Councils and other safeguarding agencies should prioritise tackling “weak” risk assessment and decision making in child protection, a panel of advisers has said.
The panel, a group of government advisers, including chief social worker Isabelle Trowler, tasked with analysing serious cases, assessed 482 serious safeguarding incidents notified by local partnerships in 2020, including 206 where children died. It found risk assessment and decision making was a “critical cross-cutting theme” in the cases, as well as many inquiries historically.
Influencing care review
Panel chair Annie Hudson said that, as well as commissioning a thematic review of risk assessment and decision making, it was contributing to the children’s social care review to ensure it took account of the findings. A spokesperson for the care review, which has been set up by the government to examine how to reform children’s social care, said it had met with the panel to discuss its findings and was “keen to understand more about the quality of decision making”.
Hudson noted that the panel focused on the most serious cases of abuse and neglect, but said: “Through this specific lens, we have been able to highlight the urgent need for everyone involved in safeguarding children to address some of the stubborn challenges which have bedevilled much child protection practice”.
“Issues such as weak information sharing, communication and risk assessment have, over decades, impeded our ability to protect children and to help families,” Hudson added, in the foreword to the report.
“Despite the best of intentions (and very many inquiries), professional systems and cultures have not successfully tackled some of these deep-seated challenges.”
Risk assessment failings
The report included examples of initial risk assessments not being updated, for example, when parents formed new relationships or an adult joined the household after being released from prison. In other cases, it said, assessments did not take sufficient account of, for example, the risks associated with parental mental health or the “risk trajectory” for adolescents who had experienced trauma or neglect in early childhood.
The report called for “respectful uncertainty” during assessments and ensuring that information self-reported by parents was “triangulated” with evidence from other practitioners.
The report said management oversight and reflective supervision had a “pivotal role” in supporting practitioners to apply critical thinking to decisions, “particularly in situations of high caseloads when practitioners can experience distress and loss of analytical capacity”.
It also noted that high case numbers and limited capacity “can lead to a practice culture of working norms that are outside procedures, with reluctance to escalate concerns”.
The report was published after What Works for Children’s Social Care launched a call for researchers to undertake a rapid review of evidence on what made for high quality decision making, which was prompted by the panel’s 2019 report and will also inform the care review.
Echoing Hudson, What Works director of policy Eleanor Briggs stressed that the panel’s findings were drawn from the relatively small number of cases that had a tragic outcome, but that it was “obviously very important that we do learn from those cases”.
Briggs said that What Works, which is providing research support to the care review, it had already provided the review with evidence summaries on a range of topics but was commissioning the rapid review to identify what other research existed on decision making and whether some aspects were currently under-researched.
“We have done some work on this theme already – there’s a study with Cardiff University exploring whether a checklist intervention can help mitigate confirmation bias building on a previous project, good judgement and social work decision making, which looked at how accurately social workers can forecast future outcomes. We know there is other evidence on social worker decision making, which we are seeking to identify and understand through this rapid review. The review should also highlight significant gaps in evidence and point to urgent research needed. This will then inform the work of the care review team,” Briggs said.
The care review spokesperson said it was in the process of discussing and scoping topics for further rapid reviews by What Works.
Inequality in system
Cardiff University senior lecturer David Wilkins, who led the two studies Briggs mentioned, said he was pleased the rapid review specifically asked the chosen research team to look at defining the features of high-quality decision making as one area of focus. “It’s far from obvious, to me at least, that we have a clear and shared view of what these are in social work,” said Wilkins, who is also assistant director at CASCADE (Children’s Social Care Research and Development Centre), and whose research includes supervision and decision making in child and family social work.
Wilkins highlighted that studies consistently showed that different workers can make very different decisions about similar cases. “[This] might be inevitable to some degree, but also suggests a level of inequality within the system, which should at least give us pause for thought, if not concern,” he said.
Wilkins said various models mapping the role of different factors in decision making – from resource levels, thresholds and levels of deprivation in a local authority areas and the political climate to an individual worker’s views and experience and elements of the specific case – had been developed. But translating evidence into practice was likely to be one of the challenges for the care review, he added.
“Sometimes bad things happen despite good decision making, and sometimes good things happen more by luck than judgment. This means we have to look at not only whether the outcome was good or bad…but the process that led up to that outcome,” he continued.
Understanding a child’s daily life
The panel’s report identified other cross-cutting themes that those involved in safeguarding should address, including understanding what the child’s daily life was like and working with families whose “engagement is reluctant and sporadic”.
Understanding a child’s experience went beyond listening to their views, to reflecting on what they were trying to communicate through their behaviour, interactions with others and physical presentation, the report said.
“‘Reading between the lines’ of what children and families say and communicate (as well as what they do not say) involves time, imagination and the most proficient of relational skills. We all have responsibility for creating the conditions in which the talents and resources of practitioners can prioritise understanding what life is like for children,” Hudson commented in the foreword.
The panel said that “lack of engagement”, sometimes characterised as “disguised compliance” or “resistance”, may be better understood as “closure”: “a response in circumstances of unresolved adverse childhood experiences or socio-economic pressures, where individuals believe that what is happening to them is largely outside their locus of control and this may mitigate against their capacity for behavioural change”.
The report said relationship-based work with families was essential to understanding the role of closure and its interaction with other risk factors.
Hudson said that effective information sharing, risk assessment and decision making had become even more important in the past year due to coronavirus, while the pandemic had led to unprecedented levels of challenge for the safeguarding system. She said professionals had shown “extraordinary ability and resourcefulness”.
“That individuals have responded with extraordinary ingenuity and commitment to help and protect children is beyond doubt. It has perhaps never been more important therefore to take stock and learn in order to influence the quality and outcome of children and families’ experiences of safeguarding practice.
“It is vital therefore that government departments work together, and with the panel and local safeguarding partners, to tackle these challenges in what is always very challenging and difficult but potentially lifesaving work.”