Practitioners struggling to respond to extrafamilial harm to children, finds analysis of serious cases

Practitioners are struggling to respond to extrafamilial harm to children, with little evidence that interventions are keeping them safe, an analysis of serious case reviews has found.

Social workers and multi-agency colleagues are failing to identify children at risk by not picking up on early indicators, such as missing episodes, said the Child Safeguarding Practice Review Panel, in its 2023-24 annual report.

They are also struggling to build the relationships with children and families necessary for effective practice and are too often focusing on young people’s behaviour, rather than their underlying needs, the report found.

Practitioners were also stymied by high thresholds for accessing provision such as child and adolescent mental health services (CAMHS), and sometimes lacked effective supervision in relation to extrafamilial harm.

Among recommendations for improvement, the panel – whose role is to draw lessons from cases of child death or serious harm – called for better analysis of missing episodes, the allocation of single lead practitioners to children experiencing extrafamilial harm and improved supervision.

The children at risk of extrafamilial harm

Of 330 local case reviews analysed by the panel in 2023-24, 78 featured extrafamilial harm. Of this group, 56% of children had experienced youth or gang-related violence, 55% had experienced criminal exploitation and 40% had experienced sexual abuse or exploitation.

The proportion of black children in the extrafamilial harm cases (24%) was three times higher than in a comparison sample of other cases (8%).

A quarter of children (26%) were not enrolled at school or receiving an education, 59% had poor school attendance, 67% had been or were currently a child in need, 38% had been or were currently on a child protection plan and 49% were known to a youth offending team.

These proportions were all higher than for children who had not experienced extrafamilial harm.

Failure to identify risk factors

The most common risk factor for children experiencing extrafamilial harm was repeatedly going missing (57%).

However, the panel found practitioners were not spotting early indicators, including missing episodes.

“Several reviews pointed to missing episodes not being escalated, not being considered within the context of exploitation, not being responded to with robust multiagency plans, and not being assessed as high risk,” said the panel.

“Reviews also highlighted how practitioners often had little or no information regarding where children were going when they were missing or what was happening to them.”

Reviews described some assessments as weak, with a lack of analysis and a failure to identify extrafamilial harm or consider cumulative harm, which could lead to the level of risk being underestimated.

Adultification

While children experiencing extrafamilial harm had often faced significant trauma and adversity, practitioners sometimes did not recognise how this may affect their behaviour and willingness to engage.

There was evidence in some reviews of adultification bias, where children are seen as older than their years, an issue particularly affecting black children.

This tended to occur when practitioners were working with children who were both vulnerable to risk and posed a risk to others, which was common in incidents involving youth violence, gangs and criminal exploitation.

Too often service responses focused on offending behaviour, which was seen as a ‘choice’, so indicators of exploitation were not recognised or acted on as their involvement in criminal activity.

Struggle to build relationships

Practitioners struggled to build relationships with children and families – including because of high levels of staff turnover – preventing them from gathering information on the risks they faced.

Interventions tended to involve direct work with children aimed at changing their behaviour. However, the panel found that “there was unfortunately little evidence that interventions intended to keep children safe from harm were working”.

There were mixed results from moving children out of area. While this sometimes reduced risks for children being criminally exploited, in other cases it was disruptive, including to the child’s education, with some absconding from their placements.

For those experiencing child sexual abuse or exploitation, out-of-area placements could leave them feeling isolated and, in some cases, were not safe.

High thresholds for support

Practitioners sometimes missed opportunities to refer children to support services, including youth offending teams, and, in other cases, faced high thresholds to source support, such as in relation to CAMHS.

One review reported that CAMHS would not work with children with mental health needs if there were associated risks with gangs and criminal exploitation, leaving vulnerable children without support.

Practitioners reported that this was a challenging area of work and that they sometimes lacked sufficient support or supervision.

Key learning from panel

The panel’s learning from cases involving extrafamilial harm included that:

• Missing episodes should be carefully analysed to understand patterns and inform risk management and potential disruption work.
• As far as possible, children experiencing extrafamilial harm should have contact with a single lead practitioner who has oversight of their lived experience and support needs.
• Staff need robust support, supervision and training – including on a multi-agency basis – to optimise outcomes for children and support practitioner wellbeing.
• Interventions to reduce the risk of extrafamilial harm should be evaluated so that practice is based on evidence of what works.

Fall in number of serious cases 

Under section 16C(1) of the Children Act 2004, councils must notify the panel if a child it knows or suspects has been abused or neglected dies in its area, or where such a child who is normally resident in its area dies outside England. Councils and their safeguarding partners must then undertake a rapid review into the serious incident and submit it to the panel.

Overall, the panel received 330 rapid reviews from local authorities, concerning the deaths of, or serious harm to, 485 children in 2023-24. This was a fall from the previous year, when it received 402 reviews concerning 538 children. The fall was driven by a year-on-year drop in the number of serious harm cases.

The panel said it was not possible to determine whether this reflects a decrease in the number of serious incidents or whether fewer notifications were made compared with previous years. It said it was doing further work with the DfE to investigate the issue.

Key findings from reviews

The panel’s analyses of rapid reviews in 2023-24 found that:

• 87% of families involved in the incidents were known to children’s social care either as an open (49%) or previous
  (38%) case.
• 49% of children had experienced neglect, 48% physical abuse, 20% emotional abuse or 18% sexual abuse or exploitation.
• 22% of children had one or more mental health conditions, whether diagnosed or undiagnosed.
• In 53% of incidents, at least one of the parents or relevant adults were reported to have a mental health condition, while in 43% of cases at least one parent or relevant adult were recorded as having an addiction or as misusing drugs or alcohol.
• Domestic abuse was recorded in 47% of incidents.
• Lack of co-ordination between services featured in 81% of incidents. This often included failures in information sharing, inconsistent record keeping, role confusion, delayed responses and fragmented services.
• 66% of reviews recorded a lack of professional curiosity, for example, practitioners accepting surface-level explanations, failing to see when parents were seemingly co-operating but were not keeping to agreed plans, and not investigating inconsistent stories or red flags.
• Weak risk assessment and decision-making was evident in 62% of incidents. This included overlooking the role of extended family members or other adults being present in the home, and failing to consider comprehensive information from all agencies.