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Child Protection Failures: Have lessons been learnt?

Victoria Climbie. Baby Peter Connelly. Daniel Pelka. Ayesha Ali. Khyra Ishaq. Ayeeshia Jane Smith. Ellie Butler - to name but a few - the children brutally murdered following appalling episodes of neglect and abuse.

Child protection rarely makes the media headlines until a child dies following abuse or neglect and then a national outcry ensues with the public demanding answers and questioning why social workers, health visitors, GPs failed to do more to protect the child. The demand for answers is such that often the anger is directed towards children's services professionals as opposed to the perpetrators of the crime.

Serious Case Reviews, investigations and inquiries delve into the issues and aim to piece together what happened, what went wrong and what could be done in future to prevent another horrific death. But what have we learned over the years?

The issue will be tackled at a unique conference to be held in February which will examine themes and patterns in the history of failure in child protection, the opportunities to learn and possible remedies.

Social workers, historians, lawyers, and survivor representatives will join together as a multi-disciplinary group to discuss child protection failures at the conference which will be chaired by the new president of the family courts division Sir Andrew McFarlane and journalist and founder of ChildLine, Dame Esther Rantzen DBE.

'Things have got worse'

Dr Lucy Delap from History and Policy said: "Historical research has shown that there are clear patterns to cases of safeguarding failure, which typically occur in organisations where institutional checks and balances are not in place, where staff morale is low or where institutional reputation is placed ahead of the wellbeing and safety of children. It is sobering that these patterns have been repeatedly identified by inquiries and serious case reviews, yet culture change has been limited."

According to Professor Ray Jones, a former director of social services at Wiltshire County Council, things have got worse. Jones, who wrote a book on the Baby P case, told The Mirror that 40 per cent cuts to local authority budgets since 2010 have left social workers struggling to cope with mounting workloads. “Social workers are having to cut corners and it’s definitely not a recipe for making sure our children are protected.

“Things haven’t got better since Baby P’s death, they have got worse."

“It’s all very well changing procedures, but if you don’t have enough social workers to do the job, they can’t do the job properly," he added.

The photograph that emerged following the death of Baby P will be engrained in many people's memories. The adorable angelic toddler with big blue eyes and blonde hair. He was 17 months old when he died in 2007 after enduring an eight-month period of neglect and abuse and sustained 50 separate injuries at the hands of Peter's mother Tracey Connelly, her boyfriend Steven Barker, and Barker's brother Jason Owen.

Tracey Connelly's boyfriend, Steven Barker, had moved in with her in November 2006 and a month later, a GP noticed bruises on Peter's face and chest. Over the next few months, Peter was admitted to hospital on two occasions suffering from injuries including bruising, scratches and swelling on the side of the head.

Mutilated fingertips and missing fingernails

In June 2007, a social worker observed marks on Peter and informed the police. A medical examination concluded that the bruising was the result of abuse. Baby P was placed with a friend for safeguarding in June 2007 yet it later emerged that the "threshold for initiating Care Proceedings...was not met".

A locum paediatrician Dr Sabah Al-Zayyat saw Peter on 1 August 2007 at St. Ann's Hospital in North London yet serious injuries, including a broken back and broken ribs, seemed to go undetected, as the autopsy report believed these to have pre-dated Al-Zayyat's examination. A day later, Connelly was informed that she would not be prosecuted.

However, the next day, Peter was found in his cot, blue and after attempts at resuscitation, he was taken to the hospital with his mother but was pronounced dead at 12:20 pm. A post-mortem revealed he had swallowed a tooth after being punched. Other injuries included a broken back, broken ribs, mutilated fingertips and missing fingernails.

On 11 November 2008, Owen and his brother Barker were found guilty of "causing or allowing the death of a child or vulnerable person". Connelly had pleaded guilty to this charge. Earlier in the trial, Owen and Connelly had been cleared of murder because of insufficient evidence. Barker was found not guilty of murder by a jury.

The smile was masking her pain

The then Secretary of State for Children, Schools and Families Ed Balls ordered an external inquiry into Haringey Council Social Services to investigate whether they were following correct procedures in general. This report was presented to ministers on 1 December 2008 and Balls announced that, in an unusual move, he had used special powers to remove Sharon Shoesmith from her post of head of children's services at Haringey Council.

Lord Laming published his report, "The Protection of Children in England: A Progress Report"  on 12 March 2009. It stated that too many authorities had failed to adopt reforms introduced following his previous review into welfare following the death of Victoria Climbié in 2000.

Indeed, Lord Laming had been instructed to carry out an inquiry into the death of Victoria in April 2000 after the eight-year-old died at the hands of her great-aunt Marie-Thérèse Kouao and her boyfriend Carl Manning, worryingly in the same borough that Baby P was under seven years later.

Again the beaming bright smile of the beautiful seemingly-happy child belied the torture she was in fact enduring. In fact, the smile was masking her pain and used as a coping mechanism.

An expert in attachment theory and Dynamic Maturational Model Mary Cullen told Children First: “Children who use dismissive/avoidant and compulsive strategies (in at-risk cases) inhibit their feelings when under threat. They do what other people want, blame themselves, exonerate powerful adults, feels shame, sometimes explode with anger and have no explanation for explosive behaviour.

"In the two high profile child deaths Victoria Climbie and Baby Peter Connolly, both children exhibited compulsive strategies. They suffered horrific physical abuse but had big smiles on their faces to hide what was happening. They inhibited their own feelings and developed a strategy of smiling to appease their abusers (to reduce the possibility of dangerous consequences), however, these strategies did not keep them safe. Professionals seeing the children wouldn’t know anything was wrong," she added.

Worst case of child abuse

Marie-Thérèse Kouao took Victoria from her native Abobo on the Ivory Coast to France for a better education before arriving in London in April 1999. It is not known exactly when Kouao started abusing Climbié, although it is suspected to have worsened when Kouao and Victoria met and moved in with Carl Manning, who became Kouao's boyfriend.

After she died in February 2000, the pathologist who examined her body noted 128 separate injuries and scars on her body and described it as the worst case of child abuse she had ever seen. Victoria had been burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. During her life in Britain, Climbié was known to four local authorities (four social services departments and three housing departments), two child protection police teams, two hospitals, an NSPCC centre, and a few local churches.

Laming, the former chief inspector of the Social Services Inspectorate, was instructed to conduct a statutory inquiry into Climbié's death. The Laming report, published on 28 January 2003, found that the agencies involved in her care had failed to protect her and that on at least 12 occasions, workers involved in her case could have prevented her death, particularly condemning the senior
managers involved. The 400-page report made 108 recommendations in child protection reform.

Move from compliance to learning

Yet his follow up report following Baby P's death four years later found that many of the reforms had not been adopted. In June 2010, the Secretary of State for Education, the Right Honourable Michael Gove MP, asked Professor Eileen Munro to conduct an independent review of child protection in England.

Launching her final report, Munro said: "A move from a compliance to a learning culture will require those working in child protection to be given more scope to exercise professional judgment in deciding how best to help children and their families. It will require more determined and robust management at the front line to support the development of professional confidence."

Munro's report went on to make a series of recommendations which were "geared toward creating a better balance between essential rules, principles, and professional expertise". These included creating a Chief Social Worker position in government to advise the government on social work practice.

Local authorities should also start an ongoing process to review and redesign the ways in which child and family social work is delivered, drawing on evidence of the effectiveness of helping methods where the appropriate and supporting practice that can implement evidence-based ways of working with children and families, she added.

Fundamental change

Then in 2016, the Secretary of State for Education, the Rt Hon Nicky Morgan MP, and the Minister of State for Children and Families, Edward Timpson MP, asked former president of the Association of Children’s Services Alan Wood to lead a fundamental review of the role and functions of Local Safeguarding Children Boards within the context of local strategic multi-agency working.

It concluded that LSCB's "are not sufficiently effective" and said: "We do not have a national learning framework for considering the lessons of the tragic events that take a child’s life or seriously harms them. Despite guidance to the contrary, the model of serious case reviews has not been able to overcome the suspicion that its main purpose is to find someone to blame. Although there has been some improvement in the quality of some reviews the general picture is not good enough and the lessons to be learned tend to be predictable, banal and repetitive."

It called for "a fundamental change", urging the government to discontinue Serious Case Reviews and establish an independent body at a national level to oversee a new national learning framework for inquiries into child deaths and cases where children have experienced serious harm. It added that the framework should be predicated on high quality, published, local learning inquiries; the collection and dissemination of local lessons; the capacity to commission and carry out national serious case inquiries; and a requirement to report to the Secretary of State on issues for government derived from local and national inquiries.

Lessons inform practice

The government confirmed that it agreed with the finding and confirmed that it would replace the current system of SCRs and miscellaneous local reviews with a system of national and local reviews.

The government said the new system should:

  • bring greater consistency to public reviews of child protection failures;
  • improve the speed and quality of reviews, at local and national levels, including through accrediting authors;
  • make sure that reviews which are commissioned are proportionate to the circumstances of the case they are investigating;
  • capture and disseminate lessons more effectively, at local and national levels;
  • make sure lessons inform practice.

The government response to the Wood review confirmed that it would legislate to establish an independent National Panel which would be responsible for commissioning and publishing national reviews and investigate the most serious and/or complex cases relating to children in circumstances which the Panel considers will lead to national learning.

And in June this year, the Department for Education announced six new members to the new Child Safeguarding Practice Review Panel to work with the chair, Edward Timpson, to consider and share lessons to improve practice from the most serious child safeguarding cases.

The Child Safeguarding Practice Review Panel will be responsible for identifying and reviewing serious child safeguarding cases which the panel believes raise issues and themes that are complex or of national importance. It will look at what could be done differently to improve the protection and welfare of children, and what implications these cases have on current and future policy or practices.

Minister for Children and Families Nadhim Zahawi said: "We want to improve care and support for every child, which is why it is so important we reflect and learn from the most serious cases of abuse or neglect, to help ensure the right protection is in place for some of the most vulnerable children in our society.

"The new Child Safeguarding Practice Review Panel will play an important part in improving this understanding. Led by Edward Timpson, it will support local areas to make improvements to services where they are needed and reduce the risk of future harm to children," he added.

So where are we now?

A huge impact on social work since Laming and Munro's report is the austerity measures introduced by the government meaning many local authorities are having to increase thresholds, cut back on preventive services and focus on crises due to dwindling budgets.

90 children come into care every day

In fact, the LGA says that demand for children's services has risen dramatically. The number of children subject to child protection enquiries has increased 151 per cent in 10 years - from 73,800 in 2006/07 to 185,450 in 2016/17. Over the same period, the number of children on child protection plans increased by more than 23,000.

The total number of looked after children reached a new high of 72,670 in 2016/17 which equates to 90 children coming into care every day, and represents the biggest annual rise of children in care in seven years.

Meanwhile, funding has been cut. By 2020, local government in England will have lost 75 pence out of every £1 of core central government funding that it had to spend in 2015.

Overall, councils are facing a £3 billion funding gap for children’s services by 2025. In 2015/16, councils were forced to overspend on their children's services budgets by £605 million across England. Government funding for the Early Intervention Grant has been cut by almost £500 million since 2013. It is projected to drop by a further £183 million by 2020.

It is against this backdrop that the conference at the King's College in London on 22 February will explore whether indeed wisdom has arisen from past failings, bringing in the unique mix of historians, lawyers, social workers and survivor representatives. The keynote speaker is Times columnist Matthew Syed – the bestselling author of ‘Black Box Thinking’, a ground-breaking book which analyses the logic of failure, confronting complexity and coping with the blame game.

Other speakers include Professor Louise Jackson, Professor of Modern Social History at the University of Edinburgh, Peter Garsden, President, Association of Child Abuse Lawyers and Gabrielle Shaw, CEO, National Association for People Abused in Childhood.

The conference is presented by WillisPalmer and History and Policy in conjunction with the Association of Lawyers for Children. WillisPalmer's Philip King, Expert Social Worker in Child Protection and Abuse Claims and Martha Cover, Barrister and Co-Chair at the Association of Lawyers for Children will also address the conference.

Dr Lucy Delap concluded: "Safeguarding is not just a case of having the right policies; it requires a more proactive and intelligent approach that continually assesses the adequacy of protection. And despite a better understanding of the need to safeguard, we cannot assume that the lessons have been learnt. History is full of repeated failures – child abuse has been repeatedly ‘discovered’ over the past century, and then forgotten."

Find out more and come and join the debate: Wisdom from Failure: A Kaleidoscope on Child Protection, 22 February 2019, King's College, London

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