The review’s central proposal is the creation of specialist child protection teams including social workers, mental health workers, police officers, paediatricians and child psychologists to oversee cases where children are at serious risk of harm.
The report sets out the circumstances of what it calls the “unimaginably horrific deaths” of Arthur and Star and highlights a number of chances missed by child protection teams to save the children. There were multiple warnings from wider family members that the children were in danger.
In both cases serious shortcomings in local child protection practice reflected wider national weaknesses, the report says. Safeguarding was too often ineffective and there was a lack of experience to handle complex and high-risk decisions, it says, requiring a strengthening of local and national safeguarding arrangements.
“We think that there is too much inconsistency and ambiguity in child protection practice in England. This does not serve children, their families or practitioners well,” said the chair of the child safeguarding practice review panel, Annie Hudson, who carried out the review.
Although she said this did not mean that the system was “broken” – every day, many thousands of children are protected from harm by conscientious, committed and capable professionals – Hudson said the current arrangements were “not consistently supportive or sophisticated enough to ensure the very best practice”.
Child protection work is intrinsically complex and complicated and should be led by multi-agency child protection units, the report says. Too often inexperienced professionals – social workers in particular – are asked to undertake this work without sufficient supervision and support. “This is not fair to the social workers or the children they serve,” it says.
The proposed new teams would be based in council children’s services departments, and would carry out formal investigations into local children at risk of harm, and chair child protection case conferences. Professionals from a range of agencies would be seconded to the units.
The education secretary, Nadhim Zahawi, welcomed the review and promised to publish a “bold implementation plan” later this year to put its recommendations into action. “We must waste no time learning from the findings of this review – enough is enough,” he said.
Arthur Labinjo-Hughes was abused, tortured and beaten to death by his stepmother, Emma Tustin, of Solihull, in June 2020, during the first Covid lockdown. In December Tustin was jailed for 29 years, while Arthur’s father, Thomas Hughes, received 21 years for manslaughter.
Star Hobson, was 16 months old when she was beaten to death in September 2020 by her mother’s partner after months of abuse. In December Savannah Brockhill, of Bradford, was sentenced to life for the murder, while Star’s mother, Frankie Smith, got eight years, later increased to 12, for causing or allowing the death of a child.
In each case, social workers, police and other professionals missed opportunities to intervene. They failed to develop a proper understanding of what daily life was like for Arthur and Star, or robustly share or interrogate and assess new information that came to light about them, the review found.
Arthur’s wider family repeatedly raised concerns with police and social workers that he was being beaten and abused, but their reports were not taken seriously, the erport says. Safeguarding officials were too quick to accept Hughes’ explanation that his relatives’ warnings was “harassment” of him and Tustin.
Star’s relatives’ warnings were similarly ignored, with professionals assuming wrongly that relatives were motivated by dislike of Brockhill and Smith’s lesbian relationship. Professionals failed to “unpack biases and assumptions”, which affected their assessment of the risk to Star, the review concluded.
In Bradford, the quality of safeguarding was undermined by high staff turnover and workload, the review found. In 2020, social workers in the city oversaw an average of 20 families each, compared with a national average of 16. Health visitors were underfunded, and caseloads rose from 299 new mothers in 2018 to 479 in 2022
This contextual pressure meant the work with Star was superficial and inadequate, the review says. “In 2020 Bradford children’s social care service was a service in turmoil, where professionals were working in conditions that made high quality decision-making very difficult to achieve.”