More than half of reviews of serious child safeguarding cases concerned children who had suffered neglect before incident, independent panel reveals

The Child Safeguarding Practice Review Panel has called for "accelerated change" in multi-agency safeguarding practice, after reviewing local safeguarding incidents when a child has died or suffered serious harm and abuse.

In its fourth annual report, the panel revealed that it received 393 serious incident notifications between April 2022 to March 2023, of which 146 (37%) were in relation to child deaths and 227 (58%) were related to serious harm.

The report found that more than half (53%) of reviews received by the panel featured a child who had experienced neglect prior to the incident. Panel Chair Annie Hudson warned that this “warrants attention”.

Further, a high proportion of school-age children who died or were seriously harmed were either not in school (11%) or reported to be regularly absent (29%), the panel noted.

Analysis also revealed that, in over three-quarters of cases reviewed, the family of the child was known to children’s social care, and a third of children were either on, or had previously been on, a child protection plan.

Additionally, nearly a fifth of children were being ‘looked after’ by the local authority, either at the time of the incident or prior to it, while 21% of children were reported to have a mental health condition.

The panel identified “insufficient attention” being given to a child and families’ context, history, and what life has been like for a child.

The panel also observed that reviews often focus on a specific incident or episode, rather than evaluating the impact of family history and experience over time with different agencies.

The report highlighted the importance of a “whole family approach” to risk assessment and support. The panel wrote: “The absence of a whole family approach was evident across many of the reviews with services often focused on one specific family member, most often the mother or the child who was the focus of the review.”

On domestic abuse and harm to children, the panel warned that in cases where parents have co-parenting responsibilities, there tended to be a focus on removing the perpetrator “without considering whether this may in some regard be harmful for the children, particularly if the perpetrator may also have a protective role in their care”.

Panel Chair Annie Hudson said: “Our annual report provides important data and analysis about the English safeguarding system, highlighting patterns in practice, strengths and areas for improvement.

“[...] That 53% of our reviews concerned children who had suffered neglect prior to the incident, for instance, is striking and warrants attention. Likewise, the fact that 21% of children were reported to have one or more health conditions underlines the vital importance of health, local authorities, police, education and other services working seamlessly together to help keep children safe.

“A range of factors are exerting considerable pressure on agencies: workforce challenges (for example, in social work and health-visiting) and the sufficiency of preventative services and high-quality placements can undermine the ability of agencies to help and protect children. Notwithstanding these system pressures, practitioners and leaders are bringing creativity and resourcefulness to protecting children.

“However, as the report makes clear, too often the work of safeguarding agencies is not as ‘joined up’ as it must be, undermining their ability to know what is happening to a child and take decisive action when this may be needed. [...] We welcome the important safeguarding reforms that have been initiated, but the momentum for change must be accelerated to help families and protect children."

Responding to the Panel’s annual report John Pearce, President of the Association of Directors of Children's Services, said: “The death or serious harm of any child, though thankfully rare, is a tragedy. England has one of the safest child protection systems in the world. However, it’s crucial that we learn lessons when things do go wrong and that we continuously strive to improve the safeguarding system and in turn children’s outcomes.

“We welcome the report’s focus on supporting councils and our safeguarding partners to keep children safe. Child protection is difficult and complex work, even where children are known to us, abuse and neglect can be actively hidden by individuals seeking to deceive professionals. The report also identifies other issues that can hinder our collective ability to help and protect children. This includes workforce challenges, a lack of suitable placements and the loss of preventative services over time. It also identifies systemic issues and injustices that need action to radically improve all children’s experiences, including poverty and racism. Councils and our partners cannot address these issues alone, we need support from government. While there is a national plan in place to address some of the workforce challenges councils face in relation to social workers and a wider children’s social care reform agenda, this must be properly resourced and rolled out at pace."

Pearce added: “Councils are committed to working with our safeguarding partners to keep children safe. All councils, their safeguarding partners, and others should read this report and take note of the themes and learning that it helpfully draws together. We hope this report and safeguarding reforms underway result in improved safeguards and, crucially, outcomes for all children.”

Lottie Winson