Ellie Butler case shows we need scrutiny of family courts

First, the case of Mrs Justice Hogg, who, sitting in the family court, returned Ellie Butler to her birth parents. Ellie was murdered by her father just months later, with her mother helping the cover-up. Second, the worryingly large number of local authorities judged as "inadequate" on one or other of the inspection frameworks, and where senior staff lose their jobs after an otherwise unblemished career. Third, the Wood review of Local Safeguarding Children Boards, which has been accepted by the government and is being made part of the Children and Social Work Bill, with provisions for "local safeguarding partners" and "local child safeguarding practice reviews" among other system changes.

There are relatively few reasons why professionals get things very badly wrong. They can be badly trained or incompetent, so they just don't recognise warning signs when they see them. They can be badly managed so that there are incentives not to report concerns, perhaps because "someone else is bound to report it", perhaps because it will just make more work in a busy schedule. They can be grossly over-loaded or under-resourced, leading to lack of focus on high-risk cases. They can fail to join up the dots with other agencies - a common one, driven by differing priorities and work processes. They can be working in a system where there are structural flaws, either local or national in origin - it is in this area where the government tends to intervene, often by putting in place more specific requirements to "make" people work well together. Sometimes professionals - from frontline workers to top executives - can be manipulated and fail to see the wood for the trees.

There is synergy between all these, of course, and there is rarely a single cause of failure. What seems incontrovertible to me is that almost no one in the professional arena wants children to be at risk of serious harm - the Dr Harold Shipmans of this world are truly exceptional.

I'm not an apologist for professional failure, but equally I believe it is far too easy to scapegoat individuals. Nor do I believe in magic bullets - there are no simple solutions to any of this, or we would have found them years ago. There are systemic improvements that can be made, but most of what is needed relates to local leadership, practice and culture, operating in a stable national framework.

Which all leads back to the family court and Mrs Justice Hogg. I don't know about her workload, training, general competence or management, but she made a serious error. The questions are, why did she make the judgment she did and can similar errors be avoided in future?

When I was learning the job of being a senior children's services professional, I sat alongside a judge in the family court for a couple of days, just observing what happened, and hearing his reflections on the cases. My eyes were opened on a very different world. The court system is fundamentally adversarial. Typically, both sides are lawyered-up, the emotional temperature is often high, sometimes the evidence is incomplete or even missing. It seems likely to me that Mrs Justice Hogg was manipulated by the parents into believing their story, to the extent that she simply failed to give appropriate weight to the local authority as corporate parent, and to the grandfather who had cared for Ellie. She said "It is a joy to me to oversee the return of a child to her parents…" so, clearly, she felt no doubt. Worse, the serious case review concluded that in expressing her judgment as she did, she disempowered other professionals who had concerns in the following months.

What do I conclude from this? Certainly, not that Mrs Justice Hogg was either incompetent nor ill-meaning. I do think, though, the family court should be opened up, as has happened to other parts of the system, with all cases being scrutinised with a sceptical eye - there are parents who mistreat their children and try to cover it up, often very convincingly. That was the lesson of baby Peter Connelly and far too many others. We must all be vigilant to manipulation, even judges.

John Freeman CBE is a former director of children's services and is now a freelance consultant  

Read his blog at cypnow.co.uk/freemansthinking