Star Hobson: ‘turmoil’ in council led to practice failings in toddler’s case, finds review

    Assessments 'too superficial' due to high workloads and unstable workforce, as practitioners 'too readily' accepted family concerns about risks to Star as malicious, says panel

    Star Hobson
    Star Hobson (credit: West Yorkshire Police)

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    The “turmoil” in Bradford’s children’s services led to practice failings in Star Hobson’s case that meant allegations of harm against her were not treated sufficiently seriously, a review has found.

    Assessments were “too superficial” and did not enable the identification of risks to the toddler or a plan to mitigate them, found the Child Safeguarding Practice Review Panel’s inquiry into Star’s murder by her mother’s partner, Savannah Brockhill, in September 2020.

    It said the numerous concerns of family members about the risks to the girl posed by Brockhill and Star’s mother, Frankie Smith, were “too readily” dismissed as malicious. Also, alleged domestic abuse by Brockhill towards Smith – who was convicted of causing or allowing Star’s death – was not assessed or understood.

    Call for expert child protection teams

    The panel’s key lessons from its combined reviews into the murders of Star and Arthur Labinjo-Hughes were the need to significantly improve both multi-agency working and child protection expertise. It has urged the government to set up multi-agency expert units in each area to handle child protection work, to address both issues, with ministers due to respond later this year.

    However, in Star’s case – much more than Arthur’s in Solihull – it highlighted the role of high workloads and significant staff instability in inadequate-rated Bradford.

    The five safeguarding referrals concerning risks to Star in 2020 took place when Bradford’s integrated front door was focused on managing high volumes, which “resulted in minimal information gathering, including checking background information”, found the panel.

    Star’s case was handled first by a newly qualified social worker (NQSW) with unclear managerial oversight and then by an agency social worker who left before completing their assessment, weeks before Star’s murder.

    ‘A service in turmoil’

    At the time of her death, a third of social workers in Bradford were from an agency and a quarter of social work posts were vacant, a situation that got markedly worse in the subsequent year, according to government figures. Earlier this year, the Department for Education (DfE) decided to hand the city’s children’s services to a trust on the recommendation of Bradford’s children’s commissioner, Steve Walker, though with the authority’s agreement.

    “In 2020, Bradford children’s social care service was a service in turmoil, where professionals were working in conditions that made high quality decision making very difficult to achieve,” said the panel.

    It said the “the scale and depth of systemic problems in children’s services in Bradford” had “a substantive and material impact on the quality of practice and decision making about Star”.

    “The volume of work and significant problems with workforce stability and experience, at every level, meant assessments and work with Star and her family were too superficial and did not rigorously address the repeated concerns expressed by different family members,” the report added.

    This, along with weaknesses in multi-agency working, resulted in “professionals not knowing about or addressing the harm she was suffering”.

    Missed opportunities before and after birth

    Star was born in May 2019, to Smith, then 18, who was in an on-off relationship with the baby’s father, a care leaver, which ended in September of that year.

    The review found that agencies missed opportunities both before and just after Star’s birth to understand the vulnerabilities of both parents and consider potential risks to the girl, as well as the support she would need to be adequately looked after.

    Children’s social care received referrals from Bradford’s leaving care service and transitions team – both of which supported Star’s father – in February and May 2019, respectively, the second highlighting potential risks.

    This should have prompted consideration of a pre-birth assessment, which would have provided a “baseline” for considering the risk factors that emerged after Star’s birth, including lack of settled accommodation, domestic abuse, substance misuse, mental health issues and family tensions within Smith’s family.

    However, neither referral was followed up because children’s social care felt there was sufficient support available from Smith’s family. But, the review found, the decision regarding the May 2019 referral came when the service was focused on managing high call volumes at the front door. with managers and practitioners interviewed for the review admitting there was little consideration of background information.

    In addition, relevant information – notably the fact that Smith’s father had been removed from the family home following a domestic abuse incident towards her mother – was not shared by the police.

    Domestic abuse concerns

    In January 2020, the council received the first of five safeguarding referrals regarding risks to Star, from a domestic abuse service for children and young people who had been passed information by a friend of the family whom it was supporting. The friend reported domestic abuse by Brockhill towards Smith, that Brockhill had smacked Star, who was then eight months old, and that Smith was increasingly leaving Star’s care to the friend.

    The review found several problems in the handling of the referral, which the domestic abuse service anonymised to protect the identity of the referrer and which also did not name Brockhill.

    Firstly, as the integrated front door (IFD) flagged the case as a child protection concern, the council should have convened a strategy discussion to share information across agencies and plan for the home visit. Instead, the duty social worker called Smith, who denied any domestic abuse, with Brockhill present during the call, and then requested a police welfare check, which found no concerns. The review found the call to Smith was problematic as it alerted the couple to what would be discussed.

    The panel said consideration should have been given to a section 47 child protection enquiry, given the referrer had alleged Brockhill had smacked Star, and a domestic abuse, stalking and honour-based violence (DASH) assessment should have been carried out and a crime also reported in relation to the alleged domestic violence.

    However, instead the referral resulted in a child and family assessment, by the NQSW, which lasted until March 2020, involving three home visits, but identified no concerns and no need for further involvement from children’s social care.

    Though the social worker’s practice supervisor asked her to establish Brockhill’s identity and any risks she presented, the completed referral just included her first name and no other details. The social worker also did not know that, in February 2020, Smith had ended the relationship and asked Star’s great grandmother to look after the baby as she could not cope.

    ‘Superficial and mechanistic’

    The review found that the “case notes showed a superficial and mechanistic approach to the assessment”, and its limitations “significantly affected” how subsequent child protection concerns were viewed and addressed.

    The social worker’s supervision was equally split between their team manager and practice supervisor, resulting in “a lack of clarity as who was driving practice decisions and had oversight of the quality of assessment practice”. While the practice supervisor asked the social worker to identify the risks from Brockhill, they did not subsequently see the assessment document so could not consider the quality of analysis or whether there was any missing information.

    In May 2020, Star’s maternal great grandmother contacted children’s social care to say Smith had abruptly removed the girl from her care after resuming her relationship with Brockhill, and that Smith’s younger siblings had reported Brockhill grabbing Star by the throat and slamming her against the wall.

    Again, a child and family assessment was carried out – by the same social worker – involving an unannounced visit, which uncovered no cause for concern after Smith told the NQSW the referral had been motivated by the great grandmother’s dislike of being prevented from seeing Star and disapproval of her parenting methods and same-sex relationship. Though Star’s father subsequently told the social worker Smith had slapped their daughter and been domestically abused by Brockhill, Smith denied this.

    A safety plan was agreed for Star’s grandmother to oversee contact with Star and in June, the case was closed.

    The review found that it was “unrealistic to expect a single agency process undertaken by an inexperienced social worker to uncover and address” the complicated child protection issues in the case which, as a result, “were either left unexplored or addressed in an insufficiently in-depth way.

    ‘Malicious referral’ claim ‘too readily accepted’

    Smith and Brockhill’s claim that the referral was malicious was “too readily accepted” and there should have been much greater challenge to their explanations and “forensic follow-up” of the divergent opinions from Star’s father and the maternal family.

    A multi-agency strategy discussion would have provided a better chance of finding out what was happening to Star, by enabling professionals to challenge assumptions that the family were being malicious and evaluate the allegations against Brockhill and Smith.

    The review also criticised the failure to convene a strategy discussion in June 2020 after Star’s father and maternal family members raised concerns including bruising to Star, Smith slapping her and Brockhill punching Smith. When police visited, they found bruising to Star, which Smith explained by saying she had banged her head on a coffee table. A subsequent child protection medical confirmed the bruising was consistent with Smith’s explanation.

    Bradford’s children’s social care guidance states that a child protection medical should be carried out as the outcome of a strategy discussion, which did not take place, and the review said that the medical’s findings should not have been considered in isolation but in the context of all the previous allegations of harm to Star.

    The day after the medical, a fourth referral was made by a family member alleging slapping and verbal abuse by Smith towards Star, prompting an assessment that involved a virtual home visit by the social worker, who accepted Smith’s explanations of bruising to Star and that the allegations were malicious.

    Case closed ‘without due reflection’ due to team pressures

    The panel questioned why a virtual visit was carried out as it limited the social worker’s ability to use their observational skills and made them reliant on what they heard and were shown. It said too much weight was, again, given to Smith and Brockhill’s account, too little time spent with Star and family members’ concerns were not given due weight. The case was, again, closed in July 2020.

    The fifth and final referral came through at the start of September, when Star’s maternal great grandfather contacted the integrated front door to say he had seen a video of bruising to Star, while also reporting domestic abuse by Brockhill towards Smith. In a phone call, Smith said Star had bruised herself falling downstairs. An agency social worker then carried out a home visit, finding the home clean and tidy and good attachment between mother and daughter. Though they wrote up their case notes, they left the authority without completing the assessment, leaving this to the team manager. The case was closed on 15 September – seven days before Star’s murder – on the grounds that the concerns were unsubstantiated and the referral malicious.

    In an interview for the review, the team manager said they were under “significant pressure to re-assign the cases that had been held by the agency worker” at a time of high caseloads on the locality team.

    “It was because of these circumstances, and because of the number of cases the manager had to re-allocate, that the assessment was concluded and the case closed without due critical reflection and challenge,” said the panel.


    On the back of its report, the panel called on safeguarding partners in Bradford to:

    • Commission and resource a comprehensive, early help service, accessible before, during and after any children’s social care assessment.
    • Agree clear expectations regarding risk assessment and decision making, including ensuring they involve multi-agency information gathering that includes listening to family and friends and going beyond self-reporting.
    • Immediately provide practitioners with guidance, training and supervision on enquiring about domestic abuse, including in same-sex relationships, developing safety plans for children and families and supporting perpetrator interventions.

    The review said it recognised that the Bradford Partnership, which oversees safeguarding in the city, had acted to address issues raised in local learning from the case, as well as to deliver on the recommendations of Bradford’s children’s commissioner, Steve Walker.

    ‘We must put things right’

    “On behalf of the Bradford Partnership, I want to say first and foremost that Star’s death in such awful circumstances should not have happened and that we are truly sorry that it did,” said its chair, Janice Hawkes. “We know agencies let Star down and we must put things right.”

    Hawkes said agencies were taking steps to improve safeguarding, but more needed to be done, as she backed the panel’s recommendation to establish multi-agency expert teams in every area in the context of “how complex and challenging working in child protection can be”.

    Hawkes, a social worker by background, who took up post this month, added: “As the new chair of the Bradford Partnership, I am absolutely committed to making sure we do everything in our power to strengthen how we keep children safer in our district.”

    Chair appointed for Bradford trust

    Meanwhile, children’s minister Will Quince has appointed Eileen Milner as chair of the Bradford children’s trust, which is due to launch in April 2023.

    Milner was most recently chief executive of the Cambridgeshire and Peterborough Combined Authority – which is responsible for economic development in the two areas – and previously head of the DfE’s Education and Skills Funding Agency.

    In a letter to Milner, Quince said: “As chair, you will be critical to the success of the trust, and in securing high-quality services and the best possible outcomes for vulnerable children and families in Bradford. A decisive fresh start is essential considering the findings from the commissioner’s and the national panel’s reports and the level of entrenched failure within children’s social care services.”

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    9 Responses to Star Hobson: ‘turmoil’ in council led to practice failings in toddler’s case, finds review

    1. DM May 30, 2022 at 5:40 pm #

      It upsets me to say this as a Bradford social worker but even if there been a specialist team here, it’s unlikely that there would have been more proactive work undertaken given the chaos we were working in. Until senior managers,not the hapless burdened team ones, get to feel the blame too nothing will improve. I’ve received more e-mails about the City of Culture bid than an honest acknowledgement of how poorly supported we were then. I get shouted at and I get threatened and I get called a murderer. Our senior bosses are insulated from such direct anger. Or they find a way to move onto equally senior posts elsewhere. Don’t just blame agency workers, don’t just blame team managers. Make it safe for staff to speak honestly, tackle the causes for high vacancies and we will make a better job of it.

    2. Yoni May 30, 2022 at 7:42 pm #

      Why is it that time and time again someone who is not a social.worker feels they can run social work organisations? Would doctors let their services be run by non doctors? I doubt it.

    3. Dedicated Social Worker May 30, 2022 at 7:56 pm #

      You can trace Bradford’s “Turmoil” all the way back to Hamzah Khan’s tragic death in 2012 and the subsequent press and political furore, which led to, or influenced the resignations of the director and safeguarding chair, and I believe many social workers also left due to feeling undue pressure and stigma. At that time, Bradford was considered by many social workers to be a good, stable employer.

      • Brian May 31, 2022 at 11:50 am #

        There is never a mass exodus when social workers work for good and stable employers. I and many many other social workers stayed and ploughed on in Haringey and Brent through some of the most vicious and vindictive press coverage of social workers. Please do not let the narrative flit away from employers owning their accountability. The problems social workers face and the consequences of that on experts by experience are structural. I may be the worst social worker in the istory of social work but I could never cause catastrophic harm if the systems around me were sound.

    4. Tom J May 31, 2022 at 3:05 pm #

      I regularly speak to children social workers who have a caseload of 25, haven’t had quality restorative supervision in months, and regularly work evenings to catch up with recordings.

      Reading the full review and seeing the expectations; I can guarantee you that there is no way that any social worker with a caseload of 20+ is able to go anywhere near meeting the level of practice with each of the children on their caseload. Many are fire fighting whether that be completing visits and assessments on time, or responding to the latest disclosure.

      Unless huge change comes including investment- there will be another national review just like this that will be written ten years from now.

      • Beverley May 31, 2022 at 8:38 pm #

        Bradford is not the only local authority that needs a massive reset. In another, you have an NQSW taking on cases run on agency staff no consistency with families. Families lives turned upside down, waiting in limbo for social services to get in touch only to find another agency social worker has taken over. No one truly knows your case and believe me this comes across as the social worker in being 100% incompetent they can’t make decisions they have to address their senior management and then never get back to you, and again another agency takes over the case
        It’s an absolute joke how local authorities have so much power.

    5. Lesley June 1, 2022 at 2:02 pm #

      Why are we always blaming overworked and undertrained. The fact remains it just keeps happening. There should all wear cam corders if traffic warden do why is sosciel services not doing. This. Because we kniw when it goes wrong we are kept from knowing who the sosciel workers are and they are normaly moved to another place out of site. Yiu get ut wrong stop blaming everyone and anything. You see bruises and ignore. And thats ok. You get more than enough repirts. You dont follow up. Its wrong. Just say it stop blaming the fact sociel workers have sometimes no comon sense. What ealse can it be.

    6. Chris Sterry June 4, 2022 at 9:20 pm #

      Much is wrong with Social Care in England, be it children’s or adults and there are many reasons.

      Some as stated in the article, but some that are not.

      For finance is also a major factor, for since 2010 the tory Governments have been inflicting large austerity cuts on Local Authorities, (LAs) and while social care was to some extent shielded from cuts, in time reductions, or as readily known, savings. but effectively there was no opportunity to make savings, so real cuts to services had to be made. Savings are generally made by improving efficiencies by taking out assumed ‘slack’ in the services. But in many instances there was no effective slack, so the slack was created by cutting staff, increasing workloads and restricting supervisions and maybe training.

      This is bound to create chaos, but the Governments of the day had no wish to hear of LAs problems and LAs were reluctant to advise Governments, due to the threat of Governments bringing their own staff to run LAs departments.

      perhaps some social workers were not as efficient as they should be, by inexperience, low moral, over worked, too large case loads, management expectations not realistic and others.

      But there is honesty, transparency and others which are not evident in LAs and certainly Government, just an unrealistic attitude from Governments and LA management.

      Work pressures not being dealt with, mainly because of insufficient staff, inexperienced staff, insufficiently trained staff, insufficient and effective supervision, which sufficient funding could have gone some way to improve.

      It is always the social workers who are blamed and maybe their managers, but never the Government, all need to be accountable, especially the Government and Government Ministers.

    7. Anon June 4, 2022 at 10:00 pm #

      I work in a “first contact team”. We deal with the incoming referrals, triage/assess and decide what needs to happen. It’s non case holding but is exceptionally busy. Every single “concern” about a child is reported in no matter how small. We are completely swamped at the moment and there is no funding for more staf and we go out of timescales pretty much daily due to amount of work coming in.

      The assessing teams who are the next team along are completely overwhelmed and well beyond capacity. There are even 100-200 cases “stacked” waiting for assessments. Cases are closed to early due to capacity issues, theres constant re-referrals, constant concerns about CSE and CCE alongside the usual DV/DA and child abuse etc.We just dont have the resources to deal with the amount of referrals coming in anymore.