There is a need for sharper specialist child protection skills and expertise, especially in relation to complex risk assessment and decision making, a report into the deaths of Arthur Labinjo-Hughes and Star Hobson has found.

The national review, carried out by the Child Safeguarding Practice Review Panel, was commissioned by the government following the deaths of Arthur and Star after the conclusion of the two murder trials.

In analysing what happened to Arthur and Star and how public agencies responded, the panel has identified a set of issues which hindered professionals’ understanding of what was happening to Arthur and Star. This includes:

• A need for sharper specialist child protection skills and expertise, especially in relation to complex risk assessment and decision making; engaging reluctant parents; understanding the daily life of children; and domestic abuse.
• Weaknesses in information sharing and seeking within and between agencies.
• A lack of robust critical thinking and challenge within and between agencies, compounded by a failure to trigger statutory multi-agency child protection processes at a number of key moments.
• Underpinning these issues, is the need for leaders to have a powerful enabling impact on child protection practice, creating and protecting the optimum organisational conditions for undertaking this complex work.

“These are not new issues; they recur across the reviews of serious incidents that the Panel sees on a fortnightly basis. They come up in all analyses of serious case reviews and thematic practice reviews; and they have featured in all previous inquiries into child deaths,” said the report.

The report highlights that protecting children from abuse is “intrinsically complex and challenging work”.

This is due to:

• Requiring great expertise in finding out what is happening in the intimate nature of family life.
• It involves intruding into private spaces to evaluate and make professional judgements about parenting, the development and wellbeing of children, and whether a child or infant is experiencing harm.
• Child protection professionals must also address the complex issues of extra-familial harm, including child sexual and criminal exploitation outside of the family
• All child protection practice requires confidence, capability and the use of expert authority to make decisions about children’s lives, as those decisions will have enduring and life shaping consequences.

“These involve, for example, initiating court-led decisions that a child should be removed from their parents, or deciding that the best thing for a child is to remain safely with their parents, even where this involves managing complex ongoing risk,” said the report. “At its heart, child protection practice requires consummate skill in blending ‘care’ and ‘control’ functions, helping families to protect children.”

This can only be achieved by building trusting relationships with parents and children whilst recognising that how things appear may not be the reality of a child’s experience.

This review has highlighted two important factors about child protection in England:

• The review contends that multi-agency arrangements for protecting children are more fractured and fragmented than they should be.
• There has been insufficient attention to, and investment in, securing the specialist multi-agency expertise required for undertaking investigations and responses to significant harm from abuse and neglect.

While there are examples of excellent multi-agency practice, too often critical, life changing decisions are being made by children’s social care alone or with only superficial and partial involvement of other agencies. The report urges genuinely joint, challenging, rigorous decision making every time there are concerns about a child.

Across England, the review wants to see fully integrated multi-agency investigation and decision making, professionals with the appropriate expertise and skill undertaking child protection work and leaders who know what it takes to deliver an excellent child protection response to create the organisational context in which this can flourish.

“We are recommending that Multi-Agency Child Protection Units – integrated and co-located multi-agency teams staffed by experienced child protection professionals – are established in every local authority area,” said the review.

These will include professionals with huge levels of child protection expertise and experience and will see the key child protection agencies of the police, health and social care working together as a single team.

Other recommendations are made around enabling the proposed new Multi-Agency Child Protection Units to deliver excellent practice.

However, the review states that the most important enabler of excellent practice is leadership. Therefore, the review recommends strengthened multi-agency leadership and accountability, and for better multi-agency co-ordination and system oversight from central government.

The review urges new National Multi-Agency Practice Standards to be developed for child protection, to consistently deliver good practice nationwide. Local area child protection practice across all agencies should be frequently inspected to ensure these national standards are being adhered to.

The implementation of these new arrangements should be overseen by a new Ministerial group.

“Child protection is a major public concern and should be matched by sufficient and sustained political leadership across all relevant Government Departments,” the report concludes.

Child protection in England