Social workers believe racial bias greatly affects child protection practice, a poll has found.

This follows a recent report by the Child Safeguarding Practice Review Panel on the impact of race, ethnicity and culture on cases where children have died or suffered serious harm.

The case reviews studied, which involved mixed-heritage, black and Asian children, were “silent” about the presence of racial bias in professionals’ decision making and on the role of racism in services’ responses to families.

The panel found that children’s race and ethnicity were often not recognised, appropriately explored or understood by practitioners, resulting in them not having a full understanding of children’s lived experience and the vulnerabilities they faced.

Only 7% said racial bias affected child protection practice “not at all”, while 5% believed there was “little” influence.

The national panel’s report is the latest in a series of studies to highlight issues with the way the social care system responds to children and families from black, Asian and ethnic minority communities.

Practitioners did not sufficiently consider children’s needs in relation to their race, ethnicity and culture in responding to child sexual abuse, found a review last year carried out for the panel by the Centre of expertise on child sexual abuse.

Meanwhile, a 2023 Nuffield Family Justice Observatory study identified significant ethnic inequalities in the use and timing of care proceedings.

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A “sea change” is needed in practitioners’ approach to race in child protection cases to better safeguard Black, Asian and mixed-heritage children from harm.

That was the message from the Child Safeguarding Practice Review Panel in a report on the impact of race, ethnicity and culture on multi-agency practice where children have died or suffered serious harm.

The study was based on 54 case reports – 14 local child safeguarding practice reviews and 40 rapid reviews – 25 involving mixed-heritage children, 15 concerning Black children and 14 relating to Asian children.

As previously reported, the panel found that reviews were “silent” about the presence of racial bias in professionals’ decision making and on the role of racism in services’ responses to families.

But to the extent that reviews did address race, they identified significant practice issues, said the panel, whose role is to oversee and draw together learning from serious cases.

Race ‘not recognised’ by practitioners

Race and ethnicity of children was often not recognised, appropriately explored or understood by practitioners, resulting in them not having a full understanding of children’s lived experience and the vulnerabilities they faced.

Fourteen reviews noted that children and families faced service barriers relating to race, ethnicity or culture, including because of past experiences of racism, language barriers, cultural perceptions that seeking support indicated an inability to cope, and practitioner bias.

The latter included the issue of adultification, where professionals attribute adult-like characteristics to Black children and treat them as more responsible than others of a similar age.

One example of this concerned a Black Caribbean child who was viewed as suspicious by professionals for wearing protective clothing after witnessing the murder of a friend. When they were subsequently injured in a knife incident, they were viewed as a perpetrator, not a victim.

‘Not hearing the child’s voice

Seven reviews found that children’s voices and wishes had not been heard by practitioners, while a further 11 highlighted barriers to hearing the child, including fear of retribution from disclosure and communication difficulties.

In 19 reviews, risks to the child had been at least partially recognised, but this had not translated into a professional response, including because disclosures by children had not been appropriately addressed.

This included “several cases” where girls of Asian or mixed Asian heritages had made disclosures about sexual abuse, but these appeared either to have been dismissed as untrue or not carefully followed up.

‘Silence around racism deeply concerning’

Jahnine Davis

Race and safeguarding expert Jahnine Davis, the panel’s lead for the report, said: “The silence around race and racism in child safeguarding practice is deeply concerning.

Improving the safeguarding of Black, Asian and mixed-heritage children meant “challenging current policies, practices and how services are designed and delivered, recognising how racism and racial bias impact our work to protect children”, she added.

Recommendations included that safeguarding partnerships create conditions to empower practitioners to have conversations with children and families about race and identity, and build their skills and confidence. They should also ensure appropriate internal structures are in place to support practitioners to recognise, discuss and challenge internal and institutional racism, the panel said.

Leaders ‘need to equip staff with confidence’

Association of Directors of Children’s Services president Andy Smith said the report made for difficult reading but “must act as a catalyst for further change”.

“Leaders across public services have an important role in addressing discrimination and bias and in supporting anti-racist practice in their organisations by equipping our staff with the confidence and the courage to do so via appropriate training and support, including challenge where necessary,” he added.

“As the panel recognises, these conversations can be hard, but the consequences are too great if we do not get this right in terms of children being seriously harmed, or worse.”

‘Stark evidence gaps’

Sector evidence body Foundations said there were “stark evidence gaps about the experiences and outcomes of racially minoritised children in children’s social care, despite the over-representation of these children in safeguarding reviews”.

Its chief executive. Jo Casebourne, added: “Foundations is committed to taking a proactive role in addressing the issues the panel identifies.

“We will continue to integrate considered and critical examination of race, racism and racial bias into our work, generating evidence on what works to inform local safeguarding strategies, empower leaders and practitioners, and strengthen our collective ability to protect children.”

The murder of a two-year-old girl by her mother’s boyfriend has highlighted the need for guidance on protecting children when families move across council boundaries, a local child safeguarding practice review (CSPR) has concluded.

The panel reviewing the case of Isabella Jonas-Wheildon, who moved area twice in the weeks before she died, said it showed that issues around cross-border working and information sharing needed to be addressed.

It called on Central Bedfordshire Safeguarding Children Partnership, which commissioned the review, to raise the issue with the Child Safeguarding Practice Review Panel with a view to it developing national guidance on cross-border working.

The national panel, which is responsible for reviewing serious cases and drawing lessons from them, said this was “an important issue which we take very seriously”. It added that it would be addressed in the report of its national review into the case of Baby M, which was initiated in October 2023.

Toddler murdered by mother’s boyfriend

Isabella’s body was found on 30 June 2023 at a hostel in Ipswich, Suffolk; it was estimated that she had been dead for about three days. She had extensive bruising and fractures to her wrist and pelvis, with the latter causing bone marrow to enter her bloodstream triggering an embolism that, along with skeletal trauma, caused her death.

The injuries were all inflicted after her mother, Chelsea Gleason-Mitchell, started a relationship with Scott Jeff, in May 2023.

In December 2024, Jeff was jailed for a minimum of 26 years after being found guilty of murdering Isabella, along with two counts of child cruelty. Gleason-Mitchell was imprisoned for 10 years after pleading guilty to causing or allowing the death of a child and two counts of child cruelty.

Alleged domestic abuse

Isabella spent most of her life in the Central Bedfordshire area with her parents. Gleason-Mitchell had been known to children’s services in the area herself and had a history of mental health problems, including anxiety, depression, self-harm and suicidal ideation.

She separated from Isabella’s father in April 2023, making allegations of domestic abuse against him that, at the criminal trial, she said were untrue.

This prompted a referral to Central Bedfordshire’s children’s services, after which Gleason-Mitchell was allocated an independent domestic violence advocate (IDVA), while she also made a homelessness application on the grounds that she was fleeing domestic abuse.

However, she rejected an offer of temporary accommodation after being told that her new boyfriend – Jeff – could not stay with her there.

Jeff was also known to multiple services in Central Bedfordshire due to diagnoses of ADHD and autism, mental health problems, longstanding issues with anger management and reported domestic abuse. During the police enquiry into Isabella’s death, Jeff’s former partner disclosed domestic abuse by him, including coercive control, several assaults and, on one occasion, strangulation.

Multiple moves in Isabella’s final weeks

On 1 June 2023, Gleason-Mitchell, Jeff and Isabella moved to Great Yarmouth in Norfolk and the couple made a housing application.

Great Yarmouth council offered emergency accommodation to Gleason-Mitchell and Isabella, but not Jeff, an offer which was not taken up. They were subsequently found to be staying in a tent on the beach by the police, after which they were given temporary accommodation.

The case was referred to Norfolk children’s services, via the emergency duty team, on 19 June 2023.  However, on the same day, the family moved across council boundaries again, to Ipswich in Suffolk.

Gleason-Mitchell and Jeff made an application for housing to the local borough council, claiming they were fleeing domestic abuse from Isabella’s father, and were offered temporary accommodation.

Referrals were also made to Suffolk children’s services, both by Ipswich council’s housing service and Central Bedfordshire council.

Child protection or child in need

Over email, Central Bedfordshire advised that Suffolk undertake a child protection enquiry, under section 47 of the Children Act 1989, because Isabella appeared to be at risk of significant harm. It said this was on the grounds that the family were at risk of being street homeless, had not acted to safeguard Isabella by turning down accommodation twice, had not been open with agencies and had left Norfolk without a plan to safeguard the child.

Central Bedfordshire added that Gleason-Mitchell appeared to be prioritising Jeff over Isabella, and that its housing staff and those in Great Yarmouth had raised concerns about him being controlling. It offered to be part of any strategy discussion to determine whether a section 47 should proceed.

However, following a multi-agency safeguarding hub (MASH) assessment, Suffolk decided to undertake a child in need assessment, under section 17, on the grounds that the threshold for a strategy discussion had not been met. It concluded that the most significant concern – homelessness – had been addressed and that the other issues could be explored through a section 17 assessment.

The case was passed to the child in need team on 23 June, but the first attempt to contact Gleason-Mitchell was not until 28 June, two days before Isabella was found dead. Suffolk has since tightened up its procedures so that an attempt to contact the family takes place no later than one day after a case is passed to a team for assessment.

‘Siloed’ decision making

The review panel concluded that the case had been characterised by “siloed” decision making by agencies, particularly when the family moved across areas at speed.

This included Isabella’s voice and lived experience not being considered by professionals in the last month of her life, Gleason-Mitchell’s vulnerabilities as a parent not being taken into account and the failure to examine records to uncover knowledge of Jeff and the potential risks he posed.

The review recommended that Central Bedfordshire Safeguarding Children Partnership should:

• Seek assurance from agencies that they always include the voice and lived experience of children, including toddlers and those who are not able to fully communicate verbally, in their assessments and actions, and ask them to provide evidence of the methods they use.
• Remind agencies that assessments and interactions with families consider the role, presence and history of partners living in, or closely associated with, a household.
• Raise professionals’ awareness and understanding of domestic abuse and neglect, including that these are always harmful to children and that practitioners should be able to spot the signs and symptoms of coercive control.
• Initiate discussions with the Child Safeguarding Practice Review Panel to consider developing regional or national guidance on cross-border safeguarding.

Cross-border safeguarding being considered in national review

A Child Safeguarding Practice Review Panel spokesperson said: “Isabella’s death was deeply tragic and shocking…The local review raises important issues about the quality of information sharing and risk assessment across agencies. These issues need to be addressed at both a local and a national level.

“The Child Safeguarding Practice Review Panel has noted the review’s recommendation about the need for national guidance to support the protection of children when families move across geographic areas.

“It is an important issue which we take very seriously as has been highlighted in other reviews.  We intend therefore to address this issue further in the report on our national review about Baby M.”

Agencies acting on recommendations

In a joint statement, Central Bedfordshire, Suffolk, and Norfolk’s safeguarding children partnerships said all the agencies involved had started implementing the recommendations.

They added: “This has been a case that has touched many people across our counties, and all the safeguarding partnerships involved in this statement have been truly shocked. We all offer our sincere condolences to Isabella’s family and will continue to offer support to anyone who has been affected by her death.”

On behalf of Central Bedfordshire Council, executive member for children and families Steve Owen said: “My focus is on ensuring that the learning from Isabella’s story makes a real difference here in Central Bedfordshire and beyond, and on doing our utmost to keep children, especially young children, as safe as possible.

“I know officers in Central Bedfordshire have been deeply saddened by Isabella’s death and have already implemented many of the recommendations. I will also contact my counterparts in Suffolk and Norfolk to see how we can, together, ensure Isabella’s story brings real change across our areas to better protect children.”

Staff shortages pose a risk to government plans to bolster the safeguarding of the growing number of children not in school, the Association of Directors of Children’s Services (ADCS) president has warned.

Andy Smith told MPs this week that several councils had less than one full-time equivalent elective home education worker, meaning the workforce was “significantly insufficient” to take on new responsibilities in the Children’s Wellbeing and Schools Bill.

The bill would require councils to create registers of children not in school, collect information on their education arrangements and support parents of home-schooled children with their education on request.

Parents would need to seek councils’ consent to home educate children subject to a child protection enquiry or plan, while councils would need to review the home and learning environments of home-schooled children subject to such safeguarding measures to determine whether they should be required to attend school.

Growing numbers of home educated children

The measures are designed to improve both the safeguarding and education of home educated children, the number of whom has risen from 116,300 during 2021-22 to 153,300 in 2023-24, according to Department for Education data.

In separate appearances before the education select committee and the committee of MPs scrutinising the bill, Smith said councils’ “hollowed out” elective home education (EHE) workforce would lack the capacity to take on these responsibilities without extra resource.

According to a 2021 ADCS survey of directors, councils’ average spend on EHE services in 2020-21 was £86,211, while they employed an average of 2.2 FTE staff for this purpose.

Lack of staff in local authorities

In his evidence to the public bill committee considering the legislation, Smith said that several councils – including his own authority, Derby – had less than one full-time equivalent staff member working on EHE.

“If you superimpose the changes envisaged by the bill, that provision would be significantly insufficient,” he said.

ADCS president for 2024-25, Andy Smith (picture supplied by ADCS)

“If we think about the practical things around visits, understanding the offer, trying to understand what is happening to children and building up that picture, there would need to be sufficient capacity to get sufficient workers in post across places to do that, and they would need be sufficiently trained.”

The point on training was picked up by Child Safeguarding Practice Review Panel chair Annie Hudson, who gave evidence alongside Smith to the education select committee this week, as part of its current inquiry into children’s social care.

‘Need to skill up home education staff on safeguarding’

Hudson said visits to children’s homes to consider whether they should be required to attend school when subject to a child protection enquiry or plan would be carried out by EHE staff, who would “not necessarily have deep safeguarding knowledge and expertise”.

“They should have the foundation knowledge, but we will need to be clear so that those officers undertaking that work know what they might need to look at and look for and families know that
so that it is a transparent relationship when the local authorities execute that duty,” she added.

The government is yet to set out how much funding will be available to implement the legislation, but Local Government Association (LGA) assistant director of policy Ruth Stanier said it was vital all new burdens on councils were suitably resourced. She said the LGA and the DfE were holding talks about this already.

Multi-agency child protection teams

Stanier said the bill’s introduction of multi-agency child protection teams was another area that would require additional resource.

Under the plans, councils, chief officers of police and relevant NHS integrated care boards (ICB) would have to set up one or more multi-agency teams for the relevant local authority area. These would comprise at least one representative from each of the NHS and the police, along with at least two practitioners appointed by the local authority, a social worker and an educational professional.

Under the bill, the teams’ role would be to support the relevant local authority in the exercise of its child protection functions, though it is likely that they would in effect carry out those functions.

The idea, which is being tested in 10 areas under the families first for children pathfinder, was based on a recommendation from the Child Safeguarding Practice Review Panel in its 2022 report on the murders of Arthur Labinjo-Hughes and Star Hobson.

Suggested benefits of joint safeguarding teams

Hudson told the education select committee that, while not a panacea for the challenges facing the child protection system, the introduction of the teams had three potential advantages:

1. Making it much easier for professionals from different agencies to share information about children, giving them a “much more real-time picture of what is going on in a child’s life, particularly when there are sudden changes”.
2. Pooling the expertise of different professional disciplines and enabling practitioners from different agencies to challenge, as well as support, one another.
3. Enabling joint decision making about the child, as opposed to the “siloed decision making” evident in the Arthur and Star cases.

Based on the model being tested in the pathfinder area, the multi-agency teams would include so-called lead child protection practitioners, whose role would be to lead child protection enquiries and hold cases.

Concerns over social worker burnout

While expressing broad support for the teams, Smith reiterated ADCS concerns about social workers holding only child protection cases and not working across a wider spectrum of children’s needs.

“We need to mitigate and minimise issues around burnout and make sure that social workers, through their professional development, have a rounded experience of social work across a broad
array of service users and service types,” he told the education select committee.

The teams are one of a number of measures designed to improve multi-agency safeguarding. These include the introduction of a single unique identifier (SUI) for each child, which professionals should use when sharing information, and a duty to share information for safeguarding and welfare purposes.

‘Risk of increasing volume of information’

Smith was cautious about the potential benefits of the changes, given the barriers to information sharing arising from agencies having separate and unconnected IT systems, distinct recording practices and different cultures.

He said the benefits of information sharing came when practitioners from different agencies came together to “understand what is happening for children…moving beyond single incidents”.

“There is a risk that increasing amounts of unanalysed information that might pass from A to B does not necessarily keep children safe,” he told the select committee.

Citing ADCS research that found councils received 3,001,339 safeguarding concerns in 2023-24, Smith warned: “Starting to add additional information that might come through the single unique identifier could increase that exponentially.”

The DfE plans to pilot the SUI prior to nationwide implementation.

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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.

Reviews of serious cases are “silent” about the role of racial bias in child protection decision making, safeguarding experts have found.

Case inquiries relating to black, Asian or mixed heritage children inconsistently featured the voice of the child and their recommendations failed to provide high-quality learning for practitioners on working with these groups of children.

Inquiry into race and child protection

Those were among early findings from a Child Safeguarding Practice Review Panel inquiry into the impact of race, racism, and ethnicity on practice where a child has died or been seriously harmed.

The panel has examined 54 reviews submitted from 2022-24, 25 of which involved mixed heritage children, 15 relating to black children and 14 involving Asian children. The children ranged in age from under one to 17, with 32 being male and 22 female.

Thirteen children were recorded as having a disability, however, this information was missing in 16 cases; similarly, while 11 were recorded as having a neurodivergent condition, such as autism or ADHD, this information was not reported in 23 reviews.

This lack of data hampered reviews’ ability to undertake an intersectional analysis of children’s lives, panel member Jahnine Davis told this year’s National Children and Adult Services Conference (NCASC).

‘Silence’ about racial bias

More broadly, reviews did not consistently identify the extent to which race, racism, racial bias or culture impacted on practice responses to black, Asian and mixed heritage children, said Davis, a researcher specialising in the safeguarding of black children.

There was a silence about the presence of racial bias in professionals’ decision making and on the role of racism, whether internalised, interpersonal, institutional or structural, in services’ responses to families.

This was despite other forms of bias – such as in relation to sex/gender – being highlighted in reviews.

Davis, who is also the Department for Education’s national kinship care ambassador, said that reviews inconsistently featured the voice of the child.

Voice of the child lacking

“There were significant missed opportunities to include the child’s own words within review reports,” she added. “It’s been a struggle in the 54 reviews to identify an explicit quote from that child to bring to light what their experiences are.”

Meanwhile, review recommendations “infrequently featured high quality and vital learning for practice with black, Asian and mixed heritage children”, said Davis.

Recommendations tended to be generalised, rather than specific to these groups of children, and some were insufficiently detailed to promote effective practice changes.

Practice deficits

To the extent that reviews did address issues around race, they found that practitioners’ understanding of black, Asian and mixed heritage children’s lived experiences was incomplete, meaning they had a poor understanding of their vulnerabilities and risks, Davis added.

Her panel colleague, Jenny Coles, told NCASC delegates: “Reviews are highlighting an urgent need to understand the extent to which racism reverberates across the safeguarding system. Race, racism and bias are not being understood and this seriously impacting on the safety of those children.”

The panel’s report is due to be published early in 2025.

The “door could be open to the abuse and neglect” of disabled children due to the government’s cost-driven decision to shelve a planned expansion of advocacy for the group.

That was the message from the Child Safeguarding Practice Review Panel, as it led sector criticism of the Department for Education’s (DfE) decision to halt the previous government’s planned introduction of requirements to provide non-instructed advocacy to children.

This involves providing representation for children who are unable to instruct an advocate or communicate their views, wishes and feelings because of a disability, mental health issue or medical condition.

Inquiry into abuse of disabled children

Providing disabled children with independently commissioned, non-instructed advocacy from advocates with specialist training was a key recommendation from the panel’s inquiry into the serious abuse of disabled children in three residential services from 2018-21.

Just two of the 108 children whose experience was examined in the review were given access to independent advocacy during their time at the three settings in Doncaster run by the Hesley Group, all of which have now closed.

The then Conservative government accepted in full just two of the panel’s nine recommendations for reforming the safeguarding of disabled children in residential settings, one of those being on advocacy.

Plan to extend advocacy access

This would have been through revisions to national standards and statutory guidance on advocacy for looked-after children, children in need and care leavers, consulted on last year.

These would have introduced a standard requiring that children who were unable to give instructions on a specific issue could access non-instructed advocacy.

The Conservatives did not publish its response to the advocacy consultation, let alone implement the planned changes, before they left power in July last year.

In a letter to the panel providing an update on the government’s response to its safeguarding disabled children review, education secretary Bridget Phillipson said the consultation “highlighted the need to properly fund” any new advocacy standards.

Government shelves policy on cost grounds

She then said the Labour administration could not commit to implementing the panel’s recommendation given its fiscal inheritance from the Tories, whom the independent Office for Budget Responsibility calculated left £9.5bn in undisclosed spending pressures to the new government.

Education secretary Bridget Phillipson (Photo Lauren Hurley / No 10 Downing Street)

“Given the difficult financial landscape our new government has received, extremely difficult decisions are required on where and how our funding is allocated,” wrote Phillipson, in the letter to the panel, published last week.

“We are making investments across the children’s social care sector and further consideration is required on the feasibility of this recommendation within the current budget.”

‘Door could be open to abuse and neglect’

However, panel chair Annie Hudson said the decision was “a concern”.

“Whilst recognising resource constraints, the failure to commit to prioritising advocacy for this group of vulnerable children could leave the door open for abuse and neglect.”

The panel’s concerns were echoed by a host of sector bodies, including the Council for Disabled Children (CDC), whose former strategic director, Christine Lenehan, led the Hesley Group review on behalf of the panel.

Advocacy needed ‘to ensure voices of disabled children are heard’

“For too many children and young people growing up in a placement far from home, life can be like imprisonment, with little contact with their home communities and loved ones,” said CDC director Amanda Allard.

“Due to the extent of their disabilities and health needs, their cries for help can be easily dismissed when they are subjected to abuse.

“Whilst we understand the difficult financial landscape, we urge the government to prioritise the creation of new advocacy standards to ensure the voices of disabled children and young people with complex needs are heard and acted upon by the professionals responsible for their welfare. This measure is a vital element of the response to the Hesley review.”

Coram Voice, which provides children’s advocacy, described the DfE’s decision as “very disappointing”.

Existing advocacy standards ‘woefully out of date’

Linda Briheim-Crookall, Head of Policy and Practice Development at Coram Voice:

“Existing standards and guidance on advocacy are woefully out of date, and it is essential that the government urgently takes action to update the framework,” said its head of policy and practice development, Linda Briheim-Crookall.

“The current lack of clarity around what should be available to whom means that too many children are not supported to have their voices heard. Without fixing this issue we will continue to see children failed by the system.”

Fellow provider the National Youth Advocacy Service (NYAS) also joined the criticism.

Government ‘must urgently reconsider decision’

NYAS Group chief executive Rita Waters said: “Non-instructed advocacy is vitally important for children and young people who face additional challenges in communicating their views, wishes and feelings.

“This is something that must be equally accessible for every child or young person who requires it, and not prevented because of budgetary reasons. We urgently call on the UK Government to reconsider their decision and make a commitment to accepting the panel’s recommendation in full.”

And children’s rights charity Article 39 described the decision as “unforgivable”, while highlighting the lack of specific plans in the DfE’s wider social care strategy to ensure the voices of children and young people are heard.

Commissioner’s call for non-instructed advocacy to be available

The DfE’s decision also comes despite Children’s Commissioner for England Rachel de Souza recommending that looked-after children deprived of their liberty should have access to advocacy, including non-instructed advocacy, where appropriate, in a recent report.

While not criticising the decision, de Souza stressed the importance of advocacy provision for disabled children in particular.

Children’s Commissioner for England Rachel de Souza (credit: Office of the Children’s Commissioner)

“When advocacy works well it can keep children safe and improve the care they receive,” she said. “This is especially true for disabled children, who may face additional barriers to having their voices heard and their needs met.

“It is crucial that advocacy services are inclusive and tailored to the unique circumstances of every child, ensuring that no child is left behind. I will continue to use my role to ensure all children’s voices are heard.”

Agencies are not equipped to protect children from sexual abuse within the family, safeguarding leaders have found.

Children are too often ignored or disbelieved by practitioners who lack the knowledge, skills and confidence to combat infrafamilial child sexual abuse, according to an analysis of serious cases involving 193 children and 177 perpetrators.

As a result, they are frequently not being identified by practitioners, nor are they receiving the response needed for their ongoing safety and recovery, reported the Child Safeguarding Practice Review Panel.

The panel, which oversees and draws national lessons from serious cases, urged the government to produce a national action plan to drive up the quality of practice, including through improved training and supervision.

‘Robust strategy needed’

“The systemic issues identified in this report are longstanding,” said panel chair Annie Hudson.

Annie Hudson, chair, Child Safeguarding Practice Review Panel

“It is vital therefore that government integrates the findings from this review into their reform programme and provides strong leadership to deliver a robust strategy to address [the] stark reality of child sexual abuse in the family environment.”

The review was carried out for the panel by the Centre of expertise on child sexual abuse (the CSA Centre), the Home Office-funded body that seeks to improve the understanding of, and response to, this form of harm.

What the review involved

The CSA Centre analysed 136 reviews of serious cases submitted to the panel from from June 2018 to November 2023. These involved 193 children who had been sexually abused by a family member.

The centre also held online discussions with 107 practitioners and managers who had been involved in 10 of the cases,  interviewed two children who had been abused and five people who had sexually abused a child.

In addition, they reviewed recent research and practice guidance on intrafamilial CSA and consulted other experts by experience and practitioners from agencies including children’s social care, the police and health.

Over-reliance on children reporting abuse

A consistent theme from cases analysed and discussions with practitioners was an over-reliance on children verbally reporting abuse.

Practitioners reported being told in training that they needed to wait for children to approach them to disclose abuse, rather than proactively talking to them when they had concerns.

They were also deterred from speaking to children by an “overriding fear of interfering with any possible future criminal investigation”.

This approach ran contrary to research indicating the multiple barriers children faced in disclosing CSA. Some children in the reviews reported waiting for someone to ask them in order to be able to disclose.

Not believing children

Despite these barriers, there was evidence that children had told someone about the abuse – sometimes on multiple occasions – in 72% of the reviews analysed.

However, the review found “many situations where children had directly told practitioners they were being sexually abused and were not believed”.

Photo posed by model (credit: Erika Richard/Adobe Stock)

When some children later retracted their disclosures, practitioners often took this as evidence the abuse had not happened, without exploring whether this was down to fear, shame, embarrassment or intimidation. As a result, children were left at greater risk of further harm.

Lack of consideration of disability and race

Practitioners also did not sufficiently consider children’s needs in relation to their race, ethnicity and culture, said the report. This included not identifying signs that a forced marriage was being planned for 14-year-old black African child from a Muslim family, who was subsequently raped by the adult cousin she was married to.

In another case, a boy of mixed white and Asian heritage was subjected to adultification bias by practitioners, who treated him as being older than his age and blamed for his behaviour.

Few of the reviews concerning disabled children provided evidence that their impairments had been taken into account.

Those who were non-verbal or pre-verbal were left without any response to their abuse because of the reliance on verbal disclosure, while practitioners did not pursue signs of possible CSA in children with learning disabilities because of potential communication barriers.

In other cases, practitioners attributed children’s distressed behaviour to their condition, for example, autism or ADHD, rather than considering CSA.

Not identifying signs of CSA

More broadly, professionals lacked understanding of the signs that might indicate a child was being abused, including harmful sexual behaviour or other sexualised behaviour, distress, seeking emergency contraception or sexually transmitted infections.

“We saw many situations where practitioners would seek other explanations for symptoms and behaviours in children that could indicate possible sexual abuse without seeking to establish a wider picture of the child and their family circumstances or build a picture of concern about child sexual abuse,” the report said.

Inadequate risk assessment of perpetrators

A third of cases involved a family member with a history of sexual offending or who was known to present a risk of sexual harm.

However, in some cases, they moved into homes with young children without a risk assessment or an effective safeguarding response being put in place.

Adults convicted of sexual offences against other adults were not perceived as a risk to children, while those whose offending was less recent were particularly unlikely to be identified.

Social work assessments criticised 

The report also criticised the quality of child and family assessments, which “did not sufficiently analyse signs and indicators of
child sexual abuse, despite this often being the impetus for them taking place”.

Photo: Krasimira Nevenova/Fotolia

It said it was “particularly striking” that those who knew the children best were often not invited to contribute, or practitioners’ views were disregarded when these differed from those of the assessing social worker.

Assessments often did not focus on the adult about whom there was concerns, even when the child had reported CSA, while the report said there was little use of genograms or other such tools to consider children’s relationships with extended family.

Where other forms of abuse had been reported along with CSA, as was the case with most reviews, practitioners tended to focus on them, “with the concerns of sexual abuse becoming lost from sight”.

Concerns over evidence thresholds

Practitioners also felt that the criminal justice standard of proof (beyond reasonable doubt), rather than the safeguarding threshold (the balance of probabilities), was needed to take action in a case.

As a result, referrals were either not made or were rejected on the basis that they did not meet the threshold for action, and investigations which resulted in no further police action led to all agencies ceasing their involvement.

This meant that not only was support not provided to the child, but further signs of abuse were then missed, for example, through councils rejecting further CSA referrals about the child.

Police and child protection enquiries ‘completely separate’

Poor joint working between the police and children’s social care was another issue highlighted by the review, which found that, in some cases, criminal investigations and child protection enquiries “happened completely separately”, with a lack of clarity about what information should be shared.

At times, the police acted on concerns before discussing these with children’s social care or holding a strategy discussion, which then undermined the assessment of risk

Lack of training, guidance and supervision

The panel’s report attributed the practice failings it identified to a lack of effective training, guidance and supervision for practitioners.

It noted particular training gaps in relation to identifying signs of CSA, understanding of grooming, child development, working with disabled children, assessing sexual risk.

It also found “a lack of robust supervision and managerial oversight” left practitioners “lacking confidence in organisational support to take action”.

On the back of its report, the panel said the government “must signal in the strongest possible way their commitment to make
sure that necessary improvements are secured and provide assurance that
this will be fully translated into concrete actions to make a tangible difference
to children’s lives

Recommendations for government

The panel’s key recommendation is for the government to produce a national plan to “secure the necessary practice improvements identified in this report”.

Alongside this, it said that ministers should:

• Review and update initial training, early career and ongoing professional development and supervision, so practitioners can improve their identification and response to CSA. As part of this, it should make guidance and training available for staff in universal and specialist services, such as social work, about how and when to talk to children and families when CSA is suspected.
• Require safeguarding partners to audit and review local guidance and practice so a clear distinction is made between thresholds about significant harm to a child (balance of probabilities) and those influencing criminal investigations (beyond reasonable doubt). It should also stress that safeguarding decisions must be based on all indicators of sexual abuse and should not rely solely on verbal statements from children.
• Review the application of the child sex offender disclosure scheme – also known as Sarah’s Law – to ensure police proactively inform the person best placed to protect a child when someone in the family environment has a conviction for sexual offending or intelligence has been received that they pose a risk.
• Make sure that whenever information comes to light which indicates that someone in the family (adult or young person) has a previous allegation or conviction (spent or unspent) for any type of sexual offending, this leads to a multi-agency discussion, which involves an up-to-date assessment of risk.

Social care reforms ‘will address recommendations’

In response to the report, a Department for Education (DfE) spokesperson said: “Any instance of child abuse is abhorrent, and this report importantly highlights the weaknesses in the system that have shielded abusers and left children at risk of harm.”

They said that the government’s children’s social care reforms, unveiled last week, would help address the panel’s recommendations.

“We will require every council to implement a joined-up approach to child protection, strengthen safeguards for home education and improve information sharing, to prevent children falling through the cracks,” the spokesperson added.

Recommendations for local safeguarding partners

The panel also made a number of recommendations for local safeguarding partners, including:

• Undertaking a multi-agency training needs assessment in relation to CSA and meeting identified training needs.
• Auditing multi-agency decision making in response to CSA.
• Ensuring that, following the conclusion of child protection and police investigations, multi-agency discussions are held to consider risk to children and how they will be protected and supported.
• Reviewing how people who present a risk of sexual harm and who have contact with children are assessed and managed, with consider the use of civil orders and other measures to effectively manage the risk.
• Take necessary steps to ensure that all practitioners (including foster carers) understand and are confident in talking directly to
  children, and families about CSA concerns, taking due account of ethnicity, language and disability.

Directors urge prevention focus

Giving the Association of Directors of Children’s Services’ response to the review, president Andy Smith said: “Prevention must be the ultimate goal to ensure that no child is subject to abuse. We need tackle this issue as a collective, with the full commitment of central and local government, all child protection agencies, voluntary organisations and the wider community.

“Directors and their local authorities are committed to working with our partners to ensure the right safeguards are in place to prevent child sexual abuse in all its forms so that all children are able to lead safe and happy childhoods.”

A project has been launched to improve the quality of reviews of cases where children die or are seriously harmed following known or suspected abuse or neglect.

The Child Safeguarding Practice Review Panel, the national body that oversees learning from serious cases, has commissioned the work to explore how local child safeguarding practice reviews (LCSPR) could be delivered more quickly and be more effective in promoting learning.

Safeguarding partners must decide whether to commission an LCSPR in any case where a child in, or normally resident in, their area dies or is seriously harmed following known or suspected abuse or neglect.

This should be based on whether the case is “serious” and raises “issues of importance in relation to the area” and whether the partners believe a review would be “appropriate”. The purpose of a review is to “identify any improvements that should be made by persons in the area to safeguard and promote the welfare of children” (section 16F of the Children Act 2004).

Good and bad practice in case reviews

In its latest annual report, covering 2022-23, the panel said it had seen some improvements in the quality of LCSPRs, with the best examples having clear lines of enquiry and triangulating findings from the individual case with those from wider issues in their area and research.

Good practice also included having “clear recommendations that translate into specific actions with accountable owners, and which are designed to impact clearly on practice”, along with a clear strategy for evaluating the impact of the review.

However, the panel found that some LCSPRs were “still weak in the analysis of why things go wrong”, instead providing a chronology of events. Also, most reviews focused on learning for practitioners and, to some extent, local safeguarding systems, with “very limited consideration or analysis of the role and accountability of senior and middle managers and learning that may be specific to them”.

Ensuring reviews can improve practice

Launching the improvement project, panel chair Annie Hudson said: “We know that local safeguarding partners put a lot of time and effort into ensuring they learn from serious incidents, yet external factors and internal constraints mean they can sometimes struggle with delivering timely and effective reviews.

“We want to give safeguarding partners the support they need to ensure their review processes, approaches and methodologies can deliver the best impact and improve practice with children and families.”

The panel has commissioned Research in Practice, the University of East Anglia’s school of social work and the national policing’s Vulnerability Knowledge & Practice Programme to carry out the project.

Research in Practice said that “surprisingly little” was known about why reviews varied in quality and how recommendations were developed.

It said the project would look at where review processes were getting in the way of timely learning, how families and professionals can be engaged effectively and how learning can be translated into action.

The findings will be based on discussions with safeguarding partners and independent reviewers.

To find out more about the project, or how to get involved, email projectsupport@researchinpractice.org.uk.

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.

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:

1. “A discernible increase in the numbers of children” with mental health issues, with evidence of increased waiting times for assessment, diagnosis and services.
2. The insufficiency of care placements, leaving “too many children…living at considerable distances from their family and community networks”.
3. “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.
4. 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.”