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
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.”