Arthur and Star cases show need for expert child protection units, finds review

Inquiry into lessons from children's murders finds structural overhaul needed to combat lack of child protection expertise and fragmented multi-agency safeguarding arrangements

Annie Hudson, chair, Child Safeguarding Practice Review Panel
Annie Hudson, chair, Child Safeguarding Practice Review Panel

What would most improve child protection in England?

  • Lower caseloads for child protection social workers (63%, 701 Votes)
  • Setting up expert multi-agency units to handle all child protection cases (16%, 184 Votes)
  • Improved multi-agency working without setting up expert units (6%, 69 Votes)
  • Improved practice in the police, health and/or other agencies (5%, 61 Votes)
  • Improved training and supervision for child protection social workers (5%, 53 Votes)
  • Ring-fencing child protection casework for "expert" social workers (5%, 52 Votes)

Total Voters: 1,120

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The murders of Arthur Labinjo-Hughes and Star Hobson demonstrate the need for child protection practice to be handed over to specialist multi-agency teams of expert practitioners.

That was the verdict today from the Child Safeguarding Practice Review Panel’s inquiry into the lessons from the killings of six-year-old Arthur and 16-month-old Star, in each case at the hands of the partner of one of their parents, with those parents’ complicity.

In Arthur’s case, the panel found that professionals in Solihull had only a limited understanding of what life was like for him, did not always hear his voice, did not challenge their initial framing of his father, Thomas, as protective, and did not take the concerns of his wider family seriously.

Arthur Labinjo-Hughes

Arthur Labinjo-Hughes (photo: West Midlands Police)

It said children’s social care’s failure to convene a multi-agency strategy discussion in April 2016, after Arthur’s paternal grandmother reported bruising that she felt may have been carried out by his stepmother, Emma Tustin, was not appropriate and undermined agencies’ response. Last year, Tustin was convicted of murdering Arthur, who died from a single blow to the head, in June 2020, with Thomas Hughes convicted of manslaughter.

‘Systemic flaw in multi-agency working’

Overall, the review found a “systemic flaw in the quality of multi-agency working”, with “an overreliance on single agency processes with superficial joint working and joint decision making”.

The panel found a number of similar findings in the case of Star, who was murdered by her mother’s partner, Savannah Brockhill, in September 2020, with her mother, Frankie Smith, found guilty of causing or allowing her death.

Star Hobson (credit: West Yorkshire Police)

It said that professionals in Bradford had limited understanding what life was like for her, did not listen to wider family members and that the responses to safeguarding referrals “were significantly weakened by the lack of formal multi-agency child protection processes”.

In addition, it found an inadequate response to concerns of domestic abuse towards Smith from Brockhill and that assessments by children’s social care “were not fit for purpose”, at a time of “turmoil” within Bradford’s children’s social care service, in 2020.

Two key lessons

The panel, which is also responsible for analysing serious child protection incidents reported by councils, said that what happened to Arthur and Star were not isolated incidents and their deaths reflected wider problems in child protection practice. In particular, it identified two key lessons from the cases and its wider learning from safeguarding concerns:

  • Multi-agency arrangements for safeguarding children are too fragmented, with inadequate information sharing making it “extremely difficult” to build and maintain an accurate picture of what life is like for the child.
  • A need for “sharper specialist child protection skills and expertise, especially in relation to complex risk assessment and decision making; engaging reluctant parents; understanding the daily life of children; and domestic abuse”.

Specialist child protection units

Among a number of recommendations designed to tackle these issues, the review called for the creation of dedicated multi-agency child protection teams in every area, based within local authorities, but made up of secondees from the police and health as well as social workers.

The units would be responsible for convening and leading strategy discussions, carrying out section 47 child protection enquiries, chairing child protection conferences, overseeing, reviewing and supporting child protection plans, recommending court applications and advising other teams and agencies on child protection.

It said this arrangement would ensure fully integrated multi-agency decision making throughout the child protection process, delivered by those with the appropriate skill and expertise.

Panel chair Annie Hudson said: “At the moment, each professional who comes into contact with a child holds one piece of the jigsaw of what is happening in a child’s life. Our proposed reforms would bring together experts from social work, police and health into one team so that they can have a better picture of what is happening to a child, listening carefully to relatives’ concerns and taking necessary actions to protect children.”

Backing for expert practitioner role

In relation to social work, the panel backed the recommendation of the Independent Review of Children’s Social Care, in its final report, published on Monday, to establish the role of expert child protection practitioners, obtained in future by passing a five-year assessed early career framework.

It also accepted the care review’s proposal that such expert practitioners co-work cases with family help teams to avoid fragmentation. Under the care review’s blueprint, these teams will have been working to support the family prior to child protection processes being initiated – but the panel stressed that the child protection units should have decision-making authority in such cases.

Unit police and health representatives would need to be well-connected to their employing agencies and maintain their professional development to ensure they could co-ordinate the involvement of their professional colleagues in cases, enabling effective multi-agency working, it added.

The recommendation matches a proposal put forward in a piece for Community Care last week by former government safeguarding adviser Sir Alan Wood. This drew significant criticism from some social workers and academics, who argued that inadequate resources and excessive workloads – not lack of skill – explained child protection challenges and that Wood’s proposal was not rooted in evidence.

‘An extremely difficult and complicated task’

However, in an interview with Community Care, Hudson said: “What we see very strongly in the stories of Arthur and Star is, perhaps inevitably, that what parents, parents’ partners and carers say cannot always be taken at face value, and the skill of getting underneath what people are saying is an extremely difficult and complicated task.

“But the way in which we organise our child protection systems does not enable professionals taking some of the most difficult public service functions to do those to the best of their ability.”

She added that, while all social workers in children’s services needed to have a good understanding of safeguarding and child protection, “there are additional skills and attributes that you need when you are undertaking this very difficult work of investigating abuse and overseeing the work to protect children following an investigation”.

‘Social work career development neglected for too long’

In relation to the panel’s backing for the care review’s early career framework proposal, Hudson -formerly chief executive of the defunct College of Social Work – said: “I support those recommendations and that direction of travel and I believe strongly that for too long we haven’t offered social workers the opportunity of clearly structured and appropriately resourced career development.

“If you look at teaching, medicine, nursing and policing, those career development journeys are well established. We haven’t had that in social work and I think that will be really crucial in terms of retention of social workers because it gives them the opportunity to develop.”

The panel’s other recommendations were for the government to:

  • Establish national multi-agency practice standards for child protection, capturing the best available evidence of what works when working with children and families.
  • Set up a national child protection board involving representatives from central government departments, local government, the police and health, to ensure greater co-ordination of child protection policy and performance management.
  • Strengthen local multi-agency safeguarding partnerships, in line with the recommendations of the care review, to address issues including lack of senior representation, inadequate oversight of practice and problems agreeing funding levels.
  • Increase the role of multi-agency inspection in holding partnerships to account, strategically and operationally, potentially reducing the number of single-agency inspections as a result.
  • Fund peer support for safeguarding partners, overseen by the panel itself, in order to share learning.
  • Convene a task group to improve the way data is used by professionals to better protect children.
  • Promote the way safeguarding partners work with domestic abuse services and ensure professionals in their areas have adequate knowledge of the topic. The panel itself will produce a practice briefing this summer on safeguarding children in families where there is domestic abuse.

Earlier in the week, the Department for Education warmly welcomed the care review and gave in principle backing to the early career framework, with children’s minister Will Quince specifying that this would focus on improving child protection practice.

Zahawi: ‘We must waste no time learning from findings’

It will give a fuller response to the care review, alongside an implementation plan, later this year, and today education secretary Nadhim Zahawi said this would also incorporate its full response to the panel’s report.

However, in a written statement to the House of Commons, Zahawi said he was “committed, with colleagues across this House, to acting on [the panel’s] recommendations”, and that “system change on a national scale is needed”.

In a separate statement, he added: “We must waste no time learning from the findings of this review – enough is enough. I will set up a new child protection mnisterial group, a first and immediate step in responding to these findings, before setting out a bold implementation plan later this year to bring about a fundamental shift in how we support better outcomes for our most vulnerable children and families.”

In its response to the panel’s report, the Association of Directors of Children’s Services said there was learning for all local areas and government from it.

“For example, sharing and piecing together timely and relevant information about children and their circumstances is key to getting a full picture of a child, their needs and the risks posed to them, as is securing enough resources from all safeguarding partners for child protection work,” said president Steve Crocker.

“Domestic abuse is the most common reason why children come to the attention of children’s social care, the learning that will come from the [panel’s] review on domestic abuse in the summer will be a helpful addition to our understanding of this complex issue.”

Directors cautious on specialist units

On the panel’s proposal for specialist units, Crocker expressed caution, adding: “We will need further details to understand how such units would work in practice and the relationship with the wider system of children’s social care, ensuring that lessons are learnt from previous attempts to implement similar models while identifying any potential unintended consequences for children, families and our staff.”

Referencing the recommendations of the care review for investment to reform children’s social care and shift its focus towards family help, he said: “Investment in both early help and child protection work is needed to shift the dial towards supporting more children and families earlier on, before they reach crisis point and we hope that the government recognises the call from the independent review of children’s social care that investment of £2.6bn is urgently needed to re-set the system.”

‘Devastating loss’

Hudson, Zahawi and Crocker all highlighted the horrific abuse Arthur and Star suffered.

Hudson told Community Care: “I think it’s really important to state what happened to these two children is very much at the heart of what we’re saying in this review and important to recognise the devastating loss to family members and others who cared for them.”

Zahawi said: “Nothing is more tragic than the death of a child, but when that child dies as a result of abuse or neglect it is incomprehensible. The deaths of Arthur Labinjo-Hughes and Star Hobson appalled the nation and highlighted the urgent need for action and change.

Crocker said it had “been difficult to read the harrowing details of what Arthur and Star endured in their short lives”.

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20 Responses to Arthur and Star cases show need for expert child protection units, finds review

  1. Red May 26, 2022 at 6:45 am #

    This states the most common reason a child comes to the attention of childrens social care is due to domestic abuse, until the police and courts are strengthened to tackle this it doesn’t matter what social services do with their structures.

  2. Mark Monaghan May 26, 2022 at 1:20 pm #

    We are ‘Experts’ they offer the same rhetoric whilst seeking to draw inferences similar to the care review….Give the experts the tools, IT, support, legislative guidance , etc, and we will continue to do our best.

    Dont forget though we can police all the monsters who want to abuse, maim, hurt and kill children. We endeavour to continue to try where we can.

    Stop talking about learning lessons and do something, the support for families has eroded considerably year on year since I’ve been a social worker, nearly 20 years ago!

  3. Kitty May 26, 2022 at 1:53 pm #

    I agree with Red and additionally what is new about what is being suggested….” child protection teams including social workers, mental health workers, police officers, paediatricians and child psychologists to oversee cases where children are at serious risk of harm.”
    There are so few of any of these workers hiving them off into
    ‘ super’ Teams means less availability elsewhere. They are also all currently involved in Child Protection cases to a lesser or greater extent
    All of this change alongside a radical overhaul of the care system. All done in the blink of an eye and then not funded and then not fit for purpose.
    Two disappointing reports in two weeks that are both hugely critical of everyone currently involved in helping vulnerable children and their families both tell us what we already know and both then go on to offer easy answers to complex problems…glad to be near to retirement and might bring that forward…

  4. Melanie May 26, 2022 at 10:55 pm #

    The idea of expert child protection units filled with specialist practitioners is interesting and should not be dismissed. Perhaps by thinking it through and strategising about ways this could potentially occur, would be a positive response.

    Please lets all remember that practitioners are only as good as their last case. This means that if practitioners continue to be over worked, overly stressed, rushed to meet never ending deadlines then this will continue to lead to practitioners providing reports that has little to no quality information, due to work pressure, bureaucratic processes, then those super teams will soon be our usual social work teams that is burnt out.

    • LizHoward June 2, 2022 at 8:14 pm #

      Only as good as their last case??? What an awful statement to make

  5. Pam May 26, 2022 at 11:11 pm #

    I’ve been in this job for over 20 years and have seen no positive changes. All these promises to make it easier for us has never happened, except giving us more repetative paperwork and less time with the families. Would love for these people making these decisios and changes to come and actually spend some weeks with us on the frontline and see what we do. Half the time is wasted on chasing other services for information, to put these puzzles together (some services are good and some really bad at sharing)

  6. Craig May 27, 2022 at 8:36 am #

    Care Review, Sir Alan and now this. A cynic might conclude it’s not a coincidence.

    • Suspicious minds May 27, 2022 at 2:04 pm #

      Manufacturing consent

  7. Carol May 27, 2022 at 9:15 am #

    When these murders happen social workers always tell us that failures are by multi-agencies that they shouldn’t be the only ones blamed. This review recommends sharing of protection responsibility and asks that other collagues are brought in to formalise responsibilities in a single team. I am baffled why some leaders and some social workers are now suddenly against shared responsibility. The glaring omission here is the indepth look into the skills, abilities, knowledge and expertise of managers and supervisors. Ultimately social workers are beholden to our bosses. We are not autonomous practitioners who make our own decisions. It may be that “expert” investigators are the way forward but how will they be managed? Also why so little on the role of the PSW? There’s clearly agenda setting for further specialism given Sir Alan, MacAlister and now this. Time will tell if this is based on good evidence indicators or political directing.

  8. Rachael Douglas May 27, 2022 at 5:14 pm #

    Having read the report into the actions of professionals in Solihull and Bradford when Arthur and Star respectively were being abused and then murdered by their carers I do agree with the author that specialist child protection teams should be set up. However, I really do think that it is time to separate out different types of social worker so that parents/carers can learn to trust them when this is needed. Giving all social workers the same title means we, the public cannot differentiate between those who are investigating us, as opposed to those whose intention is to support us to keep the family together. The other issue is that social worker is also synonymous with cock-up and and cruelty, when parents are wrongly abused of harming their children and I would like to know that this is not the case with the majority of them. Suggestions for new job titles are: Child Protection Officer; Family Social Worker (not to be confused with Family Support Worker who would work under the auspices of the Family Social Worker); Disability Social Worker (I believe these already exist); Kinship Practitioner; Reunification Officer (tasked with reuniting familees where this is deemed safe; Siblings Support Officer.

    • Bear June 16, 2022 at 10:51 pm #

      Every statutory social worker should be working to ‘keep families together’ as that is what the law says has to be done, as long as it’s safest option for the child.

      The Family Court have final say about whether a child is removed or not.

  9. Constance May 28, 2022 at 9:23 am #

    There’s clearly a new ‘vision’ emerging as it cannot be a coincidence that Hudson, MacAlister and Sir Alan push the same line. Pay and bureaucracy are the easy ones to get heads nodding but that wasn’t the only reason for Bradford being in “turmoil” was it? We have had decades of bad management too. Our post qualifying training is non-existent, our ability to speak out and be heard increasingly limited. For far too long the cultures that shape our work have been fad driven, unfocused, advice and guidance contradictory. The malaise in social work manifests in every level of our work, from nonsense around hot desking to who is worthy of a lap top to coffe perks from employers to being ‘allowed’ to think about our work. Flexibilty, agility, resilience and all the other MBA buzzwords infecting management think does not necessarily make for more effective practitioners. Our leaders are too easily seduced by baubles, too complacent about where “regulation” has led us. Bureaucracy over relationships should never be the driving force in social work. But it is. They count numbers, reprimand without acknowledging their failings, are mechanistic in their thinking about “standards”, complacent and over confident simultaneously and more shamefully unbothered by the world outside of the work environment. All of this is can be evident in us bog standard social workers too but we don’t ofcourse have the power to enact change. Which is why when we speak up we get accused of moaning. If the aim really is to minimise harm, improve practice, be more effectively in control of the ” manipulating” then tackle training too. PSW would disagree but has degrees really made for more competent social workers? Are we more analytic, intellectually curious, better informed for having an MA? Who does the teaching, what is their relationship with practitioners, is SWE really competent to set standards, are practice educators an add on or integral to how we develop, allow a discourse that validates our experience of academia. Questioning the desirability of shoe-horning a vocation into a faux profession would be my starting point. Have a real committment to meaningful post qualified training, ditch the tick boxing that is e-training. I work in a “multidisciplinary” team. It’s not a panacea per se. Sitting in the same room doesn’t create a common reality nor shared values. I say bring back “problems” and ditch “challenges”. Not every complex situation needs a Catherine wheel solution.

  10. Twizza May 28, 2022 at 10:41 am #

    I think Social Workers and their managers are in a difficult position led by ‘stats’ not families.

    Stats reveal it ‘too many’ strategy meetings are held which they state inspectors see as a bad thing so I can see why Solihull developed their approach of a ‘threshold visit. Inspections are viewed negatively from the top down and social workers are allocated children before a visit to ensure every child has a named worker in place, rather than talking with inspectors about the issues, risk assessing referrals and explaining why they cant do certain things, these issues are hidden and the burden is placed back on the social worker and ultimately the family who may have to speak to several social workers when either:

    A the worker goes off sick with stress
    B they leave the profession
    C after the inspection the family is reallocated to a new worker as the reality is the worker cannot physically do what is expected of them.

    At times social workers are completely alone in making these decisions and face daily threats trying to carry out their work which impact on the strongest of workers.

    Face to face office work is still not in place meaning social workers hold the risk themselves and are more isolated than ever before.

    Social workers are leaving the profession and no one seems to know why or they do and take little action instead talking bg about more specialism when really there are not enough social workers around to do the ‘basics’ or just a joint visit when needed needs to be planned.

    Local authorises are short staffed, visits are rushed as you may be asked to do many in one day.

    Caseloads are high and they are unable to manage the timescales dictated for them which were of course put in to make things better, instead making the work unachievable it’s actually mathematically impossible to fit the expectations on us within the timescales dictated not just legally but additional ones by each local authority.

    Computer systems are slow and clunky and involve repeating the same information over and over again to appease management and inspections and notes from managers which relay the work is late. Adding more pressure and meaninglessness input into a file which really is about the child and something they can read when they are older to understand what has happened to them.

    We all know the issues….

    • Paul May 30, 2022 at 9:42 am #

      It’s all so strange. Isn’t SWE meant to ensure safe practice and provide social workers a route to highlight these things? Either SWE is not fit for purpose or social workers are more comfortable being victims than doing something.

  11. adarynefoedd June 1, 2022 at 1:13 pm #

    The poll does not include better access to Level 1 and 2 services eg Family Centres, Sure Start, relationship building in communities is one of best ways to prevent and protect, Anti poverty work is also crucial. Unfortunately team location and adherence to targets prevent much effective work being done with local communities. Few relationships with local providers unless there is a crisis.

  12. Alison Greenwood June 1, 2022 at 1:47 pm #

    Social Workers need lower caseloads – how long do we have to keep saying this

  13. Abdul June 1, 2022 at 3:11 pm #

    We need more social workers, less cases, less paperwork and report writing, and more time with clients, and more resources and support services. I feel like I’m an admin worker, constantly writing reports and people’s life stories, but I don’t have time to spend with the children or do any of the much needed interventions. We judge social workers by their ability to meet timescales and write reports, but none of it on the actions behind it, which keep children safe.

  14. John Stephenson June 1, 2022 at 6:40 pm #

    How about allowing social workers to be social workers,before I retired at least 50% of my time was doing admin tasks.

  15. Kathleen Ritchie June 1, 2022 at 8:34 pm #

    Going into my 15th year in child protection work I made the decision to leave and have never looked back. Year on year failings of the system and child deaths are reported but the same issues remain, ie lack of resources, lack of support when managing extreme and unhealthy ongoing levels of stress, lack of understanding/recognition by government/policy makers of the complexity of child protection work, high caseloads, extensive admin and high turnover of staff. Sadly I have seen many amazing social workers burn out and leave the profession over the years, alongside more of a focus on meeting targets and the life being squeezed out of any community resources.

  16. Gail June 2, 2022 at 4:18 pm #

    Yet again another report of professionals failing in a system that continues to set unrealistic expectations in sectors that are continually underfunded and under resourced over decades.
    High case loads, unreasonable work hours, lack of resources and services to support those who are vulnerable in society prevail. Governments continually change systems, reword what is known, blame training and deficits in a sector that has continued to deliver services as best they can in challenging situations.
    I have yet to meet a social worker that does not worry about the families they work with as they strive to understand the lived experience of each child in families in situations where you are not always welcome.
    Life is messy and complex, society has its views, everyone is a jury and judge. professionals don’t have a crystal ball, social workers do their best as Government Leaders add layers to guide social workers good practice yet in reality they create defensive practice, environments that set unacceptable work hours, poor work life balance, high staff turnovers, resulting in a profession that is continually undermined, underpaid and under appreciated.
    The social work profession is a marginalised, the public view is mixed and the professional organisation itself is reactive. Since 2012 we have had 3 professional organisation changes, the professional standards reworded to ‘reshape, strengthen, enable’!! The staff turnover is crippling the sector and the social worker lifespan in the profession is 8 years and given the education costs alone it is an expensive qualification.