Knowledge Bite
Key messages from the Child Safeguarding Practice Review Panel
Annual Report 2020
The
Child Safeguarding Practice Review Panel is an
independent body that was set up in July 2018, under
the Children and Social Work Act 2017, to oversee
reviews when children have died or been seriously
harmed. It brings together experts from social care,
policing and health to provide a multi-agency view on
issues that are complex or of national importance.
The Panel received notification of 482 incidents
occurring between 1st January and 31st December
2020, relating to 514 children. Of those 482
notifications, 206 were in relation to child deaths and
267 related to serious harm. Nine notifications related
to other factors, such as where the young person was
a perpetrator of harm.
Rapid Reviews were
completed in relation to all of these children;
Local
Child Safeguarding Practice Reviews (LCSPRs)
then explore in more depth the learning and practice
themes from selected rapid reviews.
“We all have responsibility for creating the conditions in which the talents and
resources of practitioners can prioritise understanding what life is like for children”
(Foreword by Chair, Annie Hudson).
Background
The Child Safeguarding Practice Review Panel’s Annual
Report 2020 was published on 14th May 2021, drawing on the findings of an
Analysis of Safeguarding Partnerships’
yearly reports 2019-20: Overview report (whatworks-
csc.org.uk) and a commissioned
Analysis of Rapid
Reviews and Local Child Safeguarding Practice Reviews
completed by the University of East Anglia and University
of Birmingham: see further reading.
Covid-19 impact
The COVID-19 outbreak in itself continues to present increased risk for vulnerable children and families.
These four key factors, in combination, were found to increase vulnerability:
• Parental and family stressors
• Exacerbated vulnerabilities for children and young people
• Impact of school closures: identification of, contact with, and support for vulnerable children and
young people
• Impact of adaptations for COVID-safe practice
On a positive note, the report concludes that local safeguarding partners have shown resilience, creativity
and adaptability to maintain support for vulnerable children and families during the pandemic.
Notifications to the Panel in the period April to September 2020 were 27% higher than the same period in
2019. The increase in serious safeguarding incidents where COVID-19 was a factor was most marked in
NAI in children under 1, sudden unexpected death of infant (SUDI) and suicide.
Diversity characteristics of the children involved
• 274 (53%) were
male and 238 (46%) were
female. There were two
transgender young people. The
Panel’s thematic analysis of notifications relating to children who had committed suicide noted that
gender identity issues had emerged as a significant factor in seven of the incidents in the sample.
• The age distribution showed a predominance of infants
under the age of one (35%) and a second peak
in
15-17 year olds (30%).
• The majority (69%) of children were of
White British ethnicity. However, compared to the ethnic
breakdown of the 0-17 year old population in the 2011 census, there was a
higher proportion of ethnic
minority children among the incidents notified to the Panel. This was particularly marked among
black
teenagers and among
mixed ethnicity children of all age groups. Those from
Asian ethnic groups
were under-represented in all age groups compared to the general population. There are several cases
where the child’s
ethnicity was not recorded in the serious incident notification.
Factors relating to the children and families:
•
Suicide accounted for 20% of all incidents reported. Young people feeling isolated during the
pandemic/lockdown was a contributory factor in a number of incidents.
• Neglect was a feature of 35% of incidents.
•
Domestic abuse was a feature of 42.6% of incidents involving serious harm. The
combination of
domestic violence and substance misuse appears particularly strong, accounting for 24% of all
incidents.
• There were 15 incidents involving children who were reported to be
electively home educated. Often
these children were ‘invisible’ as they were not in school and not visited at home.
The Annual Report identifies
six key learning
themes to make a difference in reducing serious
harm and preventing child deaths caused by abuse
or neglect. The majority of the learning for all
agencies is not ‘new’; these same themes have,
sadly, been identified over and over again in reviews
of child deaths and serious incidents over decades.
For your ease of reference, we have pulled out the
learning with the most relevance to our practice
below, linking to internal and external resources
which are available to support your work.
Key
Messages
This first learning theme is absolutely central
to our work as FCAs where our key duty is to
make sure that children’s voices are heard in
the family courts. ‘Together with Children &
Families’, our new Practice Framework, is
underpinned by the importance of forming
trusting and respectful relationships with
children and families.
We now have clear expectations about the
requirements and timescales for seeing
children in the Seeing and Engaging with
Children Policy.
We need to see beyond what children say and retain an awareness that ‘chal enging’ or help-seeking
behaviours for children may well indicate harm and distress.
Evidence from the practice reviews suggests that the impact of culture on parenting is not always fully
considered or evidenced and we need to be clearer about the potential impact of cultural assumptions and
norms in relation to safeguarding risks. We need to ask about, record and analyse diversity factors for all
children and parents. We also need to recognise our own cultural identity and its impact on others.
Practitioners should identify and respond to racism when they encounter it.
See: Diversity and inclusion for practice staff (eLearning), Diversity Monitoring (Knowledge Bite), Talking
with children and young people about racism and Black Lives Matter (Knowledge Bite).
Resources to support your practice:
• Cafcass Diversity wheel: the Cafcass ‘Diversity Wheel’ can help you think of the range of areas which
you might want to explore with each individual child to understand their lives better.
https://cafcass.sharepoint.com/sites/diversity/Shared Documents/ED&I/D and I Wheel.pdf
• Voice of the Child App webinar
•
Suite of direct work tools for working with and observing children on our website: Cafcass resources for
professionals
• ‘Together with Children and Families’ Workshops: storyboards present a new method of engaging with
children.
• FJYPB
‘top tips’
COMING SOON: A suite of information leaflets with tips for working with children with a range of disabilities
and additional needs; a Knowledge Bite on having diversity conversations with children and young people; a
Knowledge Bite on working with Black children and families.
This learning point is perhaps less directly relevant for us than for
social workers in local authorities, but we do need to ask ourselves
some questions where we cannot engage a child or family in any
area of our work:
-
Is the family engaging with other agencies?
Practice
-
Is there a specific worker with whom they have a good
relationship who could introduce me?
Point
-
Does this pattern indicate increased risk?
-
Does it necessitate an expert assessment, for example of the
person’s learning needs?
-
Do I need to speak to other professionals or make a
safeguarding referral?
Resources to support your practice:
• Trauma affects relationships: individuals who have
experienced trauma may struggle to effectively engage with
services, as they may feel suspicious and find it difficult to trust
people.
Trauma%20Informed%20Social%20Work%20Practice%20Kno
wledge%20Bite.pdf
• Motivational interviewing can be a powerful tool to engage
families and to effect positive change: Course: Motivational
interviewing (learningnexus.co.uk)
• Where children minimise potential risks of harm and are
reluctant to accept support: (Child criminal exploitation (CCE)
and County Lines eLearning, Child Sexual Exploitation (CSE) eLearning, Child Trafficking eLearning and Safeguarding
children at risk from criminal exploitation - GOV.UK
(www.gov.uk)
• The Report highlights that a number of the children who came
to serious harm were electively home educated. Social care
commentary: hidden children - the challenges of safeguarding
children who are not attending school - GOV.UK (www.gov.uk)
Don’t rely on single sources of information or accept parents’ self-
report of positive progress. Always triangulate and check out
information.
Practice
Remember, from April 2021, we no longer need to obtain consent to
Point
undertake safeguarding checks in non-C100 cases and checks on
new partners or other adults. (See Cafcass Police Checks
Handbook).
Adopt a position of ‘respectful uncertainty’ (Laming report) for all children in trying to understand what life is
like for them and what the risks are. Beware of the prevalence of confirmation bias, which can be defined as
a the tendency to search for, interpret, favour, and recall information in a way that confirms or supports
one's prior beliefs or values. Always explicitly revise your risk assessment when screening any new piece of
information which you receive.
If we make a safeguarding referral and you feel that it merits further assessment but the local authority do
not agree, you should discuss with your SM and escalate via a Cafcass Assistant Director Safeguarding
Policy.
The review identifies specific risks for children who are questioning their gender identity or who identify as
trans. See: trans awareness eLearning, LGBT+ eLearning, Mermaids, Working with trans adults and young people – Peer practice specialist page.
Case study
Cafcass contributed to a local child safeguarding
practice review published in September 2020 by
Warwickshire Safeguarding Partnership. Sisters
Alice and Beth were aged 3 years and 3 months
From the overview report we know that:
and 1 year and 5 months respectively at the
• In January 2018, Alice was admitted to
times of their deaths within two weeks of each
hospital on three occasions after her mother
other.
reported her having seizures. Sadly, on the
third occasion, Alice was deceased on arrival.
After a police investigation and the post-
Alice was known to us in 2017 when her father
mortem, Alice’s death was deemed not to be
Mr Barlow made an application to spend time
suspicious.
with her. He was subject to a Restraining Order
• The family continued to receive family support
following a conviction of battery and threatening
via the local authority.
behaviour towards Alice’s mother. Mother Ms
• Within two weeks of Alice’s death, the mother
Platt also alleged that Mr Barlow had
contacted the health line reporting Beth as
inappropriately chastised Alice. In his
drowsy. Ambulance staff attended and found
application, Mr Barlow raised concerns that Alice
Beth unconscious. Emergency care was
had experienced “rough handling” by her mother;
provided at the scene and Beth was
he made further allegations of possible cannabis
conveyed to hospital, where despite the best
and alcohol use by her and historical
efforts of emergency staff, she was
depression. He denied being the perpetrator of
pronounced dead.
rape or domestic abuse. A safeguarding letter
was filed advising the court to direct a S37
assessment which the court agreed with.
The death of Beth led the police to investigate both deaths. The investigation revealed that the cause of
both deaths was believed to be third party interference with the normal mechanics of breathing. These
findings initiated the investigation and subsequent prosecution of the mother.
The review (links below) has found that based on the information available at the time, no single
professional or agency would have been able to predict the deaths of Alice and Beth. There was significant
learning identified for all agencies as below:
➢ Where a family
moves between areas the new authority and relevant partners need to be informed.
➢ When making a referral to the local authority,
ensure that the referral fully articulates the concerns of
the referrer.
➢ Professionals were confronted with a situation where there was conflict between parents and serious
allegations being made. Some of the concerns raised about the mother, by both her current and ex-
partner, could be easily refuted. The danger is that professionals can be prone to dismiss other
information in the same vein.
Professionals need to keep an open mind on all concerns being raised
until there is clear information which negates it. The rationale for negating the concern needs to be
clearly recorded.
➢ Fol owing Alice’s death, all the information available from all professionals led to the belief that the death
was unexplained as opposed to being suspicious, i.e. that her death resulted from medical reasons as
opposed to third party intervention or trauma. On reflection, professionals who had been involved felt that
they would exercise a more ‘healthy scepticism’ going forward and explore the hypothesis that a parent
may have caused the harm, to be able to develop it further or discount it. Having a
mindset of ‘thinking
the unthinkable’ when approaching child death or indeed child protection discussions is appropriate.
Alice_and_Beth_SCR_-_Report.pdf (safeguardingwarwickshire.co.uk);
Alice_and_Beth_Lessons_Learned_Briefing_-_FINAL.pdf (safeguardingwarwickshire.co.uk)
Always think ‘What? – So What? – Then what?’ whenever you
receive any new piece of information:
•
WHAT? Use clarifying questions; ‘WH’ questions: what, when,
where, how, why; how long, duration, severity etc. Use tools to
Practice
drill down into issues. What is the evidence for this
concern/information? Is it new/unreported/unknown information?
Point
•
SO WHAT? What does this mean for the child or others in the
family network? What does it tell me about their safety right now?
What does it tell me about future risk?
•
THEN WHAT? Think of the range of options/actions. Always
discuss with SM/PS if unsure. Do I need to make a referral? It is
our responsibility to check that others have passed on
information which indicates risk.
Remember that risks relating to domestic
abuse, substance misuse and mental
health are interacting factors which
significantly increase risk or serious harm
to children.
The Annual report highlights that the role of
fathers/adult males in a family is often not
sufficiently understood or taken into
account in assessing risk. Practitioners
should explore previous histories and
involvement with children’s social care,
either in childhood or as parents, and
inform the mother of the risks if
appropriate. Consideration of fathers’
supportive and caring capacity avoids a
binary view of men as either good or bad.
Case study
Wigan Safeguarding Children's Partnership undertook a review following the death of Annie, aged just
fourteen months when she died. She was in the care of her father and had sustained a range of non-
accidental injuries prior to her admission to hospital and subsequent death. The father was charged with
Annie’s murder. We did not know Annie; however, her father and paternal sister Lily were known in
private law proceedings where the father was seeking to spend time with Lily. There was information
known about the father previously admitting to drug and alcohol misuse, poor mental health and suicide
threats. At the time of his application, he was living with his partner and Annie. During the work to first
hearing it was not clear from the case recording what, if any, consideration was given to making a
safeguarding referral in relation to Annie as a child connected to Lily. The court had been advised that
the father should not have unsupervised contact with Lily at the time this application was made. The
analysis in the overview report published states:
Given what was known and what could have been established by partner agencies, Child Y’s death
could not have been predicted or prevented by services. That notwithstanding, there were opportunities
for services to have gained a better understanding of Child Y’s lived experience. The response of
services and what they knew, and could have known, has been considered.
The learning identified for Cafcass is on page 14 and 15 of the report Serious Case Review - Child Y
(wiganlscb.com).
Resources to support your practice:
• CIAF suite of tools to assess the situation for children where there is domestic abuse, harmful
conflict, refusal or resistance to spending time with a parent and other forms of harmful parenting
• Public law tools
• Resource re working with fathers:
Working with fathers: key advice from research | Community Care
When we share information, give behavioural detail; be specific
about what we mean. Define what is happening for the child: rather
than ‘I am concerned about neglect’, say instead ‘When I visited, the
Practice
mother told me that she had no food in the house; the child was
Point
wearing only a nappy, his skin felt cold to the touch and there was
no bedding on his cot’.
We need to ensure that we share information wherever a child
may be in need of services (s17) or at risk of harm (s47). This
relates to the children with whom we are working as well as
other children in their families, or known to their families.
Always speak to your PS or SM if you believe a referral may be
required.
We need to go back to the local authority - in both private and
public law - if the information
they provide to
us is not of
sufficient quality for us to understand the risks for the child(ren)
properly.
Resources to support your practice:
• Safeguarding policy sets out our responsibilities for sharing
information to safeguard children and vulnerable adults
• Safeguarding other children linked to the family you are
working with: Safeguarding connected children (Knowledge
Bite)
It is well recognised within Cafcass that practitioners cannot carry out high quality work with unmanageable
caseloads and active work is underway to reduce caseloads via the prioritisation work.
Always keep in mind the need for situational supervision, especially
at pivotal moments in a case: for example, wherever you are making
a finely balanced recommendation, considering a 16.4 or ICFA
recommendation, where your recommendations differ from those of
Practice
a local authority or you are recommending/supporting reunification
in a public law matter.
Point
‘Together with Children & Families’ group supervision sessions will
aid reflective discussion and analysis on behalf of children.
Cafcass has a wide range of resources for us to use in our work with children and families and it is useful to
re-familiarise yourself with what is available from time to time:
National Psychology Service
Cafcass’ National Psychology Service offers an opportunity for practitioners to discuss aspects of their case
work that may benefit from a psychological perspective to support their assessments (private or public law).
This involves a telephone consultation session with one of the Psychology service team and can also serve
as a broader learning opportunity. The service aims to enhance risk assessments skills and improve
professional confidence and can also be used by managers to support teams, or individual development
needs.
Peer Practice Specialists
Our Peer Practice Specialists are FCAs and managers who have built up considerable learning and insight
in specialist areas of practice. They are available to provide consultation on areas including assisted
conception, working with trans adults and young people and unaccompanied asylum-seeking children. A full
list of areas covered, including topic guides and information about accessing the service, can be found
here.
They can provide guidance in respect of casework and signpost relevant resources or services. The service
ensures that the breadth of expertise that already exists among staff is shared throughout the organisation.
Cafcass Learning
Cafcass Learning is the on-line resource for all your learning and development needs, a ‘one stop shop’ for
all the eLearning and Knowledge Bites that are available to you. Why not browse the
Learning Library to
find a course suitable to your role?
Library
The
Cafcass Library and Information Service offers a comprehensive remote service to all staff, regardless
of location. The service can help you to develop evidence-informed practice and use research in your work,
support your Continuing Professional Development (CPD), academic studies, placements and more.
Further reading:
•
Analysis of Safeguarding Partnerships’ yearly reports 2019-20: Overview report (whatworks-
csc.org.uk), May 2021.
•
A commissioned analysis of Rapid Reviews and Local Child Safeguarding Practice Reviews
completed by the University of East Anglia and University of Birmingham. A summary is available on
the NSPCC website: A summary of the annual review of Local Child Safeguarding Practice Reviews
and rapid reviews (nspcc.org.uk)
•
CSPRP briefing: Supporting vulnerable children and families during COVID-19 (darlington-
safeguarding-partnership.co.uk)
•
Assessing Risk of Harm to Children and Parents in Private Law Children Cases
(publishing.service.gov.uk)
•
Working Together to Safeguard Children 2018 (publishing.service.gov.uk)
Created June 2021
