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.”

A case review has begun after 10-year-old Sara Sharif’s father and stepmother were convicted of murdering her.

After a 10-week trial, a jury found Urfan Sharif, 42, and Beinash Batool, 30, guilty of murder, and Sara’s uncle, Faisal Malik, 29, guilty of causing or allowing her death.

Sara’s body was found at the family home in Woking, Surrey, on 10 August 2023, after Sharif called police to admit to having killed Sara, having fled to Pakistan with Batool, Malik and five of Sara’s siblings.

100 injuries on child’s body

Surrey Police said specialist doctors and pathologists found evidence of around 100 separate internal and external injuries on Sara’s body, including a traumatic brain injury, multiple broken bones, extensive bruising and scarring.

Sara Sharif (credit: Surrey Police)

There was also evidence of burns, including one on Sara’s buttocks, which had been intentionally inflicted using a domestic iron, and human bite marks.

The BBC has reported that the family were known to Surrey council from 2010, before Sara was born. This was due to concerns about violence towards the children and domestic abuse perpetrated by Sharif towards Sara’s mother, Olga Sharif, before they separated.

Services’ involvement with the family will now be considered through a local child safeguarding practice review.

‘Perpetrators went to extreme lengths to conceal truth’ 

Following the trial verdict Surrey council’s executive director for children, families and lifelong learning, Rachael Wardell, said: “Sara’s death is incredibly distressing and we share in the profound horror at the terrible details that have emerged during the trial.”

“The focus of the trial has been on the evidence needed to secure the convictions of those responsible for Sara’s death,” she added.

“This means that until the independent safeguarding review concludes, a complete picture cannot be understood or commented upon. What is clear from the evidence we’ve heard in court is that the perpetrators went to extreme lengths to conceal the truth from everyone.”

Wardell said the council would “play a full and active part in the forthcoming review”, a point echoed by Surrey Police, for whom detective chief superintendent Mark Chapman said: “The murder of a child is shocking, but the injuries, abuse and neglect that Sara suffered during her short life has made this case particularly disturbing.”

‘Profound weaknesses in child protection system’

Children’s Commissioner for England Rachel de Souza said that Sara’s murder was “a heartbreaking reminder of the profound weaknesses in our child protection system that, as a country, we have failed time and time again to correct”.

On the back of the case, de Souza made three proposals for reform that are already in the government’s plans:

• Making schools the fourth statutory partner – alongside the police, health and local authorities – in local safeguarding arrangements.
• Improving oversight of children education at home – as Sara was before her death – through a register of children not in school and requiring councils to sign off on home educating requests for vulnerable children. (Under the government’s plans, council consent would be required when the child were subject to a child protection enquiry or on a child protection plan.)
• Giving each child a unique identifier to improve information sharing and stop them falling through gaps in support and protection.

De Souza also called for the defence of reasonable punishment, which permits parents to smack their children in England to be removed, something the government is also reportedly considering (source: BBC).

Inadequate information sharing between agencies has been an all-too-familiar finding of reviews into child deaths or other serious cases over many years.

It was a key factor behind agencies’ failure to prevent Victoria Climbié’s murder in 2000, as Herbert Laming, who chaired the inquiry into the eight-year-old’s death, recalled in a recent interview with Community Care.

And, 20 years later, the Child Safeguarding Practice Review Panel found similar failings in relation to the cases of Arthur Labinjo-Hughes and Star Hobson, in its 2022 report into their murders.

The Department for Education has made improving information sharing a key part of its children’s social care reform strategy, including by strengthening guidance and testing the establishment of multi-agency child protection teams, as recommended by the panel.

However, social workers appear divided about the effectiveness of information sharing between agencies in child protection cases, according to a Community Care poll.

Just over half of the 606 respondents were positive, with 31% saying information sharing was quite effective and 24% very effective.

But 45% expressed dissatisfaction, rating it as either not very effective (36%) or not at all effective (9%).

What are your thoughts on how well information is shared between agencies during child protection cases?

Note: There is a poll embedded within this post, please visit the site to participate in this post's poll.
Social work opinion is divided on how effective case reviews are in improving safeguarding practice, a Community Care poll has found.

In late March, the local child safeguarding practice review into the murder of 10-month-old Finley Boden by his parents, 39 days after his return to their care, was published. 

Though the inquiry acknowledged that practitioners’ jobs had been made harder by workforce pressures and lockdown restrictions, it found that a series of safeguarding failures ultimately led to Finley’s return to his parents, Stephen Boden and Shannon Marsden, and to his death.

These included practitioners’ over-optimism about Marsden and Boden’s capacity to care for Finley and his elder sister, ineffective use of pre-proceedings and “very limited” multi-agency work.

Safeguarding reviews similar to Finley’s case have been conducted for decades to examine the factors behind the deaths of children and adults involved with social services. 

But while their aim is to learn lessons and, consequently, improve safeguarding practice, is this what they typically achieve?

A recent Community Care poll found that respondents’ views were divided on whether or not case reviews improved the quality of safeguarding.

Of 540 votes, 52% viewed such reviews as effective, with 37% saying they were “somewhat” effective and 15% opting for “very”.

However, 48% reported them being either “somewhat” (26%) or “very” (22%) ineffective.

One social worker in the comments of the related article questioned whether the review on Finley’s case delved deep enough into the wider systemic issues that contributed to his death.

“The review looks at the face value issues and missed opportunities, but how much of this could have been prevented if there were adequate staffing levels, lower caseloads and less pressure?” said Anna B.

“Don’t get me wrong, if an individual is neglectful in their practice this should be highlighted, but at what point does all the failings point to a failure in the system and funding rather than the failings of individual practitioners every time?”

What are your thoughts on the effectiveness of child and adult safeguarding practice reviews?

By Ray Jones

This article is the first of a new five-part series by professor Ray Jones for Community Care’s 50th anniversary. Each part will look back at key events from the previous five decades – starting with the 1970s – that have shaped the social work sector today.

It is fifty years since the launch of Community Care as a resource for social workers and others within social services.

Maria Colwell, pictured on the front page of Community Care

It was also fifty years ago, in 1974, that the Maria Colwell inquiry report was published. Its significance was recognised at the time – it was on the front cover of Community Care – and has not diminished over the past five decades.

Maria was seven years old when she was killed, in 1973, by her stepfather after being returned from foster care to the care of her mother. It was shaped as a ‘tug-of-love’ story between the mother and the foster parents and it captured the attention of the media and the public.

Maria experienced severe neglect and also physical abuse. She suffered brain damage, a fractured rib, extensive external bruising and internal injuries.

A novel response to a child’s death

Following campaigning by the local MP and the local newspaper, a public inquiry was launched.  At the time this was a new and novel response to a child’s death.

A previous inquiry in 1945 into the killing of twelve-year-old Dennis O’Neil was undertaken by a judge in private and took four days.

The Colwell inquiry, however, was held in public, had a three-person panel, and took 41 days. During the inquiry, the local authority social worker was described as ‘the defendant’, was threatened and harassed when arriving and leaving the inquiry, and had to have personal protection.

The inquiry report included concerns about inter-agency and inter-professional working, limitations in the sharing of information and the content of social work training.

Although Maria was seen by multiple other services, including the NSPCC, housing officers, health visitors and others,  it was the social worker from what was then a recently established social services department who became the focus of media and public hostility.

So the dye was cast. For the first time, an inquiry into the death of a child was held in public. It took over a month of daily hearings and drilled down, in great detail, into the circumstances of one child, with all the benefits of unfettered time and hindsight. It also attracted extensive media attention.

The legacy of the Colwell inquiry

It set the scene for the way in which many future inquiries were to be held, including the inquiry following the death of Victoria Climbie in 2002.

This, however, is not the only continuing legacy of the Colwell inquiry. The government’s response following the publication of the inquiry report has shaped what is still the focus and process of much social work activity.

The early 1970s was the time when the unified profession of social work was created across the country, with local authorities in England, Wales and Scotland becoming the lead statutory social services agency and the homebase for the employment of most social workers.

The intention was that the departments would provide a family service embedded within communities to help individuals and families in difficulty and to prevent problems from escalating.

But the Colwell inquiry, press coverage and the government’s response meant that, by the mid-1970s, child protection was the predominant focus and first priority for social workers, and this included implementing a new raft of government-defined procedures.

There was the introduction of the infrastructure, which is still recognisable and dominant today, of child protection (then called child abuse) case and review conferences, child abuse plans, child abuse registers, and what were called area review committees (now local safeguarding children partnerships).

Prioritising child protection over family support

So, in 1974, the death of a seven-year-old little girl led to the process of inquiries into child deaths, where there is suspected abuse, and the child protection procedural infrastructure still recognisable today.

It pushed social workers and their employing social services departments to prioritise children’s risk assessments, risk management and monitoring over family support.

This led to further policy reviews and legislation in the late 1980s to seek to rebalance the work of social workers with children and families and to give more attention to disabled and older people.

Ray Jones is the author of ‘A History of the Personal Social Services in England: Feast, Famine and the Future’ (Palgrave Macmillan 2020) and led the Independent Review of Northern Ireland’s Children’s Social Care Services in 2022-23.

Our interview with Lord Herbert Laming is part of a new series of profiles of key figures who have shaped social work over the past five decades, to mark Community Care’s 50th anniversary.

More than 20 years after delivering his report into the death of Victoria Climbié, there is still a quiet sadness about Lord Herbert Laming at the mention of her name.

In 2001, the government tasked the former chief inspector of social services with chairing a statutory inquiry into the murder of the eight-year-old Ivorian girl by her great aunt, Marie-Therese Kouao, and Kouao’s boyfriend, Carl Manning the previous year.

The extent of the abuse Victoria had suffered shocked the country. Lord Laming’s report, published in 2003, called her a “victim of almost unimaginable cruelty”, with the post-mortem examination revealing 128 separate injuries to her body.

“It is the worst case of child abuse and neglect that I have ever seen,” said a hospital consultant who treated Victoria in her final days.

Yet almost as disconcerting were the several opportunities missed to save Victoria by the numerous services she had been in contact with prior to her death, including social services, hospitals and the police.

‘A gross failure of the system’

Lord Laming on the Victoria Climbié case

Victoria Climbié

While Laming acknowledged in his report that these agencies were “underfunded, inadequately staffed and poorly led”, he described Victoria’s death as an “inexcusable” and “gross failure of the system”.

Not one of the opportunities that arose to intervene required “great skill or would have made heavy demands on time to take some form of action”, his report concluded.

Looking back now, Laming says poor communication between services was the catalyst behind their failure to save Victoria. Several staff at the time uttered words to the effect of: “But had I known that, I would have acted differently.”

“The sad thing is [her situation] was known, but it was not shared with other services,” he says now.

Laming’s report made 108 recommendations, designed to increase the priority placed on children within government, local authorities and other agencies, enhance joint working and significantly improve the quality of practice by social workers and other agencies.

The then New Labour government implemented several through the Children Act 2004 and its wider Every Child Matters agenda, including requiring councils to appoint directors of children’s services.

The ‘Baby P case’ and Laming’s second report

Peter Connelly, who died in Haringey in August 2007

However, in 2008, child protection practice came under the microscope again following the convictions of those responsible for the death of 17-month-old Peter Connelly (‘Baby P’): his mother Tracy Connelly, stepdad Steven Barker and Barker’s brother, Jason Owens.

A serious case review found Peter’s “horrifying death could and should have been prevented”.

So the government called back Laming to review progress on child protection since his 2003 report. His second report, in 2009, praised Every Child Matters, including for prompting additional investment in preventive services, but warned that a “step change” was needed to protect children from harm.

This time, he made 58 recommendations, including further injunctions to strengthen accountability for children’s services, enhance inter-agency working, improve practice and boost funding for preventive and child protection services.

While the response from ministers again was positive, the report’s impact was critically undermined by its timing.

More child protection cases and less funding

The Peter Connelly case appeared to trigger a shift to more risk averse practice, as the number of child protection enquiries and plans and applications to take children into care rocketed.

Then, in 2010, the incoming coalition government embarked on its programme of public spending cuts to close the deficit created by the 2007-8 financial crisis.

As a result, local authority spending on children’s services fell by 9% in real-terms from 2010-11 to 2015-16, according to government-commissioned research. With the increase in child protection and care cases, expenditure on family support was squeezed.

Spending has since increased, but children’s services have faced new and different pressures, not least the experience and lasting impact of Covid-19 on the risks children face and the complexity of their needs.

Just in the last two years, child protection practice has been heavily criticised in the cases of six-year-old Arthur Labinjo-Hughes, one-year-old Star Hobson and, more recently, 10-month-old Finley Boden.

Laming’s doubts about child protection improvements

Lord Laming on whether there has been improvement in child protection since 2003

So, 21 years after his first report and 15 years after his second, has Laming found that things are better?

There was a time he would have said yes, he says. Unfortunately, he is no longer sure.

Laming attributes this in part to the decline in funding after 2010.

Lord Laming

“I think the financial cutbacks in recent years have led to each of the services withdrawing into themselves and I fear that sometimes they only act once the crisis has happened,” he says.

“I am a great believer that one of the strengths of social work is the opportunity to meet people at a time of pending crisis in their lives, to identify and assess what the issues are and [create] a plan of action that will help recover the situation.”

The need for children’s services to shift from crisis response to prevention was also a key conclusion from Josh MacAlister’s Independent Review of Children’s Social Care, which reported in 2022. It has also been adopted by the Department for Education in its 2023 strategy for the sector, Stable Homes, Built on Love.

Under this, some local authorities are testing a new model, ‘family help’, designed to provide families with earlier and more effective support to stave off crises and keep children at home, an approach broadly endorsed by Laming.

A preventive outlook, he adds, would not only keep children out of care, but save local authorities “a lot of money in the process”.

‘Realistic expectations needed’ for social workers

Lord Laming comments on the current funding crisis in social work

Yet, despite funding constraints, Laming notes that expectations for frontline staff have continued to climb higher.

“It’s no use to dream and want to live in a castle but only have the funding for a one-bedroom flat,” he says.

“I tell you we went through a phase where, if you read the objectives for social care services, there were lots of statements [with] the word ‘excellence’ featured a great deal. It’s no use saying to frontline staff our objective is ‘excellence’, but we’re not going to give you the resources to achieve anything like that.”

It is “people detached from the field”, he says, who continue to make important funding decisions. And so it is on councils and senior management to be “absolutely realistic, honest and open” with both social workers and the government about what can and can’t be achieved, he stresses.

“I don’t like putting staff in a position where the expectation is high, but they know that delivery will not be anything like that.”

Progress in practitioners’ expertise

Still, he acknowledges the “enormous” progress that has occurred in practitioners’ expertise and attitudes towards disability, mental health, alcoholism and drug addiction – and their work with families, local communities and the ageing population.

“I think that social workers have gotten a much better understanding of their role, responsibilities and their powers.”

And it’s not that he hasn’t encountered exemplary work in social services – he has met remarkable people. But, the crossbench peer says, some of that outstanding work has been lost.

“Not because of the lack of enthusiasm, professionalism or commitment, but because the resources have been taken away. Frontline staff have found themselves constricted in what they can do and how much time they can give.”

Social work ‘needs to be purposeful’

Lord Laming on why social work needs to be purposeful

There is eloquence in the way Laming speaks. His careful answers are preceded by long pauses where he deliberates on each question to ensure the message is, as he would say, purposeful.

It is a word he thinks needs to be connected more with the work social services do.

“Each of the reports that have happened since [Victoria] into awful deaths of children have highlighted some of the same issues about not sharing information, about not having an action plan,” he says.

“The thing about social work is it can go on for years with the same individuals, but it’s got to be purposeful. I personally attach a lot of importance to the discipline of doing a thorough assessment of where we are, whether or not there’s been progress and whether it’s gone in the right direction.”

He recalls his start in probation services in the 1960s when he had to be very disciplined and clear in the plans he made for individuals placed under a probation order.

Later, as a social worker, he never went on a home visit without being transparent about what the purpose of his visit was, he says.

“I’m very clear that in social work it’s not about the chat. It’s not about having a cup of tea. These things might help but it’s about the purpose behind being there.”

Assessments ‘are about using your senses’

In the past, he has witnessed that ‘purpose’ lacking in assessments of potential children in need.

An assessment should not be a tick-box evaluation, but instead one based on basic senses, he says.

“Go in and use your eyes. See how the adults relate to each other, how the child or children relate to the adults. Do they go rushing up for comfort and reassurance or cower? Smell – is this place neglected or not? Use your ears. What am I hearing about how they address each other? Is it antagonistic or disparaging? Where are the toys?

“So when you walk out of your visit you’ve got a good picture of the family dynamics. You won’t get everything all at once, but you’ll get a reasonable idea of whether or not that is a child-centred home.”

More direct work, less paperwork needed

(credit StockPhotoPro / Adobe Stock)

Laming is the first to admit that nowadays he is far more removed from the sector and the daily realities of social work than he used to be.

However, pressures on social workers mean that his vision for assessment feels as far away as ever.

A poll of 716 practitioners by the Social Workers Union recently revealed that 58% find their workload either not at all or only partially manageable. And in 2022, children’s social workers reported spending 59% of their working time doing case-related paperwork.

Laming is very candid about his displeasure towards senior leadership about this administrative burden.

“I really don’t understand it. When social workers [tell me] that, I want to ask, ‘Does the director of children’s services or your senior management know that?’. Because you’re employed as a frontline worker to work with people. There must be a way of ensuring that the bureaucratic stuff can be kept in its place. I’m all for record-keeping – I’ve read too many bad records [as a chief inspector]- but it is a means to an end. The end is the child.

“We’ve never had such a means of easy communication as we have now. What we mustn’t do is make it the master. It is the servant and enabler. It is the thing that releases the social worker to get out and do the main part of their job.”

A child’s journey through services

These days, Laming is also concerned about the link between children’s and adults’ services, particularly issues that arise when a young person transitions from the former to the latter.

Laming tells me of a severely disabled young adult who, until the age of 18, had been well supported by children’s services. But upon reaching adulthood, when the child got referred to adults’ services, it was as if the young person’s history with children’s services had been erased.

“They started again as if there was no previous contact with this child. An early social history had to be taken and a new file had to be created, etc. And I think to myself, we’ve got to see the whole person.

“But then I’ve also seen some wonderful work where adults’ services were brought in when the child was some years away from finishing school and the authority arranged for prospective employers to be engaged.”

Ultimately, for him, this sums up the problem in children’s services. You always “get the extremes” – a child that has had a wonderful experience and one that was failed.

“What I want to see is the good stuff, the exceptional stuff that is out there, to become the standard stuff everywhere.”

Which influential figures in social work would you like to see Community Care interview?

Professionals should have protected Finley Boden, who was murdered by his parents 39 days after being returned to their care, a local child safeguarding practice review has concluded.

Though the inquiry stressed that Stephen Boden and Shannon Marsden were responsible for the 10-month-old’s death on Christmas Day, 2020 – for which they were jailed for life last year – it said practitioners knew that the couple posed a risk of significant harm to him.

And it concluded that the fateful decision to return Finley and his older sister to their parents’ care was the culmination of multiple safeguarding failings by agencies, though acknowledged that practitioners’ jobs were made harder by Covid-19 restrictions and workforce pressures.

Parenting assessment ‘offered misleading reassurance’

The review, commissioned by Derby and Derbyshire Safeguarding Children Partnership, found both Boden and Marsden were known to services before having children. In both cases for mental health and substance misuse problems, and in Boden’s for a history of offending, including in relation to domestic abuse.

Finley Boden’s parents, Stephen Boden and Shannon Marsden (photo by Derbyshire police)

Derbyshire council made their daughter (known as ‘Ruby’ in the review) subject to pre-birth child protection and pre-proceedings plans, under which she would live with Marsden and family members, with restricted and supervised contact with Boden, pending assessments.

However, the child protection core group subsequently endorsed the couple’s wish to live together with Ruby and ended the pre-proceedings plan, following a parenting assessment that was overly reliant on their accounts of their capacity to care for their child and that received no managerial challenge.

The assessment “offered misleading reassurance to parents and professionals”, concluded the review.

Pre-proceedings initiated for second time

About eight months later, Derbyshire council initiated pre-proceedings again, after Boden was convicted of drug-related offences, reports of cannabis use by the couple, two domestic abuse-related police callouts, concerns about the home environment and instances of the couple avoiding professionals.

The girl went to live with family members (‘Mr and Mrs Anderson’), however, Boden and Marsden continued to evade professionals, while also testing positive for cannabis.

A few months later, Marsden disclosed she was pregnant with Finley. However, despite professionals having concluded that Ruby should not be returned to the couple, they took three months to hold a child protection conference in respect of Finley and no pre-proceedings plan was initiated before his birth.

Care proceedings issued

Days after Finley was born, Derbyshire issued care proceedings for both children. Following the first hearing, Ruby was placed on a time-limited child arrangements order and interim supervision order to live with Mr and Mrs Anderson.

Finley was initially placed with the Andersons on an interim care order but, after the second hearing, he was also put on a time-limited child arrangements order and interim supervision order, pending the completion of assessments.

In line with procedures at the time, Ruby and Finley’s child protection plans came to an end three days after the second hearing, making them children in need.

Covid impact and concerns over lack of management support

Shortly afterwards the country went into the first Covid lockdown, significantly curtailing face-to-face contact by all agencies with the family.

Following the first of only two virtual child in need meetings held during this time, the allocated social worker gave the family court an inconclusive assessment of Boden and Marsden’s capacity to care for their children, with no proposals for final care plans.

The practitioner (known as ‘social worker 2’), who was inexperienced in statutory children’s social work, told the review’s author that she was unclear what was expected of her and had difficulty in gaining clarity from her managers.

Another worker raised concerns with the author about the lack of management support for inexperienced staff in Derbyshire at the time.

The review said that, even without the complexities caused by Covid, producing a good-quality assessment, particularly with no established relationship with the parents, was a complex task. It required sufficient time, input from partner agencies and, for an inexperienced practitioner, “active managerial support”.

No visits or meetings for six weeks

Following a second virtual child in need meeting, at which there was no evidence long-term planning was discussed, the social worker was off sick for six weeks, during which time there were no social work visits to the children or parents and no child in need meetings held.

Before social worker 2’s return, an agency worker (‘social worker 3′) was asked to carry out an updated assessment. Based on outdoor contact sessions and time spent with Marsden and Boden, she concluded that, with time and support, they could make changes, and recommended the children’s phased rehabilitation, over six months.

On her return to work, social worker 2 carried out an unannounced visit to Marsden and Boden but was refused access and greeted with hostility. She then had a meeting with her practice supervisor, in which they discussed the parents’ hostility and dishonesty, but not care planning or possible reunification.

Plan for reunification 

However, Derbyshire’s final evidence to the court recommended a plan for reunification over four months, alongside 12-month supervision orders for Finley and Ruby and child arrangements orders with Mr and Mrs Anderson. This was signed off by a team manager and head of service at the council.

The review found that the plan was strongly influenced by social worker 3’s positive assessment that the parents had “engaged well with services and demonstrated their ability to meet all the needs of the children”.

However, the evidence for this conclusion was “weak,” said the report, and the plan also had the disadvantage of there being no legal oversight over decisions on where the children would live permanently.

The guardian’s view

The Cafcass guardian in the case had met the parents only once, with all other contact with Marsden and Boden, the children and family members being virtual, because she was shielding.

She accepted Derbyshire’s view that the parents had made “good progress” and had no objection to the children being returned, but wanted long-term decisions about them to be taken during proceedings, to ensure they were signed off by the court.

So, she proposed reducing the reunification period to six-to-eight weeks and extending proceedings, meaning the court could make final orders in favour of Mr and Mrs Anderson should rehabilitation prove unsuccessful.

What the court decided

The court agreed with the guardian’s proposed timescale and against the council, and also rejected the Derbyshire’s call to make an order requiring Marsden and Boden to undertake regular drug testing, a point on which the guardian was neutral.

Social worker 2 said she was “disappointed and frustrated by both outcomes”, feeling that a longer period of rehabilitation was in the children’s best interests and that not ordering drug testing removed a reliable source of information for the council with which it could challenge the couple.

Despite the lack of an order, the guardian believed that drug testing would continue. In conversation with the author, she attributed her view to her inexperience as a guardian and difficulties managing remote proceedings.

The parties agreed a transition plan, under which the parents would have increasing levels of contact up until the children’s full return, and would receive weekly unannounced visits by children’s social care.

Children ‘not seen in parents’ care after court hearing’

However, by the time of the subsequent child protection conference, around four weeks later, the children had not been seen by practitioners in their parents’ care, despite the fact they were, by then, primarily living with Marsden and Boden.

The conference did not include Marsden, Mr and Mrs Anderson – despite them having parental responsibility under the child arrangements orders – or representation from substance misuse services.

The social worker’s report to the conference was optimistic, with the only issues noted being uncertainties over the parents’ drug use. The resulting child protection plans reduced the frequency of visits set out in the transition plan.

999 call 

A week later, police responded to a 999 call at Marsden and Boden’s house, reportedly due to someone banging on the door to collect a drug debt owed by Boden.

However, though the officer who attended gleaned from Marsden that there were children in the house, they were not alerted to the fact that there was a ‘flag’ at the address to indicate the children were the subject of child protection plans.

As a result, the children’s details were not recorded and social care was not informed.

“In the circumstances of this case, that gap was significant,” the review concluded.

Finley Boden (photo: Derbyshire Constabulary)

‘Inadequate’ safeguarding practice

Very shortly after, the children returned to their parents’ care full-time.

The review said that the criminal trial into Finley’s murder revealed how little professionals knew about the last few weeks of his life, but concluded that “safeguarding practice during that time was inadequate”.

Of two health visitor visits that should have taken place during this time, just one occurred.

Of six social care visits that should have been carried out, only four were attempted. On one occasion, there was no answer from the parents and on the other three, issues arose that warranted further inquiry, but necessary actions were not taken.

On one occasion, Finley had a bruise to his head – which the parents said had been caused by a toy thrown by Ruby – on another, he was found sleeping unattended on the sofa and on the third, the social worker could not see him because Boden said he had Covid symptoms.

The social worker and health visitor communicated too infrequently to identify issues of concern and there was only one child protection core group conference call during the period. The health visitor was absent for this and information shared seemed to reinforce the perception of an improved family environment but without objective evidence to back this up.

Six weeks after his return home, Finley was dead, with a post-mortem finding him to have had injuries that were “abusive and inflicted”. Ruby was unharmed and returned to the Andersons’ care.

Criticism of parenting assessments

While stressing Boden and Marsden’s responsibility for Finley’s death, the review concluded that “professional interventions should have protected him”, with agencies’ failure to do so the culmination of several previous decisions, events and circumstances.

A key lesson from the inquiry was practitioners’ over-reliance on parental self-report and their over-optimism about Marsden and Boden’s capacity to care for their children, in the two parenting assessments during the review period.

For example, in the second assessment, which underpinned the council’s care plans for the children, too much weight was given to the parents’ expressed intentions to reduce their cannabis use.

“Most strikingly, parents were not asked to explain what went wrong when they were caring for Ruby, and so no insight is offered as to how they expected to avoid similar difficulties in future,” the review added.

Ineffective use of pre-proceedings

The review also criticised the council’s use of pre-proceedings, particularly on the second occasion Ruby was subject to these after she moved to live with the Andersons. Though the council concluded care proceedings should be issued because of Marsden and Boden’s unwillingness to engage, “no sustained progress was made to that end, however, during most of the six months which followed”.

There was also an “attendant lack of urgency in bringing care planning for unborn [Finley] into the legal framework”. This meant that, by the time it issued care proceedings, the council was not adequately prepared to put permanence plans before the court, which led to pressures to complete assessments that should have been carried out earlier.

‘Very limited’ multi-agency work

The review also concluded that “multi-agency work within care proceedings was very limited and that this was detrimental to Ruby’s and [Finley’s] welfare and safety”.

When they were moved from child protection to child in need plans when they were made the subject of interim supervision orders, some agencies interpreted this as a “stepping down” that meant reduced involvement in the case. This was despite a court having found that the threshold of significant harm had been met for both children.

Local multi-agency procedures in Derbyshire now require child protection plans to continue where children are the subject of interim supervision orders, until final orders are agreed. However, the review said for this to make a difference in reality, there needed to be a change in culture such that partner agencies did not see court work as a local authority task.

Reunification risks ‘not adequately understood’

The review said the inherent risks in returning Finley and Ruby to their parents were “not adequately understood”, given the “very limited evidence” of change since they were found to not be caring for their daughter sufficiently well.

Increasing the likelihood of a successful reunification would have required high levels of support and challenge to the parents, however, the transition plan did not meet these criteria.

Professionals involved with the family were not consulted prior to the reunification plan being put to the court and were unaware of the details of the transition plan. There was also no comprehensive package of support and it was not clear what concerns would have triggered a reversal of the reunification plan.

Recommendation and response

The review recommended that DDSCP should audit cases where children were returned to parents in pre-proceedings or during proceedings and, where possible, evaluate outcomes for children and families after six and 12 months.

In response, DDSCP said there had been improvements in reunification work, with the 2023 Ofsted inspection concluding that “careful, phased planning ensures that most children who return home to their parents do so successfully and sustainably”.

Workforce issues compounded by Covid

The review also highlighted the fact that the social workers and guardian involved in the case were inexperienced and reported “heavy workloads”, which meant they faced significant difficulties meeting court deadlines.

These difficulties were “compounded by the challenges of living and working during a pandemic and practising in the context of public health measures”.

The report acknowledged improvements since the time covered by the review, with a reduction, from 36% to 25%, in social worker vacancies at the council from 2019-23, and 36 more permanent practitioners being in frontline practice. It also reported that workloads had reduced at Cafcass.

The review also praised the “significant resource” that the safeguarding partnership had invested in improving child protection practice with babies, based on findings from other practice reviews. In its 2023 inspection, Ofsted found this “has led to the development of positive initiatives with health partners to ensure strong oversight of vulnerable parents during pregnancy and post-birth”.

Steps taken to improve practice and systems

Giving the safeguarding partnership’s response to the report, independent chair and scrutineer, Steve Atkinson, said: “I offer my sincere condolences to Finley’s family and apologise on behalf of the partnership for what happened.

“The partnership agencies took early steps to improve systems and practices, responding quickly to an immediate review of Finley’s death and the circumstances in which it took place.

“In accepting in full the recommendations of this review – commissioned by the partnership, completely independently of Derbyshire and the organisations involved – agencies will take the additional action necessary to further reduce the risk of a repeat of a similar incident.”

The partnership has published a report detailing progress made since the period covered by the review in addressing its findings.

Cafcass ‘profoundly sorry’ but highlights parents’ deception

In a statement on the findings, Cafcass said it was “profoundly sorry” that it and partner agencies were unable to prevent Finley’s death.

It said that, as a result of Finley’s murder, it had strengthened the management support and supervision of family court advisers and guardians in cases where a local authority was proposing to return a child to parents or carers where there has been known or alleged abuse or neglect.

In relation to the family court’s decision to follow the guardian’s recommendation on the timeframe for Finley’s return home, Cafcass said “it was not possible to say whether a longer transition plan would have prevented his death”, based on what was known at the time.

It added: “What led to his death was the ability of Finley’s parents to deceive everyone involved, about their love for him and their desire to care for him. No one could have predicted from what was known at the time that they were capable of such cruelty or that there was a risk that they would intentionally hurt him, let alone murder him.”

What are your thoughts on the current models of child and adult safeguarding practice reviews?

The social worker in the Bronson Battersby case is back at work and continues to be supported, her local authority has said.

The news came as Lincolnshire Safeguarding Children Partnership (LSCP) announced it was commissioning an in-depth review to learn lessons from the two-year-old’s death.

The social worker, from Lincolnshire County Council, found the dead bodies of Bronson and his father, Kenneth, in their flat on 9 January, almost two weeks after her last contact with Kenneth.

In the meantime, she had made two attempts to visit them, on 2 and 4 January, and searched for them at other addresses where  they might have been found.

She also contacted Lincolnshire Police for assistance in contacting the pair, on 2 January.

‘A devasting experience’ for staff

The council said the case was a “devastating experience for those working with the family”, and the social worker took time off to recover.

Lincolnshire provided the staff with regular contact from managers, supervisors and colleagues, and a range of trauma-informed support, alongside access to the council’s staff health and wellbeing service, which includes counselling provision.

LSCP has decided to commission a local child safeguarding practice review, led by an independent author, after carrying out an initial rapid review into the case. The national Child Safeguarding Practice Review Panel supports its decision.

LSCP’s independent chair, Chris Cook, said the review would “explore fully the circumstances surrounding this tragic incident and identify any potential improvements we could make”, with the family invited to contribute.

It will take about six months and will be published once other related investigations, including an inquest, have concluded.

Review into police conduct

Following Kenneth and Bronson’s death, Lincolnshire Police referred itself to the Independent Office of Police Conduct, which is reviewing whether there were any missed opportunities for the force to check on the pair sooner.

Unlike social workers, the police have powers to enter homes under section 17 of the Police and Criminal Evidence Act 1984. This permits entry without a warrant in order to arrest someone for a serious offence or for the purposes of preventing serious damage to property or saving life or limb – though the latter is a high threshold to meet.

Cook added: “Our thoughts remain with the family at this difficult time.”

In January, a social worker discovered the bodies of two-year-old Bronson Battersby and his father, Kenneth, at their home, after making multiple attempts to reach them.

The heartbreaking and traumatic experience led to the practitioner, from Lincolnshire County Council, taking time off to recover.

Heather Sandy, director of children’s services at the authority, said the social worker was “incredibly upset” and the council was making sure she was getting all the support she needed.

“This was a devastating experience for those working with the family, and all have been given an opportunity to take time off.”

The related article’s comment section also displayed an outpouring of support for the practitioner.

“I pray for the family concerned and for the social worker and her family as they navigate the extremely painful emotions following this awful tragedy,” said Bee.

“I’m certain all that could be done to support this family was done to the best of their ability and with only the best intentions towards the child and his parents.”

Support in place ‘not effective’

Bronson’s case calls to attention how frequently social workers encounter dangerous or distressing experiences at work – and raises the question of how well employers support them when they do.

Lincolnshire said it had ensured that the practitioner and colleagues who had worked with the family had “regular contact from managers, supervisors and colleagues” as well as access to a counselling service and trauma-informed support.

However, in response to a Community Care poll that drew 613 votes, the majority of practitioners (85%) said that support from employers following traumatic incidents was ‘not very’ or ‘not at all’ effective.

Only 8% called the support ‘very effective’ and 7% ‘quite’.

How effective is the support in place at your workplace?

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A social worker and her colleagues are receiving support after the “tragic” death of two-year-old Bronson Battersby.

The toddler was found dead with his father, Kenneth, at their home in Skegness, Lincolnshire, on 9 January, almost two weeks after the last known contact with them.

Bronson was on Lincolnshire County Council children’s social care caseload and the authority has launched a rapid review into the case.

Kenneth is believed to have died from a heart attack, no earlier than 29 December, 12 days before the pair were found.

Bronson’s social worker had last had contact with Kenneth on 27 December. This was also the last known contact to have taken place with him.

No response to scheduled visit

She went to the home for a scheduled visit on 2 January but got no response. Lincolnshire has said that Bronson’s was the sort of case where the child would normally be seen once a month.

The social worker then went to other addresses to find Bronson without success before contacting the police.

She tried the house again on 4 January before gaining entry on 9 January after being given access by the landlord. She then found Bronson and Kenneth’s bodies.

The social worker has taken time off because of her experience.

Social worker receiving support

“The social worker, obviously, is incredibly upset,” Lincolnshire’s director of children’s services, Heather Sandy, told the BBC’s World At One on 17 January. “She had worked with Bronson and his family over a period of time and cares very deeply about the work that she does.”

In a subsequent statement to Community Care, Sandy said: “We really value the support our staff provide to children and families across Lincolnshire, and we make sure that they are supported too. This was a devastating experience for those working with the family, and all have been given an opportunity to take time off.

“There is regular contact from managers, supervisors and colleagues, and a range of trauma-informed support is available to them. This is in addition to the council’s wider health and wellbeing support for staff, which includes a counselling service.”

When asked about whether the council and other agencies could have gained entry to the property earlier, Sandy told the BBC: “To be really clear, social workers cannot force entry, they have to gain the consent of the homeowner.”

The police do have powers of entry, under section 17 of the Police and Criminal Evidence Act 1984. This permits entry to a property without a warrant in order to arrest someone for a serious offence or for the purposes of preventing serious damage to property or saving life or limb.

However, Sandy told the BBC that Kenneth’s death was unexpected.

Police force refers itself to watchdog

Lincolnshire Police has referred itself to the Independent Office of Police Conduct (IOPC), the police complaints watchdog, which has now begun an investigation into the case.

The IOPC’s regional director, Derrick Campbell, said: “The harrowing circumstances in which Kenneth and Bronson Battersby died are truly shocking. Our sympathies go out to everyone affected by their sad deaths.

“It is appropriate we carry out an independent investigation to consider the police response to any prior welfare concerns that were raised. We will be examining whether there were any missed opportunities by police to check on Mr Battersby and Bronson sooner.”

For the county council, Sandy added: “This was a tragic incident, and we are supporting the family at this difficult time.

“We are currently carrying out a review of the case alongside partner agencies to better understand the circumstances, and we await the results of the coroner’s investigations as well. Our thoughts are with the family and friends of those involved.”