Tackling weak risk assessment and decision making is priority to improve safeguarding, say government advisers

Panel reiterates concerns over quality of child protection decision making in annual review of serious cases that will shape children's social care review

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Councils and other safeguarding agencies should prioritise tackling “weak” risk assessment and decision making in child protection, a panel of advisers has said.

The recommendation was made last week by the Child Safeguarding Practice Review Panel, as its annual report flagged concerns about the quality of decision making for a second consecutive year.

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”.

Evidence gaps

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.

Unprecedented year

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.”

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9 Responses to Tackling weak risk assessment and decision making is priority to improve safeguarding, say government advisers

  1. CaptainFog May 19, 2021 at 4:26 pm #

    When you have organisation like Ofsted who have consistently failed in their audits of schools to identify risk of sexual assaults against teenage girls once has to wonder whether more focus should be given to auditing these inspectors and checking they have sufficient assessment skills? Perhaps Ofsted inspectors should be required to go back into operational practice – some have been in their res for years and possibly lost touch.

  2. A Man Called Horse May 19, 2021 at 5:44 pm #

    How much more evidence is required that Risk Assessment is not a science, its an opinion based upon information at any given point in time. It can be out of date very rapidly as chaotic families have chaotic lives. The other problem is that analysis of large amounts of data by humans is very time consuming and often Social Workers are under pressure and simply don’t have the luxury of time pontificating about what might happen. Future prediction as we have seen from the pandemic is problematic and humans are very poor generally at assessing risk.
    Unfortunately dangerous individuals with pathologies will go on killing children their children. There have been many enquiries and it has changed nothing. It is interesting to note that most of the children killed are from poor or disadvantaged families. I see no signs that the Government plan to do anything about bad housing, lack of opportunity, poverty and general insecurity. It is interesting to note that countries with better welfare, health services, education and far better housing do much better than the UK. The chief Social Worker has nothing to say about these issues just easier to yet again try to blame social workers for not having the skills to stop children dying. There are not enough resources in Social work and not enough Social workers to do this complex and challenging work. There is zero evidence that better risk assessments would have changed the bad outcomes recorded. Bringing in 50 page risk assessments will simply lead to more stress on social workers and likely will not make a shred of difference. Good risk assessment is far better done by AI that can produce far more accurate risk analysis by looking at patterns in data that humans cannot easily see. Make Social Workers more like robots and they will do better. Sick of this blame culture being offloaded onto social workers and my guess is that many of them already feel undervalued, overworked, underpaid and sick of the obvious conservative attacks on the workforce facilitated by a chief social worker asleep at the wheel.

    • Mark May 19, 2021 at 10:55 pm #

      Spot on! Just another expensive cog in the process. I wonder if they will ever speak for us? I’m not holding my breath.

    • Lucy May 24, 2021 at 12:12 am #


    • Sonny May 29, 2021 at 11:38 am #

      Well said. We need AD’s to become more radical in challenging central government.

  3. Marrian Pattinson Vaughan May 19, 2021 at 6:48 pm #

    No of the above is new, it’s happening on a daily basis. The SW arena is failing at all levels. The government have not taken this profession seriously for decades resulting in an absolute failing of some of the most vulnerable children and families this country has known. Blame cultures, poor funding, newly qualified staff expected to hit the ground running with no experience of safeguarding other that what they have read, 30 years of high criticism, staff moving into positions of management with little experience, bums on seats policy, low morale and a whole host of other overdoing issues to many to list. 30 years post qualification IVE HAD ENOUGH

  4. Mark May 19, 2021 at 10:47 pm #

    And me Marrian, I’ve had enough of the bureaucracy. I’m out after 20 odd years and hope to never have to go back. When was the last time any of them sat at a duty desk with 30 childrens to work with. We must be the only profession to keep being challenged continually.. I have no issue with review or looking for best practices, but Trowler and her kind would be out within 2 days. I wouldn’t welcome any of them at my duty desk! And as for the managers who audit and blast us, if we are that bad get out there and do it yourself! My age group may be the last to offer you 20 or 30 years of practice. I feel sorry for the families. So Isabelle when did you last do proper social work? Answers on a postcard. Parasites….remember you dont represent me.

  5. Libertarian May 20, 2021 at 12:10 pm #

    Just let Josh MacAlister expand Frontline, Isabell Trowler reserect the Blueprint. Make all social workers self employed. Learn from Academies and Free Schools. The best risk assessment is from sanctions and insisting on personal responsibility not endless handwringing and infantalisation of “vulnerable families.” No need for further research.

  6. Wolfnut May 31, 2021 at 8:19 am #

    Another load of ……, I better not say it. The comments posted here are articulate and accurate in terms of a representation of how many social workers feel. If you give unrealistic timescales for assessments and high caseloads then it’s obvious they won’t be done as thoroughly as they could be. When you add very prescriptive forms and tick boxes because ‘ this is what OFSTED will be looking for’ you get a system that is focused on performance as opposed to critical analysis. I know of one Head of Service for Safeguarding who produced a template for recording visits that replicated the ‘ boxes’ on the computer system. He would also put notes on the file ‘ stat visit ‘ , ‘core group’ etc out of timescale because that’s all he was concerned about with an inspection looming.
    For those of us tasked with doing court work the Social Work Evidence Template is yet another example of box filling with the dreadful ‘B-S ‘ analysis .
    This article depressed me as yet again those conducting a review miss the point completely. After 45 years in social work I too have had enough. I see Managers with little experience in jobs that are way beyond their capabilities, knowledge and skill set. You can’t tell them though because experience is a dirty word. There is nothing new about this review and some people are making careers of saying how others should do it.