By Donna Ohdedar

Social workers are often the focus for blame when a tragedy occurs. When practice falls short of what was expected, leaders are under pressure to show accountability.

But where this leads to more compliance measures and defensiveness, we’re not creating the conditions for workers to do what they do best.

With high caseloads and overwhelm, a more supportive approach would encourage openness, ownership and, inevitably, a better outcome that doesn’t result in more time-consuming procedures.

Why we involve practitioners for better review outcomes

It is in all of our best interests to give practitioners a voice in reviews – and it is their right to have a voice.

Social workers hold the key information to inform our learning.”

The overview report author and agency report authors, who are at one step removed from the case, can report facts inaccurately; so we must involve practitioners for an accurate narrative.

However, the need to involve the practitioner directly isn’t always explicitly expressed in the guidance that underpins reviews in England.

What statutory guidance says

It is only the guidance for child safeguarding practice reviews in Working Together to Safeguard Children that clearly states that practitioners should be “fully involved and invited to contribute their perspectives without fear of being blamed for actions taken in good faith”.

In relation to safeguarding adults reviews, the care and support statutory guidance only asks that there is “appropriate involvement of professionals/organisations”.  This is far too vague and may not mean the frontline practitioner is involved.

Meanwhile, there is no mention of involving frontline practitioners directly in Home Office guidance (2016) for domestic homicide reviews (soon to become domestic abuse related death reviews).

New guidance was consulted on last year and is now being considered by the Home Office. Updated guidance should clearly state the need for professional to be involved.

However, regardless of whether statutory guidance requires it, we must always involve practitioners in the review process. It is disrespectful to conduct a review without including those who were involved in the case. 

Traditional models v SILP

Traditionally, in my experience, the social worker involved in the case has not been part of the review. Whilst a report will have been written for their agency to submit, they may well have felt that they lost ownership.

As thinking has progressed and more local areas have experimented with direct practitioner involvement in reviews, this is slowly improving.

Under the Significant Incident Learning Process (SILP) model, reviewers speak directly with practitioners and families, learning from what went well as well as any shortcomings. There is an emphasis on talking about the case, not only looking at written material submitted.

The review chair directly consults with the social worker involved in the case during a learning event with other practitioners. This allows for a fuller understanding of what happened, what was going on in their day-to-day work life, what was happening on the ground.

How social workers can better prepare for a review

The SILP reviewer will hold a briefing to talk through how social workers need to prepare, and will allow space for asking questions as to what is expected and needed from them. This initial meeting is absolutely vital to ensure a thorough report with appropriate feedback, so it must be attended.

Donna Ohdedar of Review Consulting

My number one requirement in all reviews is that wraparound support is available for every participant. What this means is that a manager or safeguarding lead is on hand in the lead-up to any meetings or learning events the practitioner may be required to attend.

As a supporter, you may decide to ask the independent reviewer questions about what to expect or how you will deal with specific facts or issues you will be required to discuss. The sense of anticipation before these meetings can be unnecessarily stressful, so clarity about the purpose and requirements for the meeting or learning event will help enormously.

For any safeguarding system to be able to learn about how well it’s doing, it needs good feedback about the processes and the outcomes of the services provided.

As independent reviewers, it is our role to prompt good conversations and put practitioners, who are likely feeling high levels of anxiety, at ease.

The emphasis should be on learning rather than blame, which provides reassurance to the apprehensive.”

Positive practitioner feedback

Research commissioned by Review Consulting from the University of Nottingham about a SILP review carried out in 2014 found the process enabled the experiences and views of the practitioners nearest to events to be reflected accurately as part of the learning event experience.

We have also received feedback that involving the practitioner increases motivation and engagement in the review process, encourages greater performance and enables teams to be more effective in managing change.

Every practitioner is an inheritor of the system, with all of its defects. Taking part in a review not only helps to improve the system, but may also act as catharsis for practitioners involved in cases that had a poor outcome.

In every review I undertake, I am grateful for the courage, energy and hard work the practitioners put in to ensure that the review has an accurate narrative that generates vital learning.

Donna Ohdedar, chief executive officer of Review Consulting, is an independent reviewer and consultant in safeguarding and domestic abuse cases

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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.”

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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.

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).

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.

This article is part of a series of profiles of key figures who have shaped social work over the past five decades, to mark Community Care’s 50th anniversary. Previous interviewees include Brid Featherstone, David Howe, June Thoburn, Eileen Munro and Herbert Laming.

Marian Brandon’s social work journey began in a way familiar to most practitioners, with a desire to make a difference.

After graduating in law in the mid-1970s, she began working in a residential home for young people, her goal of joining a law firm soon shifting to a passion for child protection, leading her to qualify as a social worker in 1980.

It was in the 1990s that Brandon’s acclaimed research career began, under the mentorship of Professor June Thoburn, whom she still lathers with praise.

She has since contributed valuable insights on child protection, neglect, children’s views of abuse, domestic abuse and on working with fathers.

But perhaps her most famous role was directing national analyses of serious case reviews – now known as local child safeguarding practice reviews or child practice reviews – in England and Wales covering cases from the late 1990s up to 2017.

It was a project influenced by a curiosity over the child death enquiries that found national fame compared to those that got quickly forgotten.

Brandon embarked on a decade-long journey to note the patterns, pinpoint the lessons, find the outliers, and help the sector move forward in a meaningful way.

Speaking to Community Care seven years on from the final review that she analysed, Brandon touched on the legacy of her reviews, the lessons she tried to disseminate and the subtle complexity of neglect in child deaths.

How was your experience practising as a social worker in the 1980s compared to today?

I think had more autonomy than social workers do now. There was a child whose mother lived far away and wasn’t safe to look after him. I used to drive him to have contact with her regularly because I thought it was a great way to get to know him.

I also got to maintain contact with [the mum] and see how she was doing. I had the time to do that then but I’m not sure social workers would do so much now.

Practitioners are time and resource-poor, and so have become more distanced from families. To an extent, they have lost their sense of compassion and become more defensive.

That defensiveness and the anxiety around being unable to do the job properly can affect their attitude towards families. I have always stressed to students how important it is to approach families with kindness.

You might have to make difficult decisions the family disagrees with, but you should be kind and respectful. When people are under huge pressure that can get lost.

But the work is very emotionally difficult and workers don’t always get the support they should. Without fully staffed teams and [the resources and time] to do some preventative work, it’s very difficult to do the job properly and act with empathy, compassion and understanding.

How did your analyses of serious case reviews begin?

The headline reviews at the time – for example, for Jasmine Beckford and Maria Colwell – were about children aged five, six or seven. I thought, ‘Well, how typical are these big cases compared to others where things went wrong?’.

Previous analyses of serious case reviews were only on a small sample of cases. So when we got the first commission from the Department for Education and Skills (DfES), I was very keen to capture all the reviews to pinpoint the similarities, differences and outliers.

We had a real struggle getting all the reviews but we did get a lot. We had basic information on every review and then chose a sub-sample to study in depth.

Each review felt like an important tribute to the child as a person: [the opportunity] to see them individually, in their family context and not just as the big case that hits the national headlines.

I’ve always done this research as part of a team and researchers didn’t want to work on it full-time – it was too upsetting. We always ensured researchers were working together so we could talk to each other about what we’d just read.

Did it ever take a toll on you?

Towards the end, I found it harder to read and go through the reviews. That was when I decided to stop. So I think, yes, they did take a toll.

I remember one time, I was told by a civil servant that the records needed to be put in the shredder afterwards. And I was crying while I was shredding them.

I thought, ‘This is the last information about these children. No one else will come back and find out about their lives.’

What key lessons did you draw from analysing serious case reviews?

In the first serious case review study, for Wales, what came through was professionals not challenging [decisions] when they thought something was wrong.

But to do that, you’ve got to be confident that you’re not going to make things worse, which is tricky.

I have made a point of trying to challenge unsafe practice as a lecturer working with social work students on placement – for example, when a case was closed when risks of significant harm to a child were not resolved and families were no longer getting support.

However, this was possible because I had good enough relationships with the students and their supervisors and managers.

I could discuss my concerns and follow up what decisions were made subsequently without feeling that things would get worse. From the reviews, what came across was that workers felt able to do this when they had good relationships and were well supported and supervised.

So that was an abiding lesson that stuck with me, and that’s a theme that’s come through all of the reviews from the 1990s till 2017 [my last review].

Are there any other themes that persisted over the years?

The family [that ends up in the review] looks like other families on a social worker’s caseload. So how do you tell the difference between a family where things can go wrong and one where, it might not be perfect, but the child won’t be harmed?

That comes back to knowing the family well enough to see the signs. Because things often slip quite quickly.

Neglect was also a background factor in most of the cases but was rarely the primary cause of death or harm.

Interestingly, when practitioners classified a case as neglect they sometimes failed to see what else was happening.

In one case, there’d been numerous section 47 enquiries about physical abuse – and the child did die of physical assault – but it was thought of as a neglect case and so it was treated as one.

So we should be aware that neglect can be a flag for other things happening.

You ended up doing an analysis of neglect in serious case reviews from 2003 to 2011. What is something that struck you?

Dr Ruth Garner for the NSPCC was part of the team in the early studies and she came up with the term ‘start again syndrome’.

Looking at the cases, we often found that practitioners, in an attempt to think the best of the family, particularly when there was a new baby, would say, ‘Put away these big, fat files. We won’t look at those. We’ll just start again. This new baby gives the family a fresh start.’ And it was with the best intentions.

But you need to understand how the family has gotten here. Things might be assumed to be better now but they might not be. Assessments need to happen repeatedly and that could be forgotten about.

In one case, a young mother was a drug misuser but was desperate to be a good parent. She was pregnant and always turned up for her drug test – but most of them were positive. So the worker said, ‘She’s so co-operative, she wants to be a good mum. She really is trying her very hardest.’

But, sadly, she wasn’t succeeding. She wasn’t off the drugs and it was still dangerous.

They said they didn’t want to be judgmental but, as a social worker, you do have to judge whether this person is a safe enough parent. It’s about judging in a way that’s fair and compassionate to all sides.

You have previously talked about ‘the normalisation of neglect’. What are the repercussions of that?

I think neglect sometimes stops practitioners from understanding what’s going on because it seems to be everywhere. What we tried to do in our serious case review work was ask, ‘What kind of neglect is it?’.

Neglect muddles practitioners’ thinking. You need good supervision on neglect cases to try and disentangle what it means and what may hide behind it, and see things more clearly. How is the impact manifesting on the child?

I hope the legacy of our serious case review work is to remind practitioners to hold steady in confusing, overwhelming cases, and instead of just saying, ‘It’s everywhere,’ to ask themselves, ‘What’s it like in this family, in this case, for this child?’.

How effective are current safeguarding practice reviews in helping practitioners learn lessons?

I think it’s really hard to learn from the worst cases. Hard cases make bad laws and encourage fearfulness.

I think it would be better to learn from when things go well.

I remember asking a director of children’s services in an area that had consistently done well how they maintain this progress. She said, ‘We don’t make a huge fuss when things go wrong’. They did their learning from what works.

Safeguarding reviews are helpful when they provide recommendations that improve everyday practice. But I think they’re more efficient when shorter and more to the point, which is the current direction of local child safeguarding practice reviews.

What are your hopes for the future?

I do feel more hopeful than I would have, say, a year ago.

But I think social workers need to feel hopeful and they need to feel that they can do the work that they’re trained for, and carry on putting relationships at the heart of what they do.

Maltreatment is relationships gone wrong, so the best way to understand and help maltreatment is to understand relationships and use relationships to help people function better.

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.

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?

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?