On child protection, preventable deaths and my objection to the business of Safeguarding

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DanielAs a nation, we are recoiling still as the full scale of the horror of a young boy’s protracted abuse, neglect and death in Coventry comes to light. It is heartbreaking to hear news item after news item that reports now, not only of one boy’s suffering, but of the suffering also of his older sibling, who was witness to much of the abuse, and solely responsible for trying to feed and sustain his brother during his short and brutal life.

Two young and vulnerable children whose lives should have been protected by those people, abusing parents aside, whose responsibility it is to be alert and attentive to the protection and welfare of children in their care – teachers, support staff, social workers, doctors, health professionals, and the great body of people who are employed under the burgeoning industry that is Safeguarding Children Boards.

Despite that the older sibling still lives, it is nontheless equally shocking that no professional in Coventry’s Children’s Services picked up on the distress and emotional trauma that must have emanated from every fibre of this young child’s being. Witnessing a sibling’s near drowning, or poisoning with salt, or beatings, or starvation, must have impacted on this child’s academic, social and emotional development, and been evident to any professional with half a care for child welfare.

At a Public Policy Exchange symposium earlier in September 2012 on Child and Adolescent Health and Well-being, I offended some in the audience when I commented that I was highly critical of the rise of, and industry of, Children’s Safeguarding. I can see no great or measurable gains for children and young people in the growth of this sector. My argument being, that in response to one serious case review of several years ago, the death of Kimberley in April 2005, there has been an exponential rise in the number of professionals drawn into newly created Safeguarding roles, as the fervour for this course of action knows no bounds. There is a presumption that the more prominent and high profile an authority’s Safeguarding board, the more protection is afforded its young populace.

That premise, and that confidence has proven, time and again, to be flawed,  as more protracted and appalling cases of child cruelty and deaths have occured, in each case, deaths that could have been prevented, had certain professionals taken action.

What I see as happening with alarming frequency, even within the microcosm of an independent SEN Consultant’s world, is that less people, not more, take responsibility and take action for concerns over children’s welfare and safety. There is always another person, person x, who should deal with matters like that… I have heard that phrase so often, and with such sadness and anger. The person who should act, always, and with immediacy, on concerns of child protection of any kind, is always the person closest to the act, the witness, the observer, the one who is party to information that may convict, that may disturb the peace, that may save a child’s life.

The division of roles between Safeguarding, Child Protection and Special Educational Needs, has not helped and has had an adverse impact on consistency of approach, on clear lines of communication between professionals within and beyond any given setting and on multi-agency communications. There is a disparity of approach and understanding that serves the needs of our most vulnerable young people poorly. In some schools I have been alerted to ‘differences of opinion’ or ‘professional differences’ or even ‘personal issues’ between staff with responsibility individually for Safeguarding, or SEN, or Child Protection. What madness lies there!

The ‘safeguard’, if I can phrase it such, that schools now have in relation to child protection cases, is that there is always someone else out there who knows about such matters, whose reponsibility it is to deal with such issues. Child protection, issues of special educational need, of emotional or social needs, of neglect, of abuse, are seen as someone else’s problem.

Teaching assistant xxxxx broke down in tears in court, when she said he wanted to eat “muddy and dirty” pancakes which had been on the floor.

Daniel’s mother claimed he was being treated for a rare eating disorder and school staff were not to feed him. They complied with her instructions.

The family also had contact with social workers, doctors, health visitors and police.

Education officials investigated Daniel’s poor school attendance and health visitors went to the home but never saw him, the court heard

What I find most shocking and disturbing here, and that most enrages, is that from appearance, no professional lines of conduct have been followed. The ‘eating disorder’ should have been followed up immediately with documentary evidence, if that was the case, and with a multi-professional meeting to discuss how to manage eating problems within school, if any member of staff could really believe the story woven by the abusive mother. But then we counter that with the evidence of the boy’s weight, and the comment of another member of the school staff that the boy was like a ‘bag of bones’. How could so much damage, so much abuse, have been witnessed on a daily basis within the child’s school, and not acted upon?

Attendance issues should, at that early stage, have been picked up by school staff and teachers in the first instance, given the right of every reception teacher to visit family’s at home in those early pre-school years and to continue to follow up on practical matters through home visits. Visiting SEN professionals would have been alerted at a very early stage to concerns over this child’s behaviour, welfare, appearance, yet it seems that concerns, if they were raised at all, were dismissed.

It is a great tragedy that any pre-school child should die, hidden from the world, alone and unprotected, in the relative privacy of a family home.

It is a crime that any child of school age should die, and for that protracted neglect and abuse to be witnessed by so many professionals who could have taken action, at any time, that would have prevented such an appalling outcome.

I despair of the lack of appreciation or  understanding of how people operate within schools and within communities, despite the commissioning of the Munro Review of Child Protection (May 2011). I do not subscribe to Munro’s point of view that Local Safeguarding Children Boards are key to improving multi-agency working, or that they are

well placed to identify emerging problems thorugh learning from practice…

On the contrary, I would suggest that the growth of Safeguarding has left our most vulnerable children and young people defenceless, in their homes, schools and communities, as there is a reluctance by many education and health professionals to ‘escalate’ emerging problems to a level at which something may be done.

I am aware of schools who have turned a blind eye to evidence of neglect or abuse or distress, because they regard witnesses as unreliable, or out to stir up trouble, or because if actions are taken they will lose the confidence of the parents, and they in turn will remove their child from school, and if they go, this family will remove their children also… Fresh words in my mind’s eye, because the logic of it is unfailing, but the sentiment unpalatable.

Safeguarding Boards are too heavy handed an approach to deal with the range of issues that education and health professionals face daily. They are distant, remote, large and cumbersome bodies that are best kept at arm’s length, disturbed only at great peril. They are ineffectual at responding, with a light touch, to a teaching assistant, or teacher’s concerns over a child’s welfare. Collectively, they are failing our children.

Ofsted produced a report on Good Practice by Local Safeguarding Children Boards, in September 2011, but it does not reassure. And of those examples of good practice, how many Safeguarding Boards operate in such a manner? Too few, scattered thin and sparse around the country.

Executive summary

Local Safeguarding Children Boards are the key statutory mechanism for agreeing how the relevant organisations in each local area cooperate to safeguard and promote the welfare of children, with the purpose of holding each other to account and ensuring that safeguarding children remains high on the agenda across the partnership area.

In May 2011, the final report from the Munro Review of Child Protection, A child-centred system, was published. Within this report, Professor Munro set out the important role that Local Safeguarding Children Boards have in monitoring the effectiveness of partner agencies and recognised that they are key to improving multi-agency working, to support and enable partner organisations to adapt their practice and become more effective in safeguarding children.

Munro states that Local Safeguarding Children Boards are:

‘…well placed to identify emerging problems through learning from practice and to oversee efforts to improve services in response.’ [1]

She strongly advocates a move away from a compliance culture to a learning culture and sees the Local Safeguarding Children Board as key to the development of a ‘learning system’.

This report highlights elements of good practice in the operation of Local Safeguarding Children Boards. It aims to support the development of ‘learning systems’, by encouraging all Local Safeguarding Children Boards to reflect on their practice and plan for improvement.


In this context, I can see no good or fathomable reason why the board set up to protect children’s welfare in Coventry, and who so clearly failed in that duty, should be the ones to lead the inquiry into what went wrong. In such times, the need for honesty and integrity is never more paramount.

As a final comment, I am highly concerned that the body called upon to conduct a Serious Case Review should be the authority’s own Children’s Safeguarding Board. In all instances, what is needed is transparency and confidence – confidence in a system that seeks to ensure the best possible outcome for all concerned.

As a footnote to this post, I have added a link to Coventry’s SCB which has posted an update on its site – http://www.coventrylscb.org.uk/

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