Arthur Review: Learning from significant incidents is not shared effectively with workforce

Arthur Review: Learning from significant incidents is not shared effectively with workforce

There is insufficient social work capacity in Solihull’s Multi-Agency Safeguarding Hub to effectively deal with presenting need, a joint inspection has found.

The Joint Targeted Area Inspection, carried out by Ofsted, Care Quality Commission and HMI Probation and HMI Constabulary, Fire and Rescue Services, was ordered following the death of Arthur Labinjo-Hughes.

Arthur’s step-mother Emma Tustin has been jailed for life with a minimum of 29 years after she was found guilty of murdering Arthur Labinjo-Hughes. His father Thomas Hughes has been convicted of his manslaughter and jailed for 21 years.

Following the sentencing at Coventry Crown Court, the government ordered the JTAI along with a national review by the Child Safeguarding Practice Review Panel into the circumstances leading up to murder of Arthur Labinjo-Hughes to determine what improvements are needed by the agencies that came into contact with him in the months before he died.

When the Safeguarding Review Panel announced the terms of reference for the inquiry, it was announced that it would examine the circumstances leading up to the deaths of Arthur Labinjo-Hughes and Star Hobson.

Star was just 16 months old when she was taken to hospital on 22 September 2020 after suffering a cardiac arrest and sadly died the same day. Her mother Frankie Smith has been found guilty for causing or allowing the death of a child while Frankie’s partner Savannah Brockhill has been found guilty of murdering Star following a trial at Bradford Crown Court.

The national review will draw on the Panel’s overview of the national context through the serious child safeguarding incidents it scrutinises to consider whether what happened to Arthur and Star reflects wider national issues.

It will establish what happened to Arthur and Star during their lives and investigate agency involvement with all those charged with caring for them. The Safeguarding Panel wants to try to understand what life was really like for Arthur and Star by hearing from all those involved, especially his family.

Furthermore, the review will evaluate how agencies acted to safeguard Arthur and Star and what factors enabled or limited their ability to protect them both from the fatal abuse and neglect that they suffered.

Unknown risk

Meanwhile, however, the inspectorates have published the findings of the JTAI at Solihull which was issued following Arthur’s death. insufficient social work capacity in Solihull’s Multi-Agency Safeguarding Hub at the time of the inspection in January 2022, it found:

  • Children in need of help and protection in Solihull wait too long for their initial need and risk to be assessed. This means that for a significant number of children, they remain in situations of unassessed and unknown risk.
  • Weaknesses in the joint strategic governance of the multi-agency safeguarding hub (MASH) have led to the lack of a cohesive approach to structuring and resourcing the MASH.
  • The Local Safeguarding Children Partnership does not have a clear understanding of the impact of practice from the MASH or the experiences of children and their families that need help and protection in their local area.


The inspectorates found that Solihull’s LSCP has experienced frequent changes of personnel in its membership for a significantly long period of time, which has resulted in a loss of knowledge and experience for the partnership. The business unit does not have adequate resources to support the partnership effectively to meet its day-to-day tasks. The partnership’s executive group does not receive regular information relating to the effectiveness of practice in the front door MASH or the impact on improving children’s lives.

The MASH is significantly under-resourced by all partner agencies and, as a result, too many children in Solihull face drift and delay in having multi-agency decisions made to assess their need, reduce risk and provide proportionate interventions.

This inspection identified a significant number of children that did not have an initial review of their needs and risk assessed, some of them for over a month. The local authority leaders responded promptly to this and put in place interim measures to address the backlog of work.

While the COVID-19 pandemic has had some impact on staffing across all partner agencies at various points over the last two years for Solihull and nationally and brought additional demands and pressures on the MASH, the findings identified have resulted from long-term systemic issues that cannot be entirely attributed to the impact of the pandemic and have not had a sufficiently robust and sustained response.

There are insufficient health and police resources in the MASH. While acknowledged, these took too long to address and the current level of resource from health and police partners in the MASH remains insufficient to deal with the demand, resulting in drift and delay in decision-making to reduce risk for children and improve their lives.

Social workers ‘reluctant to work at Solihull’

“The local authority has also faced long-standing difficulties in ensuring that there are enough social workers in the MASH and attempts to improve this during 2021 had limited impact,” said the report. “These difficulties were compounded by concerns raised following the court case for the murder of Arthur Labinjo-Hughes in early December 2021, which made social workers highly reluctant to work in Solihull either on a permanent or agency basis.”

Inspectors praised the current MASH workforce for being knowledgeable, committed and dedicated to improving children’s lives. However, staff face immense pressure to meet the daily demand, and this reduces their ability to respond swiftly to all concerns for children. But the report highlighted that, in partnership with the Department for Education, the local authority has arranged for additional teams of agency social workers to join the MASH, with the first team having been due to start work before the end of January.

The report warns that this capacity must be provided and sustained.

Inspectors identified that learning from significant incidents in Solihull is not shared effectively with the wider workforce. After Arthur Labinjo-Hughes was murdered in June 2020, the LSCP partners completed a rapid review the following month in July 2020. Some learning points were identified; however, this was not a comprehensive list of learning points that were present in the information available at that time.

The LSCP reviewed the learning points and took some interim actions, such as developing learning briefings on professional curiosity and listening to the voice of the child, shared guidance about disguised compliance and bruising to children and worked to develop a new policy on physical abuse. Yet at the time of the inspection, this had not been shared with the wider partnership workforce.

At risk of harm

The Birmingham and Solihull Mental Health NHS Foundation Trust and West Midlands Police initiated their own internal enquiries; however, these were not available to the inspection team. The Local Child Safeguarding Practice Review was put on hold at the time when it was announced that a national review would take place.

The health representatives in the MASH do not have access to each other’s records and this makes it difficult for them to provide support to one another when requests for health information are made. Furthermore, the MASH health representatives do not have access to information stored in crucial health systems, such as Birmingham Children’s Hospital and University Hospitals Coventry and Warwickshire.

Incomplete records in the police’s ‘Connect’ system was a further area for concern with inspectors seeing examples of separate records for the same person (because a name had been spelled incorrectly), children not linked on the system to their parents/carers, siblings or significant others and connections between children and those who pose a risk. This leaves children at risk of significant harm.

When a child protection concern is identified, timely decisions are made. However, not all agencies are invited to, or attend, child protection strategy meetings. This means that decisions are being made when those present do not have all the relevant information about a child and their family. For most children, the right decisions are made based on the presenting information, and prompt actions are taken to progress next steps.

Health and police staff reported receiving an invitation to initial child protection conferences too late meaning they cannot always attend or provide an up-to-date health assessment of the child.

Assessments are variable

The report also highlighted:

  • Operational challenges, such as the inconsistent attendance of key partners at child protection decision-making meetings and discussions, are not escalated to the LSCP meaning they are unaware of known gaps in practice that affect children’s experiences.
  • Assessments of children’s needs are variable in timeliness and quality. Local authority social work assessments are completed swiftly, but do not always involve all relevant agencies.
  • When there is an incident of domestic abuse, police staff do not always capture the voice of the child well enough. This has an impact on the quality of information shared with the MASH about the child’s lived experience.
  • Children who go missing or are at risk of exploitation are promptly reported to the multi-agency Locate team, resulting in swift referrals to the MASH. However, the timeliness of the response to children’s needs by the MASH then varies, with some children not being seen or spoken to for long periods of time.
  • The audits reviewed by inspectors identified too much focus on process rather than the child, a lack of reflection and analysis and the prevalence of over-optimism.
  • Probation staff do not routinely store information about child safeguarding on their case recording systems.

Sharing learning from significant incidents

The report urges leaders of the local safeguarding children partnership to take urgent action to understand and identify the initial needs and risks of children presenting to Solihull’s ‘front door’ services. This includes ensuring that there is sufficient multi-agency capacity within the MASH to meet children’s needs promptly, ensuring that comprehensive performance information and a robust audit programme are delivered and regularly considered by the LSCP and ensuring that the right agencies are represented in the range of the LSCP’s activities and that there are sufficient resources to support the LSCP to carry out its statutory functions.

West Midlands Police need to take urgent action to improve the quality of information held on the ‘Connect’ system to make sure that links to connected individuals are present and accurate, and to reduce multiple records held against the same person, so that risk to children can be clearly seen, recognised and shared when appropriate.

The timeliness and quality of the initial decision-making in the MASH in relation to concerns received about children needs to improve and all agencies should attend and engage with, child protection meetings and information-sharing forums.

The communication between health agencies in the MASH and their access to all health information held about children to ensure timely and effective information[1]sharing that informs decision-making for children and children’s voices should be consistently recorded across all agencies’ records.

Sharing learning from significant incidents with the wider workforce across the partnership also needs to improve, the report concludes.


Leader of Solihull Council, Councillor Ian Courts, said: “I acknowledge and accept the findings of the JTAI which was undertaken because of the recent court case concerning the tragic death of Arthur Labinjo-Hughes, who was killed by the very people meant to love and care for him. We cannot bring Arthur back but we can ensure that safeguarding in Solihull is as good as it can be.

“We are committed to working with our partners to deliver the required improvements, as detailed in the JTAI, to improve safeguarding in Solihull. The JTAI found several weaknesses across the partnership and within some of the organisations.

“We have already increased our number of social workers to make sure we can meet the rising demand and to support the work we do with partner organisations.

“We have recruited an independent chair, Penny Thompson CBE, to begin the work of improving safeguarding in the borough without fear or favour. This means we can get on with improving our safeguarding practices and respond to the JTAI recommendations.

“The JTAI was specifically focused on how Solihull’s safeguarding partnership was working to prevent harm to children and young people in the borough. We have to wait for the National Panel Review due out later this year to fully understand the circumstances around Arthur’s life and any particular findings around safeguarding practice in his case,” he added.

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