Following details revealed in court of the tragic death of Arthur Labinjo-Hughes at the hands of his father and step-mother last week, the education minister, Nadim Zahawi, announced a local inspection and national review into the case. Since then we have heard about the horrible death of 18 month old Star Hobson from Keighley at the hands of her mother’s partner, with her mother also being implicated in the cruelty that preceded the murder.
After the sentencing of Arthur’s killers the government announced a ‘joint targeted inspection’ will be undertaken by health, social care, police, probation and education inspectorates while the national review will “determine what improvements are needed by the agencies that came into contact with him in the months before he died”. It will consider the implications of this for other children and services in England. Immediately following Arthur’s death, local agencies started a ‘safeguarding practice review’ and it this that the national review team will ‘upgrade’.
We can expect to hear more from ministers regarding action that will be taken following the sentencing of Star’s killers. It is already known that five referrals were made to social work by family members over the course of Star’s short life and that her mother was in contact with them and other related services from a young age.
The impact of the pandemic
The reviews will tell us how agencies responded to the risks Arthur faced and the extent to which coronavirus had an impact on his care and oversight. We already know that public-facing child protection professionals (primarily police, education health and social work) were also at considerable risk from coronavirus or had a requirement to self-isolate, thereby depleting available resources. Social workers still operated and visited families but also shifted some contacts to video, schools were open and the most vulnerable children were given priority but not all cases on non-attendance were followed up, and health services still functioned, although in person contact was reduced.
There are many families who manage their lives reasonably well until something tips them over the edge. In ‘normal times’ it may be loss of employment, the end of a relationship, the birth of another child, or death of a family member. In many families, parenting may be ‘just about’ good enough, a child’s behaviour ‘just about’ manageable in school, and parental coping with day-to-day stresses ‘just about’ sufficient to avert more serious problems. But when reserves are low and resilience weak, families may find they can no longer cope or that they begin to dislike or resent the child for whom they are responsible, or blame them for their difficulties.
The impact of the pandemic and lockdown on domestic abuse, child abuse, mental ill-health and alcohol consumption has been well documented, although the full impact will not be clear for some time to come. In combination, these problems and impacts are highly damaging, not just for now but in the longer term.
No shortage of judgments and opinions on child protection
Already, there is no shortage of opinions on what went wrong in this case. Reduced local government funding since 2010 – by as much as by two thirds in some local authority areas – has been highlighted. Last weekend Tim Loughton, the ex-Conservative children’s services minister and Lord Laming (author of the review into the death of Victoria Climbié in 2001) lambasted government’s decimation of local authority services and the role this is likely to have played.
Meanwhile, Robert Halfron, the chair of the education select committee, appears to have already determined that, in respect of Arthur, social services are to blame saying:
“You can’t just blame this on lockdown because it seems to me there has been a dramatic failure by children’s services and the relevant authorities … While I absolutely believe that lockdowns destroyed people’s mental health and wellbeing, and that children have been affected by safeguarding hazards and domestic abuse, as well as joining county lines gangs, that shouldn’t let social services off the hook.”
Findings from reviews
It is unlikely that the reviews will find Arthur or Star’s circumstances to be very different from those of many other children who have been abused or neglected. It is likely to find the same gaps in agency practice that almost every other inquiry into child abuse has found. The most common errors are:
- Insufficient contact with the child and family.
- Insufficient weight being given to the concerns of non-professionals.
- Treating each incident or referral as a ‘one off’ rather than part of a pattern of behaviour.
- Insufficient attention to the warning signs such as domestic abuse or other familial violence.
- Professionals being too ready to believe the parent or carer’s account of injuries.
Over the years, many multi-agency processes and procedures have been introduced to prevent these errors. There are assessment tools, discussion forums, protection plans and review mechanisms. There are standards about levels of contact and requirements that children, in certain circumstances, must be seen and seen undressed. Healthcare professionals and schools have protocols to be followed when parents do not keep appointments. There are also extensive reporting and communication requirements between agencies to prevent children ‘slipping through the net’. Children’s social work education, training, retention and support have also improved and there is better oversight of cases.
The child protection label is unhelpful
These measures have led to some improvements but significant problems remain.
If a child is referred to agencies as a ‘child protection’ matter, it is a high priority and a number of procedures and checks will be instituted. But, if the case is designated a ‘child in need’ case or something else – such as a criminal justice or educational matter – the level of attention the case receives will be variable and resource dependent.
This twin-track approach leads to pressure from agencies to designate children about whom there are significant concerns as ‘child protection’ cases in order that social work resources and help are provided. But, as social work is also responsible for finding the resources to undertake the additional work that these cases require, they are under pressure to ‘screen out’ lower-priority cases.
Resource management and failure
Insufficient resources are rarely the sole reason for organisational failure, but when resources are tight or under strain, social work may resist the designation of a case as one of ‘child protection’ or may de-designate such cases as soon as they can. Assessments and inquiries may be more superficial or fail to address important areas of investigation. Unspecified and unmeasurable ‘thresholds for intervention’ may be raised to deal with workload pressures. Resource pressures threaten good judgments and priorities, meaning someone else will receive less attention.
This is not a problem unique to child protection social work and can be found in all agencies where frontline professionals have very little control over their workloads or resources and have to adjust their responses in the moment.
The extent of harm
As serious case reviews (into child deaths or serious injury) show, dozens of children every year are seriously harmed at the hands of their parents or carers. In every case, some fault is found with the agencies involved and ‘lessons to be learned’ identified.
But many children are abused for years without the abuse being detected or properly addressed. Case histories of prisoners reveal years of horrendous abuse and neglect as children, often stopped only by a child’s entry into the youth justice system – as was the case with the two boys (aged just ten and eleven) who murdered Jamie Bulger in 1993. The errors, ‘missed opportunities’ for intervention, or negligence in these cases, often remain unexamined.
We hear when a child dies who was, or should have been, under the care of child protection services but not of cases where the abuse has been severe but has not resulted in a death. Society is shocked when cases such as these or Victoria Climbié occur. Yet, the circumstances of these children prior to their death were no worse or more serious than those of other children at the time or currently being supervised now by social work or other agencies.
A children’s social work caseload is entirely made up of children for whom serious injury or neglect is an ever-present and feared risk. There is not a separate set of characteristics, rarely seen in other families, which can distinguish between the child who is likely to be murdered and the child who is not.
Perpetual anxiety for social care
There is no doubt that many of the children currently being supervised by social work should not be at home with their parents. But those children will remain at home until such time as there is a serious injury that propels the child up to the top of the priority list for a residential or foster care placement (and downgrades the priority of another equally needy child). Almost all children are taken into care in an emergency following a serious incident that leaves professionals with no other option.
Some social workers will say and will record that they consider a child is at great risk and should be removed from their family. Other agencies such as education, police and health will more often explicitly state this but they do not have to provide the resources or watch as another child of equal priority remains at home. Sometimes such statements are understood as other agencies ‘covering their backs’ should something go wrong.
Professionals often manage the risks as best they can, but are in a constant state of anxiety that something will go wrong. It is under these circumstances that errors in assessing another family as ‘happy’ or ‘able to meet the needs of the children’ is likely to occur. The mental bandwidth for heightened anxiety and risk is simply not wide enough to accommodate more.
