Crisis of care

While the Independent Inquiry into Child Sexual Abuse, which released its final report in October, is to be welcomed, Dr Bernard Gallagher argues that it represents ‘a fragmented approach to child protection’ and does not address the wider challenges currently facing the child safeguarding system.

Dec 2, 2022

The work of the Independent Inquiry into Child Sexual Abuse (IICSA) wound up last month with the release of its final report, The Report of the Independent Inquiry into Child Sexual Abuse. Parallel inquiries were convened in Northern Ireland – the Historical Institutional Abuse Inquiry (HIAI) – and in Scotland – the Scottish Child Abuse Inquiry (SCAI). The HIAI published its final report in 2017, while the SCAI is ongoing.

The IICSA was set up to investigate the sexual abuse of children in “State and non-State institutions” in England and Wales. It was charged with identifying “what went wrong and why”, and with making “recommendations to help prevent these failures happening in future”.

Any effort to raise awareness of, and address, child sexual abuse (CSA), and indeed any form of child abuse or neglect (CAN) has to be welcomed. I was a co-author on one of the IICSA’s earlier commissioned reports – Rapid evidence assessment: Quantifying the extent of online-facilitated child sexual abuse (lead author, Nadia Wager). I was also contracted to review drafts of two of the IICSA’s other outputs.

I have long, though, had concerns about the inquiry and its likely impact, or rather lack thereof. These concerns have not been assuaged by a reading of the IICSA’s final report, which runs to 459 pages, thus ensuring a miniscule readership.

The inquiry took seven years, involved 15 context-specific “investigations”, heard from 725 witnesses over 325 hearings, and processed some 2.5 million pages of evidence. The inquiry’s ‘Truth Project’ received submissions from more than 6,000 victims and survivors of abuse (The Truth Project was set up so “victims and survivors could provide a uniquely-informed contribution to understanding and learning from past mistakes and improving child protection in the future”). The inquiry cost £186 million.

What was the precise focus of the inquiry supposed to be? It was set up following suspicions or allegations that widespread CSA had taken place in a range of organisations, which was ignored or actively covered up by people who had at some responsibility for addressing the issue. The institutions and contexts within which the IICSA carried out investigations included Anglican and Catholic churches, local authority children’s homes and providers of foster care, residential schools, the Child Migration Programme (both before and after the Second World War), and political parties.

‘Westminster allegations’

Conjuring tricks work by manipulating the audience’s attention. Look at the left hand when it is the right hand where the action is. Politicians answer awkward questions with a flurry of facts or assertions of varying relevance, hiding the key point in a dust cloud of deflection. In the same way, the IICSA’s very wide remit provides camouflage for the single most consequential site of putative abuse, Westminster. A fish rots from the head and the capacity of the powerful to avoid scrutiny of their actions yields a society vulnerable to widespread wrongdoing.

Consider the widespread allegations that members of the political elite were sexually abusing children, and that these crimes were covered up, via collusion or pressure, by Special Branch, the Crown Prosecution Service, security services and politicians. It is painful to cast aspersions on the distinguished deceased. However, success in thwarting proper investigation of crimes of the powerful during their lifetimes probably means that the capacity and inclination to commit them survives to the present day.

Countless police officers, along with practitioners in children’s social care, education and health, carry out excellent child protection work day in, day out. Despite this admirable work, child protection is in crisis

‘Westminster-linked’ individuals investigated by the IICSA included MPs Greville Janner (Baron Janner of Braunstone); Victor Montague (Viscount Hinchingbrooke and latterly 10th Earl of Sandwich); Sir Peter Morrison (Parliamentary Private Secretary to Margaret Thatcher, later deputy chairman of the Conservative party); and Sir Cyril Smith, together with Sir Peter Hayman (High Commissioner to Canada). There have also been allegations that MP George Thomas (1st Viscount Tonypandy and Speaker of the House of Commons) sexually abused a child, but these claims were not investigated by IICSA.

The IICSA initially recognised the centrality of the Westminster-related allegations. It noted in its 2020 report, Allegations of child sexual abuse linked to Westminster, that there was “growing public concern that a network of child sexual abusers may have operated with a degree of impunity at the highest levels of public life”.

It went on to assert that “the public concern about Westminster child sexual abuse allegations… was a significant factor in the IICSA being established”.

The IICSA concluded that “there was ample evidence that individual perpetrators of child sexual abuse were linked to Westminster but, despite some assertions to the contrary, there was no evidence of an organised ‘Westminster paedophile network’”.

So what? Is individual ‘recreational’ child abuse outside the scope of the Inquiry? Its title does not say so, nor is its most prominent specific recommendation more directed at organised abuse. Let me return to my core point. The IICSA, by accident or design, had an excessively wide remit that served to dilute its focus on the perpetration and cover-up of CSA by leading political figures.

Inquiry leadership

The Government’s original plan was to appoint a senior lawyer to lead the inquiry. Such an appointment would have been commensurate with the harm inflicted on victimised children. A succession of inquiry chairs were offered and accepted the role. In order, these were Baroness Butler-Sloss (a former High Court judge), Dame Fiona Woolf (a then partner in a City law firm) and Dame Lowell Goddard (a New Zealand High Court judge).

Each stepped down after a relatively short time. Both Baroness Butler-Sloss and Dame Fiona stepped down after it emerged that they had connections with persons whose actions might be investigated by the Inquiry. There was, in addition, an allegation that Baroness Butler-Sloss had not properly investigated claims of CSA, against a bishop, in an earlier inquiry into abuse in the Church of England. It was reported that Dame Lowell stepped down, in part, because the inquiry was “too much for her”.

The Government then appointed Alexis Jay, a professor of social work, who saw the inquiry through to completion. I do not doubt that Professor Jay brought knowledge, understanding and skills to her role. However, I question whether she had the forensic skills and personal authority required for chairing the IICSA, which was established to investigate the actions of national political figures, and criminal justice and security agencies.

The possibility that members of the political establishment had sexually abused children and that these crimes had been covered up by the State, called into question the very validity of our ‘democratic’ system. It is in light of this existential threat, that I contend that the IICSA should have been led by a senior legal figure, and should have focused entirely upon the sexual abuse of children by political figures and its possible cover-up by State agencies. This much narrower inquiry would also have been able to report much more quickly and would have been significantly cheaper.

It may have been that an inquiry into other non-Westminster-related “State and non-State institutions” was merited, although I feel that limits may have been needed on the scope of even this inquiry, with the exclusion of, for example, CSA cases involving the internet and organised networks, given that these do not appear to constitute ‘institutions’.

Intrafamilial child sexual abuse

During my now quite extensive career researching CAN, I have increasingly come to believe that a major problem in terms of improving child protection is that many of those individuals – policymakers, journalists, campaigners, inquiry leads and academics among them – who have had some of the loudest and most influential ‘voices’, possess only a partial knowledge and understanding of CAN and child protection.

These individuals certainly do not have as deep or broad a level of appreciation of these issues as frontline professionals, such as the police, health practitioners, social workers and teachers, who deal with CAN on a daily basis.

Following on from this, the other major criticism I have of the IICSA was why – especially when its remit was so already so large – did it not examine failings in response to CSA in all settings, including, in particular, incidents within families.

A considerable proportion of CSA takes place in and around families. I have studied numerous cases where family members, relatives and other persons close to families have sexually abused children, left them in situations where they are at risk of CSA or have covered up CSA. If we, as a society, are really concerned about CSA, then why do we prioritise such abuse in some settings and ignore it in others?

The answer to this question has been provided, in part, by the Royal College of Paediatrics and Child Health (RCPCH) in its contention that there exists a “hierarchy of abuse”. Although the RCPCH put forward this notion in relation to the policy response to children at risk of FGM (female genital mutilation) specifically, I would argue that it can be applied to CAN in general. CSA is, according to this ‘hierarchy’, perceived as being more serious and important than child physical or emotional abuse, or neglect.

There is, however, an important differentiation even within this prioritisation. Society tends to be much more ready to address and condemn any manifestation of extrafamilial CSA, be it related to child sexual exploitation (CSE), institutional abuse, international child trafficking, the internet or ‘stranger danger’. Society is, though, much more hesitant about acknowledging the existence of intrafamilial CSA – possibly because to do so would involve it having to confront one of its most profound taboos.

This is a large part of the reason why the country has diverted what I judge to be a very disproportionate amount of attention towards CSE over the past ten years or more, while seemingly not being particularly aware, let alone concerned about, the far more prevalent issues of intrafamilial CSA and other forms of CAN.

FGM is the sole exception to this rule. As with CSE, it has been the focus of an excess level of policy attention over the past decade).

Although I am sure it was not its intention, the IICSA has – by concentrating upon extrafamilial CSA – simply reinforced this hierarchy, and the misconceptions around CAN and child protection more generally that it represents.

I realise that my call here for a wider inquiry might sound a bit contradictory given that I earlier suggested a narrower ‘Westminster’-focused inquiry. My point is that the IICSA should have concentrated upon the Westminster allegations, given their gravity and implications, but that if it was going to be much broader – as it was – then it should have looked at failings in response to CSA in all settings – including the family.

Serial inquiries

A further major concern I have with the IICSA and other CAN inquiries – and indeed many other equivalent reviews, inspections, reports and research projects – is the over-reliance – if not dependence – that is often placed on these enterprises. This reliance is well-illustrated by the sheer number of such inquiries and similar probes that have been carried out; none more so than in relation to CSE. CSE is a particularly apt focus, here, as this ‘type’ of CSA features quite significantly in the work of the IICSA.

One of the first major inquiries into CSE was carried out by the Office of the Children’s Commissioner for England (OCCE). It lasted two years and produced a total of six separate reports, culminating in the OCCE’s final report, in 2013 – If only someone had listened: The Office of the Children’s Commissioner’s Inquiry into Sexual Exploitation in Gangs and Groups. The Home Affairs Committee published the outcome of its inquiry into CSE the same year – Child sexual exploitation and the response to localised grooming – and then added a follow-up report a year later.

The inquiry that proved to be a watershed moment in relation to CSE was the one on Rotherham, also led by Professor Jay, and released in 2014 – Independent inquiry into child sexual exploitation in Rotherham (1997-2013). Although essentially local in its orientation, the inquiry report achieved extensive national and even international attention. It was proceeded by an inspection and eventual report ordered by the then Secretary of State for Communities and Local Government, Eric Pickles. It was carried out by Louise Casey (now Baroness Casey of Blackstock) and was published in 2015 – Report of inspection of Rotherham Metropolitan Borough Council – and it too gained national attention.

As a result of concerns over the actions of Home Office’ staff in relation to “organised” CSA, the department’s Permanent Secretary commissioned two internal reviews: ‘Review 1’ and ‘Review 2’.

The then Home Secretary subsequently asked Peter Wanless, chief executive officer of the NSPCC, and Richard Whittam, a then QC, to examine these two reviews – An Independent Review Of Two Home Office Commissioned Independent Reviews Looking At Information Held In Connection With Child Abuse from 1979-1999. All of this work is believed to have been conducted and published in 2014.

The Home Office, following doubts this time over its response to CSA in Rotherham, carried another internal review of its staff’s conduct – The Rotherham Internal Review: A review into information passed to the Home Office in connection with allegations of Child Sexual Abuse in Rotherham (1998-2005). This review was released to the public in 2018. The Home Office then arranged, also in 2018, for Mr Wanless and Mr Whittam to review this review as well – An Independent Review of the Home Office Internal Review.

Driven in part by ongoing concerns relating to issues surrounding offenders in CSE cases, the Home Office produced a ‘paper’ on CSE, in 2020 – Group-based Child Sexual Exploitation Characteristics of Offending. That same year, the IICSA released the results of related work that it had commissioned from a private research organisation, Tonic – An explorative study on perpetrators of child sexual exploitation convicted alongside others.

In 2021, the Centre for Social Justice released a report on CSE and CSA more generally – Unsafe Children: Driving up our country’s response to child sexual abuse and exploitation. The report was produced by a ‘commission’ led by Rt. Hon Sajid Javid who, besides other posts, has served as Chancellor of the Exchequer, Home Secretary and Secretary of State for Health and Social Care. Two years after publishing the research on CSE that it had commissioned, the IICSA issued a report based upon its own “investigation” into CSE – Child sexual exploitation by organised networks.

The NSPCC has a repository of more than 1,500 CAN reviews and reports (mostly local) from across the four jurisdictions of the UK and published since 1945. It is likely that there have been scores of nationally-significant inquiries, reviews and reports into CAN and child protection across the UK in the same time period. In addition to the IICSA, there have been two other official, national inquiries into CAN and child protection this year alone: The independent review of children’s social care, and the national review into the murders of Arthur Labinjo-Hughes and Star Hobson.

Inquiries have previously come in for a good deal of criticism; one being that they portray and create a highly misleading and negative impression of child protection work. Notwithstanding this issue, inquiries and reviews, and the like, do have a role to play in scrutinising and supporting child protection efforts. However, I fear that there is a misplaced zeal for carrying out these exercises – as attested to by the number of reviews that have been conducted. I worry that reviews are seen as a panacea, or an ‘end’ in themselves as opposed to being a (possible) means to an end.

CAN inquiries often receive copious political, media and public attention when they are published but much less critical analysis. Such analysis should consider the methods by which an inquiry has been carried out, the conclusions it reaches, the recommendations it makes and whether these are acted on by the appropriate authorities. I have already touched upon the first of these issues and will now address a second – the recommendations of the IICSA.

IICSA recommendations

The final report of the IICSA contains 20 “concluding recommendations”, with the inquiry having put forward a further 87 recommendations in its previously published reports.

The concluding recommendations include “extended use of the barred list of people unsuitable for work with children”; the “registration of care staff in residential care, and staff in young offender institutions and secure training centres”; “a guarantee of specialist therapeutic support for child victims of sexual abuse”; and compilation of “a single set of core data relating to child sexual abuse and child sexual exploitation”. In general, these recommendations – if implemented – could make a contribution both to preventing CSA and improving the response to it when it does occur, and for these reasons they are to be welcomed.

I do, though, also have doubts over the inquiry’s recommendations. The recommendations are, in general, fairly modest, and relate to procedural and organisational changes primarily. They do not address what I see as the profound challenge currently facing child protection.

I can elucidate these concerns via the “three recommendations [that] form the centrepiece of the Inquiry’s work” (p.16). Two of these recommendations comprise the establishment of a national (financial) redress scheme for victims/survivors of institutional CSA and the creation of a Child Protection Authority (CPA).

The financial redress scheme, while again of value, does not seem radically different in its nature to the Criminal Injuries Compensation Scheme, although I appreciate it is intended to be quite distinct in terms of its application. It appears that the main role of the CPA would be to conduct inspections of organisations working with children or to order inspections by existing inspectorates. Both of these roles would seem to incorporate a considerable and unnecessary degree of duplication with existing inspection regimes.

The remaining “centrepiece” recommendation is a call for a mandatory reporting law (MRL) in respect of individuals whose work brings them into contact with children whereby they would be under a legal duty to make a report to local authority children’s social care or to the police, where they know or believe a child is being sexual abused.

This recommendation has been widely portrayed in the media as being the key recommendation to emerge from the inquiry, and indeed it appears first in the list of recommendations in the executive summary of the IICSA’s final report. That a MDL – an issue that has been discussed in the UK for the past 50 years at least – could be conceived as being the major recommendation of the IICSA, which lasted seven years and cost £186 million, has to be questioned.

But remaining with this recommendation for the moment, the IICSA itself acknowledges that there are considerable arguments both in favour of, and against, a MRL. The Government came to a similar conclusion following its 2016 consultation exercise. It stated in its 2018 response – Reporting and acting on child abuse and neglect: Summary of consultation responses and Government action – that although a MRL “could reduce the risk that serious cases pass unnoticed”, it could also deter victims from disclosing, obscure “key cases”, and undermine both the quality of practitioner referral-related decision-making and inter-agency working.

I can appreciate both sides of this debate, but I have long since found myself opposed to a MRL, not only on the above practical grounds but as a matter of principle. I see the proposed MRL as just another example of what I would refer to as a ‘technical quick-fix’ (TQFs) – and only a hoped for one at that.

Policy responses to CAN in general, and CSA in particular, are legion, and have been dominated by TQFs. Examples include the Child Exploitation Disruption Kit, Child Sex Offender Disclosure Scheme, Disclosure and Barring Scheme and Sex Offender Register, along with Child Abduction Warning Notices, Disruption Notices, Sexual Harm Prevention Orders, Sexual Risk Orders… the list goes on.

It is not that I am against these measures per se. On the contrary, I can see that they might make an important contribution to keeping children safe from harm.

My concern is that the IICSA and the numerous preceding official inquiries, reviews and reports over the past decade have not addressed what I, and I am sure many others, see as the single greatest challenge facing child protection: the undermining of services through continual public spending cuts since the onset of austerity measures in 2010.

Child protection crisis

Countless police officers, along with practitioners in children’s social care, education and health, carry out excellent child protection work day in, day out. Despite this admirable work, child protection is in crisis.

Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) disclosed in a report last year that the Metropolitan Police Service was unable to examine all digital devices in suspected CSA cases. HMICFRS warned that “this may result in unmanaged and missed risk in terms of first-generation images and abuse in a family being identified”. The IICSA – to its credit – revealed that police services were experiencing major delays in examining digital devices.

One force was, in 2014 at least, taking up to 61 weeks before it could begin to check such equipment. Even “urgent computer examinations” could take up to 16 weeks to be initiated.

The NSPCC has reported that cuts to the Ministry of Justice budget have resulted in the closure of virtually all specialist young witness schemes. The average time it takes a CSA case to come to court has, over the past three years, increased by five months and now stands at an appalling 22 months.

More than one-third of child and family social workers responding to the Community Care annual survey stated that their caseloads were “completely unmanageable”. Researchers at King’s College London found that teachers are increasingly taking on a social worker role owing to the latter practitioners being so stretched.

Health visitor and school nurse numbers have declined by approximately one-third during the time of austerity. Over the same period, more than 1,300 children’s centres – which often serve some of the most disadvantaged and vulnerable families – have closed.

But it is not just child protection work and not only the above agencies that are in “crisis”. As a quick search on the internet will show, this same assessment has been made of policing in general, along with the judicial system, the prison and the probation services, the NHS and schools, and quite recently so. The yet further public spending cuts announced by the Government in its ‘Autumn Statement’ on November 17 will only intensify the child protection and other crises.

There is minimal discussion of ‘resources’ in the final IICSA report, and where it takes place, it is focused on meeting the needs of victims and survivors of CSA. There is no reference whatsoever to the existence of the funding crisis affecting child protection-related services. It is as if the Inquiry – which was supposedly independent – existed in a policy and reality vacuum.

Honest analysis

The final IICSA report, along with all of its interim reports, all of the preceding inquiry reports on CSA and CAN, and the other policy measures designed to combat child maltreatment, likely will have, or have had, important and much needed effects in terms of enhancing children’s safety and more general wellbeing.

But it is equally probable that the cuts to public services since the onset of the austerity period in 2010 have undermined these developments and have left children at greater risk of CAN. The recently publicised extra public spending cuts will exacerbate this risk.

The country may face a financial crisis but it also faces a child protection crisis. Those leading official CAN inquiries, but also – and much more importantly – the Government have to be honest about the existence of this child protection crisis. It is only by being honest that we can hope to even begin to resolve (ideally), or at least mitigate, this present and growing crisis.

Dr Bernard Gallagher  spent most of his career as an academic, researching child maltreatment and child protection in particular, along with allied issues, such as domestic abuse and victimisation more generally. He now works as an freelance researcher.

Ian Dean


IICSA’s final report is an opportunity for change: improving responses to child sexual abuse but also preventing it from happening, says Ian Dean

Ian Dean, director of the Centre of expertise on child sexual abuse (CSA Centre) comments on the final report of the Independent Inquiry into Child Sexual Abuse.

On October 20, the Independent Inquiry into Child Sexual Abuse (IICSA) published its final report and recommendations. Seven years on from the Inquiry launching, this final report shines a valuable and important light on the sexual abuse of children in England and Wales; both amplifying victim and survivor voices but also drawing attention to the harm that society has averted its gaze from for far too long.

It is vital that action now follows the experiences shared with the Inquiry, to embed much needed improvements across all agencies working with children and families.

The report was hotly anticipated by all those working with children, and details 20 recommendations in total.

The focus on improving data – and specifically data consistency – in these recommendations is particularly welcome. The CSA Centre has been driving a better understanding the scale and nature of child sexual abuse and helping national, regional and local agencies with data since our creation in 2017, and we were pleased to see our work drawn upon in the report.

Rightly, IICSA also highlights an expectation that all children should be able to access support when they need it if they have been a victim of child sexual abuse. Of course, this is dependent on both the provision of such support being available and referring agencies being aware of it. Our ongoing work hopes to assist in making this possible; by identifying the extent of current support service provisions for victims of child sexual abuse in contributing to a better understanding of what gaps remain.

More broadly, we, like others, will take time to consider the implications of the individual recommendations but I wanted to focus on one area that receives less attention in the final report: supporting professionals to build the knowledge, skills and confidence they need to identify concerns and respond promptly and effectively when abuse has taken place and, importantly, to prevent it from happening in the first place.

Chair of the inquiry, Professor Alexis Jay, rightly outlined in her supporting comments that child sexual abuse “is an ever-increasing problem and a national epidemic”.

In fact, we conservatively estimate that 500,000 children under the age of 16 experience some form of sexual abuse in England and Wales each year.

We need to move away from expectations that children can tell us what is happening, and invest in building knowledge, skills and confidence to identify concerns about possible sexual abuse and build proactive safeguarding practice for all those working with children.

Currently, training and guidance on child sexual abuse for those in policing is varied.

In 2019, our Policing Practice Improvement Advisers undertook a scoping review to explore police officer understanding and response to child sexual abuse.

This included discussions with strategic leads and frontline officers in nine police areas and highlighted four key themes:

  1. Although officers wanted to respond correctly and effectively – and recognised the value of preventative work – many received little or no specific training on child sexual abuse;
  2. Officers often reported that their only training around child sexual abuse was within the context of a one-day safeguarding or child protection input, and often as part of training on emotional abuse and neglect;
  3. Many officers just ‘learnt on the job’ – drawing on the experience of their peers or their own experiences – leading to gaps in confidence in key areas, including spotting the signs of child sexual abuse; and
  4. In some cases, experienced detectives in specialist teams waited up to two years to undertake Specialist Child Abuse Investigation Development Programme (SCAIDP) training.

This work informed our research published in December 2021 exploring current police practice, challenges and enablers in disrupting child sexual abuse. It also informed the development new courses on child sexual abuse for frontline and strategic policing colleagues.

As one recent participant said: “This training helped [me] to notice warning signs and notice behaviours that I wouldn’t have realised could indicate this type of abuse.” We simply cannot expect professionals to know what to do, without giving them the knowledge and skills to do so.

IICSA’s final report is absolutely right to say that “there needs to be a greater priority and focus, politically and across society as a whole, on protecting children from sexual abuse”. Supporting those on the front line to do their jobs effectively has to be central to that focus.

Deputy Chief Constable Ian Critchley, National Police Chiefs’ Council lead for child protection, highlighted in response to the IICSA report that “in the past many victims have been failed” and there was still “much to do” but that making these improvements was “a significant priority for national policing”.

This is incredibly positive to hear. We have made progress but, as this report outlines, there is so much more to do.

We need to ensure our priorities (across all agencies) are both proactive and reactive; that more children and families are adequately supported; and that we intervene so that fewer children are abused in the first place.

For more information on the CSA Centre – its training, research and resources – visit


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