2016, the report warned that a number of areas of poor practice – including around other cases involving intra-familial sexual abuse, ineffectual core groups, and the standard of management – had continued to be problematic.
Longstanding concerns
Freddie’s family had been known to children’s services since 1999, 15 years before the start of the period covered by the serious case review, due to concerns around abuse of his elder half-sister and half-brother.
These included 2004 reports by their mother of sexual abuse of the siblings at the hands of their father, allegations made in 2007 of indecent assault on Freddie’s half-brother by his father and their mother’s relationship with a Schedule One offender – one convicted of a specified offence against children – four years later, leading to child protection plans being put in place. The offender was found to have sexually abused Freddie’s half-sister, though the plan was removed in 2009 after the mother ended the relationship.
During 2011 there were also 17 contacts with children’s services relating to the mother struggling with the two elder children and Freddie, then a toddler, with seven contacts the following year. At the end of 2013, Freddie’s pre-school contacted children’s services with concerns about his sexualised behaiour and his father’s inappropriate behaviour towards him. In April 2014, his half-brother was convicted of rape – though this was later reduced to a lesser offence.
In June of that year, Freddie and his siblings were placed on child protection plans under the category of sexual abuse, with Freddie having frequently acted in a sexually inappropriate way at school and made statements about his mother and father behaving similarly towards him.
Two years later, with the plan having remained in place and Freddie continuing to display “aggressive and sexualised” behaviours, he was taken into care, where he made a number statements regarding sexual abuse he had received and witnessed.
‘Collusive’ practice
The review found evidence of agencies colluding with the mother rather than being focused on the risk of sexual harm to Freddie, with her being seen as a protective factor and being allowed to speak on behalf of the children rather than them being seen by themselves by practitioners.
“Practice from Southampton children’s services appears to have been one where the focus was on the mother’s needs with a failure to respond to the risks of sexual harm faced by Freddie,” it said.
“Given the explicit lack of recognition of actual, or likely, sexual harm to Freddie it follows that the response was equally lacking.”
Despite information provided by Freddie in 2013 and 2014 to several agencies about inappropriate behaviour by his parents, there was no evidence of follow-up discussions by social workers in supervision and strategy discussions during this time.
The origins of Freddie and his half-brother’s sexualised behaviour were never established, with a focus on managing the behaviour rather than understanding it.
“Understanding the origins of Freddie’s sexual abuse (as best as possible) was critical to creating an effective safety plan given the high possibility that Freddie continued to live in the same household as his abuser,” it said.
‘No challenge or direction’
The review found supervision and management oversight offered “no challenge or direction”, evidenced by the frequent reference to the child protection plan having not achieved any change for the children.
This was exacerbated by the lack of supervision, with Freddie’s social worker not receiving any case supervision between being allocated the case in June 2014 and April 2015.
Children’s services’ submission to the review found that the supervision the practitioner did receive was of poor quality and did not explore the risks to Freddie and the work required to create an effective safety plan.
While supervision improved after a change of team manager, this continued to result in a lack of “authoritative social work practice and drift”, the SCR found.
‘Negligible’ impact of core group
While timescales around child protection procedures had been largely observed during Freddie’s two-year statutory intervention, the serious case review concluded the impact of the core group managing the plan had been “negligible”.
The first five groups were beset by problems, including social workers being absent, while statutory visits had also been missed or gone unrecorded, the investigation found.
At review child protection conferences, meanwhile, there appeared to be “no explicit reference to checking progress against agreed actions, [with] the plan shifting each time despite limited progress”, the report said, adding that activity was mostly “storytelling”.
Apart from a complaint from Freddie’s school in February 2016, warning of “extreme concern” regarding the lacklustre social work support being provided to the family, professionals largely remained silent about the lack of progress, the review added.
It noted that from 2012, inspections and practice evaluations within Southampton children’s services had highlighted issues with management turnover, assessments and core group activity – though in a 2014 visit, Ofsted said that child protection practice had improved.
‘Severe and enduring consequences’
Later, professionals involved with Freddie’s family had four meetings with the council’s legal team, the review found, with an interim care order being considered for his “predatory” elder brother as early as August 2014. But on several occasions, as elsewhere, sensible plans that came out of these meetings were not followed up, leaving situations to drift.
“The consequences of the professional network not effectively intervening with children who have been sexually abused are likely to be severe and enduring for those individual children,” the review warned.
Responding to the review, Derek Benson, the independent chair of the Southampton Safeguarding Children Partnership, said: “The shortcomings identified in the support provided to Freddie and his family are made clear in this report and are regrettable.”
Benson added that recommendations from the review – including around evaluating the effectiveness of core groups, child protection conference chairs and legal planning, as well as reviewing an audit on cases involving sexual abuse – were being acted upon.
“The Southampton Safeguarding Children Partnership is committed to the continuous improvement of services,” he said. “We are using the report’s findings and recommendations to ensure the necessary improvements are delivered to safeguard children.”
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Poor or no supervision, staff turnover and drift. Yet another review of the same themes and the inevitable similar outcomes. This is why so many of us are leaving social work. But I am sure the bureaucrats that herd us will no doubt say with confidence ” lessons have been learnt”.
Learning the same lessons over and over again but no effective change which would support social worker teams nationwide to improve practice. Those in leadership need to seriously consider social care reforms. High caseloads and staff turnover, shortages of staff and services. It can’t go on like this.
This article is appallingly written. The subject matter is serious; let’s make it easy to access and understand by proper proof reading and editing. It does not meet the standards set by Social Work England…or even Key Stage 2 assessments.
Thank you CC; it appears that many issues are now fixed.
Oh dear. A child is alleged to have been left in harms way, a service is identified as directionless but my colleague here is more concerned to wisecrack about grammar and Key Stage 2. The ‘joke’ is on a profession that can’t see the obvious.
Hi Sue,
It wasn’t meant to be a wise crack but came from genuine frustration that the article was so difficult to read when its content was so serious. Social Workers are so often criticised because of the quality of our written work. At best this just a bit embarrassing, at worst it means that families and judges don’t to get to make decisions on good quality, clear evidence. I know it can seem like a petty frustration but we so often ask ourselves why we are not taken as seriously as other professionals. I have read reports where the mistakes change that meaning of the sentences. Our work, and the writing about us, forms what the outside world sees. When people have to work at reading something we’ve written then we’re already on the way to losing them. The children and families that we support should shine through what we have documented; their value and rights should be the most important thing. I would imagine that the story of this child got lost in poor writing; that documents were passed from professional to professional and the story was not always told clearly or perhaps even accurately.
You are right that sometimes our profession cannot see the obvious, but sometimes that’s our own fault. I was so frustrated at not being able to clearly see the points of this article. I know the author is not necessarily a social worker but this website is part of the profession’s public face. None of us are perfect. That is why we have editors, supervisors, quality assurance processes and spell check but we are all responsible for upholding the standards of our profession. We should be writing for the families that we work with; if we’re clear for them, our colleagues and the public will also be able to get our meaning.
It’s not a side issue. Most of us will live on through our reports and case notes, still having an impact on decisions made about children even once we are no longer their worker. We won’t be there to verbally clarify or correct, to explain to that child that ‘no we didn’t check the work we did that justified breaking up their family but we did absolutely check that all of the information that we used was correct’. My tone could have been better and not personal and for that I am sorry adn am in contact with the editor. This website has carried stories on how our written work has had a negative impact on service users. Our regulations include a clear standard of written work. We cannot expect people believe we meet any of the standards when we so often seem to publicly miss the mark on one and when we behave as though missing that mark is not really a serious matter.
A journalist writes an account of a serious case review and includes a link to the investigation report. Not sure why they should write as if their article would be scrutinised by a judge.
I agree that our communication in all its forms has to be accurate and clear. The problem with social work is that most of what we write is not really to inform users of our services or other agencies. The pressure on us is to conform to an expected style with an internal code that is more about blandness and conformity and defensive practice. If we are honest we will accept that we write while conscious that we should protect ourselves as well as represent the issue at hand. How many of us have changed the tone of our recording to conform to expected organisational standards rather than be true to our professional instincts? That all said the disturbing issue in this article is not the quality of records but the toxic and self regarding culture that saw bullying as the baseline from which to make and force decisions that had no regard for safeguarding. How many of us work in similar environments where our managers and leaders give more value to their own expectations than professional ethics? We should be damming these cultures rather than get sidetracked into journalistic styles.
I don’t think Jo was advocating being sidetracked into journalistic styles. Rather that communication, in the form of writing that is grammatical and clear, is a better vehicle for conveying information.
When I worked in a position involving oversight of cases going before the courts, there was no doubt that a social worker who prepared well written documents e.g. using grammatical and straightforward English, avoiding jargon and long sentences, came across as professional and earned more respect. As Jo argues, I found that well written records and reports were more analytical and thoughtful and better conveyed the child’s situation so were less likely to result in poor decision taking.
It also often meant there was less reliance on bringing in other experts and less delay in proceedings.
When I qualified I was awarded a Certificate in Qualification in Social Work after one year of training. I had to have experience in social care work and I also had to evidence my proficiency in language skills including understanding of grammatical rules when applying for the course. I had individual and a group interviews. Qualifications, care experience, personal qualities all played a part in selection. Now my colleagues have Masters degrees but there is anxiety about the standard of written and spoken communication. Address the poor standards in social work by asking why after two decades of supposed academic excellence we are talking about poorly written reports and bad grammar. Its not for Community Care to teach us how to write. It is for us to ask the question whether the obsession with making social work a “profession” has come at the expense of basic communication skills. Surely if a trainee is capable of obtaining a Masters degree they must be capable of writing to a high standard? If they are not, than ask why universities and practice educators are teaching and qualifying trainees who cannot communicate clearly.