Children’s services leaders must foster the conditions for professional curiosity and challenge to improve the quality of child protection practice, the national safeguarding body has said.
The Child Safeguarding Practice Review Panel said senior managers needed to give practitioners the “time, resources, and training” necessary for effective safeguarding, as well as promote “safe professional challenge” within and between agencies.
In an echo of previous studies, the panel’s 2022-23 annual report found that a lack of professional curiosity and challenge were among key deficits flagged up in rapid reviews of serious cases carried out by local safeguarding partnerships over the past year.
The panel, which examined 393 cases, found an over-optimism concerning parents’ capacity to give safe care and an over-reliance on parental self-report, with missed “opportunities” to triangulate this information with that from other sources.
Lack of critical thinking
The lack of critical thinking was evident in cases involving children aged under one, who accounted for 36% of the reviews, all of which involved death or serious harm to a child where abuse or neglect was known or suspected.
This included information not being identified or sought in relation to risk factors such as domestic abuse, for example, when certain behaviours were not recognised as signs of coercive or controlling behaviour.
The panel also reiterated messages from its 2021 report on safeguarding babies from male carers, including practitioners not challenging fathers or adult partners about their engagement and accepting at face value mothers’ account of separation from partners.
Criticisms of domestic abuse practice
More broadly, in relation to domestic abuse, the review criticised a reliance on removing perpetrators from the family home in order to reduce risk.
In some cases, practitioners did not consider the risks to children of ongoing contact, while the report also identified instances where staff did not consider fathers’ protective role in their children’s care.
For example, in one case, a child’s death was linked to a neglect of his serious medical condition. This was after his father, who played a significant role in his care, was removed from the family home.
Not seeing underlying issues behind behaviour
The panel also criticised a failure to see behind a child’s behaviour to identify underlying causes, an issue that was evident in cases of extrafamilial harm.
“In these cases, behaviour was viewed as the issue to deal with and manage as opposed to exploring and understanding the underlying cause, which was often associated with vulnerabilities such as mental health,” the report said.
“There were examples where practitioners referred to children as ‘troublesome’ or ‘problematic’ and where victim-blaming language was used in reports or case records.”
This also applied to some practice with families from black and minority ethnic communities, with “missed opportunities” to consider the wider social harms and inequalities they faced.
This included the practice of ‘adultifying’ some black children, by treating them as responsible for their actions and not recognising their needs, and emphasising criminal behaviour over their welfare.
‘Limited consideration’ of leaders’ role
While most reviews focused on identifying learning for practitioners and, to some extent, local safeguarding systems, the panel found “very limited consideration or analysis of the role and accountability of senior and middle managers and learning that may be specific to them”.
However, the panel stressed the importance of effective leadership and culture.
It identified cases where practitioners would have benefited from more time, resources and training to gain knowledge, skill or confidence, both in relation to child protection conferences and multi-agency processes and in relation to specific areas of practice”.
As well as domestic abuse and extrafamilial harm, the report highlighted skills gaps in a number of areas, including intrafamilial child sexual abuse, so-called honour-based abuse and complex mental health issues.
Lack of professional challenge
In relation to professional challenge, the report found practitioners not challenging partner agencies on their responses to ongoing concerns or their failure to provide requested or necessary information to inform assessments and decision-making.
For example, in one case, the review found some practitioners were “hesitant to express their views in conferences as they lacked training and were not able to be fully prepared before attending”.
The panel said that this was also something leaders could foster in, and between, their organisations, along with tackling the “perennial” issue of inadequate information sharing.
“Effective, joined up safeguarding leadership is pivotal in creating the conditions in which practitioners will seek, share and piece together information effectively, where there are high levels of trust and challenge and where there is honest and routine feedback about what is working well and what is not,” it said.
Safeguarding panel 2022-23 report in numbers
- There were 393 rapid reviews of serious incidents, where a child died or was seriously harmed and abuse or neglect was known or suspected.
- In over three-quarters of cases the family of the child was known to children’s social care either as an open case (35%) or previously (42%).
- A third of children were on, or had been on, a child protection plan and nearly a fifth had been, or were currently, looked after.
- The biggest group of children were aged under one (36%), followed by those aged 11-15 (21%).
- Children from mixed/multiple or black/black British backgrounds were overrepresented, while those from Asian/Asian British backgrounds were underrepresented.
- In just over half of cases (53%), the child had experienced neglect, while domestic abuse was identified in 50%.
- Of 156 fatal incidents, 61% involved boys and 39% girls. Among boys, the most common likely causes were sudden unexplained death (22.1%) and extrafamilial child homicide (11.6%); among girls, it was sudden unexplained death and suicide (both 19.7%).
Good practice highlighted
Alongside its criticisms, the report highlighted examples of good practice by safeguarding partnerships.
For example, some were encouraging peer-to-peer support and group supervision across agencies, which was increasing professional curiosity and understanding of partners’ processes.
Some reviews showed practice that considered the social exclusion of black and minority ethnic children, which was particularly evident in more ethnically diverse areas or where practitioners themselves were from similar backgrounds.
In relation to domestic abuse and practice with babies, the panel praised practitioners who were persistent in engaging mothers who were reluctant to engage and in identifying fathers, including where mothers were reluctant to divulge their identities.
‘Critical’ barriers to good safeguarding
As well as practice, leadership and inter-agency issues, the panel cited four “critical issues” that safeguarding partners reported were hindering their ability to protect children:
- “A discernible increase in the numbers of children” with mental health issues, with evidence of increased waiting times for assessment, diagnosis and services.
- The insufficiency of care placements, leaving “too many children…living at considerable distances from their family and community networks”.
- “Major challenges in workforce recruitment and retention”, particularly for social workers and health visitors, leading to increased reliance on agency staff, who were less able to build meaningful relationships with children and families.
- Long-term reductions in resources for early help and prevention services.
In her foreword to the report, panel chair Annie Hudson said: “Funding, recruitment, and retention pressures have had a discernible impact on the delivery of the best safeguarding practice to children and families.
“Despite these system stressors, practitioners and leaders are bringing remarkable creativity and resourcefulness to helping children and families.”
DfE’s children’s social care reforms
The report also referenced the Department for Education’s children’s social care reform agenda, including the current ‘families first for children pathfinders’ testing its proposed new approach to family support and child protection.
This involves the merger of targeted early help and children in need services within multidisciplinary ‘family help’ teams, designed to provide more effective and less stigmatising support to prevent families’ needs from escalating.
Where cases do escalate to child protection, family help teams co-work cases with ‘lead child protection practitioners’ (LCPP), specialist social workers who are also part of multi-agency child protection teams.
These child protection reforms are based on the proposal for multi-agency child protection units put forward by the panel in its 2022 review into the deaths of Star Hobson and Arthur Labinjo-Hughes.
Panel defends child protection team proposal
The existing pathfinders have reported challenges in relation to the LCPP role, including recruiting social workers to a role that was entirely focused on child protection and ensuring that it did not lead to burnout.
In its annual report, the panel referred to concerns that the organisational changes entailed by the reforms would be distracting, but defended its advocacy of multi-agency child protection teams.
“We have continued to see many reviews where there are fault lines in the way that the safeguarding system is designed, for example, with agencies working in silo, information not being brought together in a timely way, and assessments being undertaken in parallel.
“As a result, professionals do not always have a clear and full picture of what is happening in a child’s life and necessary decisions are not being taken at the right time. We think that these issues can be best tackled by establishing multi-agency child protection teams.”