Arthur, six, was murdered by his mother’s partner Emma Tustin, in Solihull, in June 2020. His father was convicted of his manslaughter.
Star was killed by her mother’s partner Savannah Brockhill, in Bradford, in September 2020. Her mother was convicted of causing or allowing her death.
A report on lessons learned from the deaths, following an inquiry by the Child Safeguarding Practice Review Panel, finds that multi-agency arrangements for safeguarding children are “too fragmented”.
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Child deaths link to pressures of pandemic and resources shortage
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Inspections Clinic: Multi-agency safeguarding
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Child deaths highlight the case for doing better
Inadequacies in the sharing of information between partners makes it “extremely difficult” for professionals to build and maintain an accurate picture of what life is like for the child, panel chair Annie Hudson has said.
She recommends that child protection should be handed over to specialist multi-agency teams of expert practitioners.
The creation of expert panels made up of professionals from local police and health services alongside social workers would “strengthen the child protection system at a national and local level so there is a more effective joined-up response”, the report states.
The teams, embedded within local authorities, would be responsible for convening and leading strategy discussions, carrying out section 47 child protection enquiries, chairing child protection conferences, overseeing, reviewing and supporting child protection plans, recommending court applications and advising other teams and agencies on child protection, according to the review
Hudson said: “At the moment, each professional who comes into contact with a child holds one piece of the jigsaw of what is happening in a child’s life.
“Professionals working to protect children have to deal with the most complex challenges and some perpetrators of abuse will evade even the most robust safeguards. However, in too many instances, there is inadequate join-up in how agencies respond to high-risk situations where children are being abused.”
Hudson has also put forward specific recommendations for local authorities in Solihull and Bradford:
Solihull
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Ensuring that all assessments undertaken by agencies draw on information and analysis from all relevant professionals, wider family members or other significant adults who try and speak on behalf of the child.
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Reviewing the partnership Multi-Agency Safeguarding Hub arrangements to ensure a “Think Family” approach.
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Reviewing and commissioning strategies to ensure practitioners know how to respond to incidents of domestic abuse and understand the risks to children of prisoners.
Bradford
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Agreeing clear expectations regarding risk assessment and decision making and ensuring these are understood by all agencies.
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Reviewing, developing and commissioning a comprehensive early help offer which can be accessed before, during and after the completion of any child and family assessment by children’s social care.
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Reviewing and commissioning domestic abuse services to guide the response of practitioners and ensure there is a robust understanding of what the domestic abuse support offer is in Bradford.
Care Review links
Hudson’s recommendations tally with those put forward in the Independent Review of Children’s Social Care in England which was published earlier this week.
The review, chaired by Josh MacAlister, recommends the creation of an expert child protection practitioner role and calls for measurable improvements in the sharing of information between local authorities and partner systems by 2027.
Responding to the safeguarding report, MacAlister wrote on Twitter: “Child protection work is really, really hard and many times professionals get it right. But the system doesn't support the expertise needed, multi-agency arrangements can be too weak and family members are often overlooked. Things need to change.
I'm grateful to Annie Hudson who led the national panel review for helping to make sure that Star and Arthur's stories informed the Care Review’s final report.”
As today's report says, child protection work is really, really hard and many times professionals get it right. But the system doesn't support the expertise needed, multi-agency arrangements can be too weak and family members are often overlooked. Things need to change.
— Josh MacAlister (@JoshMacAlister) May 26, 2022
Sector response
Steve Crocker, president of the Association of Directors of Children’s Services (ADCS), described the panel’s report as a “a contribution to our ongoing national learning as a multi-agency safeguarding system tasked with protecting children and young people from harm”.
“This report and its recommendations need to be viewed alongside the independent review of children’s social care’s final report. ADCS is committed to working with partners to improve the way we support and safeguard children, and their outcomes,” he said.
The review into the tragic murders of Star Hobson & Arthur Lanbinjo-Hughes highlights, yet again, what can happen if public services do not work together effectively & information about vulnerable children is not shared in a timely way.
— National Children's Bureau (@ncbtweets) May 26, 2022
Full Statement: https://t.co/2D4KiNlXby pic.twitter.com/rdgXrkCdMf
Peter Wanless, NSPCC chief executive, added that the review “lays bare an all too familiar story of a system struggling to cope”.
“Social workers, police, health practitioners and teachers, however hard they are working as individuals, know they cannot do this alone. To drive change in child protection we agree that national, political leadership is needed which must come from the very top of government,” he added.
This report shows that the appalling failures to protect Arthur & Star are not isolated incidents. Their horrific deaths & those of other children who have suffered from abuse are reflective of a system that is stretched to its limit & often demoralised. https://t.co/Oirr8ho2an
— Anne Longfield (@annelongfield) May 26, 2022
Meanwhile, Ray Jones, emeritus professor of social work at Kingston University, said the review has failed to properly factor in cuts to local authority social care budgets and the impact of the Covid-19 pandemic on staff in Solihull and Bradford.
“They have cumulatively undermined those who work with children, made arrangements for joint working even more difficult, and created overwhelmed workers where the priority is to close work down quickly so that they can take on the new work flooding their way.
“It should not be a surprise that there is now a major difficulty in recruiting and retaining social workers, health visitors and other key children’s workers. It has resulted in a less experienced, more unstable and exhausted workforce.”
The tragic deaths of Arthur Labinjo-Hughes and Star Hobson both shocked and appalled but also prompted serious questions that require not just answers but action. The Commissioner responds to the findings of the National Child Safeguarding Review Panel https://t.co/UvVCmkVU2F
— Children's Commissioner for England (@ChildrensComm) May 26, 2022
Jones added that the review “fails to allocate any responsibility to the government for more than a decade of deliberately damaging the public services which help and protect children”.
