For decades, child safeguarding reviews have examined the circumstances surrounding the deaths and serious harm of children following abuse and neglect, uncovering devastating stories, missed opportunities and worrying gaps in practice. Yet despite reforms, endless new guidance and repeated recommendations, many of the same issues continue to appear.
As Chair of England’s Child Safeguarding Practice Review Panel, I have the privilege to see child safeguarding practice in a broader context. I see the dedication and determination of practitioners working every day to protect hundreds of thousands of children in incredibly challenging circumstances. But I also see the reviews of every serious incident in England where a child has died or suffered serious harm following abuse or neglect. This enables me to see the troubling patterns that are often repeated. Continuing to be vocal about those challenges is essential for tackling them head on.
Too often, serious incidents reveal familiar challenges: agencies working with incomplete information, concerns not being fully shared by different agencies working with the same children and families, and service provision not reducing risk or improving outcomes for children. I also see too often that children’s daily lived experience has not been heard or understood. These are themes that have persisted for years.
The Panel has published a range of new resources examining the ten most persistent themes that we see in serious child safeguarding incidents. These span some of the most difficult aspects of safeguarding practice, from the loss of focus on the child’s daily lived experience, to struggles when parents don’t engage with services and the times when cases just feel stuck. These practical resources aim to help practitioners, managers and leaders to recognise and think afresh about these challenges at both practice and strategic levels. Alongside the rest of our learning hub materials, they also give practitioners a wealth of ideas about how to tackle them.
Professionals do not lack care or expertise. And in many respects, we know more than ever about the impact of issues like domestic abuse, parental mental ill health and substance use, exploitation and online harms on children. We know that children rarely experience these issues in isolation and that vulnerability is often complex and cumulative. But however much we care, however expert we are, however much we understand, we can never stop learning. That humility to keep learning and to apply that accumulated learning consistently will keep children safer.
One of the clearest lessons among these themes is that safeguarding children cannot rely on individual professionals or agencies alone. Children and families often come into contact with multiple services, meaning effective safeguarding depends on those services sharing information, understanding risks collectively and acting with a common purpose.
The Panel has a vital role to play too. We will continue to use the learning from safeguarding reviews to highlight persistent challenges, share learning with national policymakers and local partners, and inform conversations about where attention and change is needed most.
The government’s new Information Sharing Duty is a welcome step forward, providing much-needed clarity for safeguarding professionals and reinforcing that sharing relevant information should be part of everyday safeguarding practice. By helping every agency build a fuller picture of a child’s life, it has the potential to close long-standing gaps in the protection of children and support earlier, more effective intervention.
But better information sharing alone will not solve the challenge. It is the robust analysis of that information that will keep children safer. And it is the Panel’s duty to translate knowledge into consistent action across the entire system.
That’s why the government’s plan to establish a Child Protection Authority is so important. Crucially, it could have the powers to go beyond identifying problems, including the ability to compel agencies to provide information, require coordination across safeguarding partnerships and ensure accountability where improvement is needed. The Child Protection Authority has the potential to move the system from one that too often reacts to tragedy to one that prevents harm before it occurs.
While strong national leadership will be essential, lasting improvement will ultimately depend on how effectively these ambitions are translated into practice at a local level. We must be honest about the pressures facing those on the frontline of safeguarding. The reality is that safeguarding partnerships are navigating significant reform, increasingly complex needs and sustained demand. Many also face the challenges of workforce instability, scarce placements and difficulties accessing specialist support.
But at the same time, reform presents an opportunity to build structures with multi-agency working at their heart, including through the much-needed multi-agency child protection teams. These will help embed shared responsibility, collective decision-making and coordinated action across social work, health, police and education to better support children and families. Maintaining a focus on the persistent issues identified through safeguarding reviews, while creating the conditions for practitioners across agencies to work together effectively and do their best work, must remain central to these reforms and improvements.
Ultimately, future success should be measured by whether concerns are identified earlier and whether agencies are working together more effectively to protect vulnerable children.
And for those children whose safety depends on that system, there can be no more important responsibility for us all.
– Sir David Holmes, Chair of the Safeguarding Practice Review Panel