Dedicated child protection teams needed to strengthen ‘inadequate’ safeguarding arrangements, review finds

The national Child Safeguarding Practice Review Panel says the child protection system needs to be “strengthened” after it identified failings in how agencies worked together.

The two children were murdered by their parents’ partners and the report says concerns raised by wider family members about physical abuse were not properly investigated by police and social workers.

The report reveals that what happened to six-year-old Arthur and 16-month-old Star were “not isolated incidents” and their deaths reflected “wider problems in child safeguarding practice”, including poor information sharing between professionals and weak decision-making.

Arthur died in Solihull on June 17, 2020. His father’s partner, Emma Tustin, was convicted on December 1, 2021, of his murder. Arthur’s father, Thomas Hughes, was convicted of manslaughter. They are now both serving prison terms.

Star died in Bradford on September 22, 2020. Her mother’s partner, Savannah Brockhill, was subsequently convicted of murder on December 15, 2021, and her mother, Frankie Smith, was convicted of causing or allowing her death. They too are now in prison.

The panel is now calling for government to strengthen the child protection system at a national and local level so there is a more “effective joined-up response”.

Panel chair Annie Hudson said: “Arthur and Star suffered horrific and ultimately fatal abuse. But sadly, whilst their individual stories are unique, many hundreds of children are seriously harmed each year.

“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. Our proposed reforms would bring together experts from social work, police and health into one team so that they can have a better picture of what is happening to a child, listening carefully to relatives’ concerns and taking necessary actions to protect children.

“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.”

The panel is making eight national recommendations and a number of local recommendations for safeguarding partners in Solihull and Bradford.

National Police Chiefs’ Council lead for child protection, Deputy Chief Constable Ian Critchley, said: “Protecting children from all forms of cruelty and neglect is our collective ambition. This report acknowledges and recognises the professional and dedicated work being carried out by colleagues and partners every single day up and down the country to protect children. However, the tragic loss of Arthur and Star is a painful reminder that there is more for us still to do.

“I welcome the national panel report and recognise the important role it plays in identifying key areas of work that will help police and partners to continuously work more effectively together to protect children.

“There are several strands to the report, and we will now work with our partners and stakeholders to consider and act on the recommendations.”

He added: “Tackling child cruelty is a multi-agency endeavour with complex challenges in each part of the response. We already work closely with frontline partners in social services, education, health and other locally based partners and charities to tackle abuse, and recognise the importance of ensuring that the right information is effectively shared across agencies in all areas of the UK to safeguard children.

“We encourage anyone who believes a child is being abused to report their concerns however small they may seem. It is the responsibility of us all to ensure children are protected from abuse and can thrive in today’s world, not suffer the most appalling harm as that inflicted on Star and Arthur, who our thoughts are very much with today.”

The national recommendations include:

• Implementing new expert-led, multi-agency child protection units to undertake investigation, planning and oversight of children at risk;
• Establishing national multi-agency practice standards for child protection – this would provide a standard of quality and consistency in practice for working with children at risk and their families across the country; and
• A sharper performance focus and better co-ordination of child protection policy in central government – this involves the establishment of a national Child Protection Board, bringing together all relevant central government departments, local government, the police, education and health representatives.

Responding to the report, Assistant Chief Constable Claire Bell of West Midlands Police said: “The tragic death of Arthur Labinjo-Hughes has had a profound impact on so many people. We owe it to Arthur to not miss a single opportunity to learn from what happened to him so we can better protect children in the future.

“The report by the national Child Safeguarding Practice Review Panel makes a number of important local and national recommendations that will help police and partners to work more effectively together.

“We will continue to work with our partners to act on these recommendations, building on the progress we have already made to improve safeguarding for children across the West Midlands. This includes investing additional resources into child safeguarding in Solihull, and improving the quality and management of information held on the force records management system to enable us to identify and manage risks more accurately and improve our ability to prevent and investigate crime.”

She added: “The report acknowledges the dedicated work of officers and staff who work in child protection, who face the most complex challenges. We are committed to ensuring they have the best training and support and are providing additional training across a range of vulnerability and safeguarding, including domestic abuse incidents. This will strengthen their ability to identify and protect children from all forms of cruelty and neglect.

“We know there is still more to do and we are determined to work collectively with partners to act upon the panel’s recommendations and make the changes needed to better safeguard children in the future.”

The local recommendations for safeguarding partners in Solihull, where Arthur lived, include:

• 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;
• Reviewing the partnership Multi-Agency Safeguarding Hub arrangements to ensure a more ‘Think Family’ approach; and
• Reviewing and commissioning strategies to ensure practitioners know how to respond to incidents of domestic abuse and understand the risks to children of prisoners.

West Yorkshire Police Chief Superintendent Robert McCoubrey, district commander for Bradford where Star lived, said: “I acknowledge and accept the findings and recommendations put forward in today’s report.

“I would like to take the opportunity to reaffirm that our thoughts remain with Star Hobson’s family. This report reminds us of the unimaginable distress they have suffered.

“Star was a little girl with her whole life ahead of her, yet she died at the hands of those who should have been there to protect and care for her. The fact that Star’s murder took place in Keighley has had a profound impact on police officers, professionals, and communities across Bradford district.”

He added: “At the end of last year two women were convicted and sentenced for the roles they played in the appalling abuse and murder of Star Hobson.

“This report now provides a clear determination of how key opportunities for agencies to better protect her were missed. We must all learn from this.

“Protecting vulnerable children is of the highest priority for West Yorkshire Police and we are wholly committed to working closely with our partners in continuing the transformation and improvement of practice.

“We have already reviewed and started to address a number of areas that have been highlighted in the report and will now work collectively to implement all of the local recommendations that have been put forward.”

The panel’s local recommendations for safeguarding partners in Bradford include:

• Agreeing clear expectations regarding risk assessment and decision making and ensuring these are understood by all agencies;
• 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; and
• 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.

Ms Hudson added: There was palpable public shock just before Christmas 2021 when the unimaginably horrific deaths from abuse suffered by Arthur Labinjo-Hughes and Star Hobson became known. We will never know what their respective lives were really like in the weeks and months leading up to their murders.

“What we must do is attempt to understand how and why the public services and systems designed to protect them were not able to do so.

“Despite the intentions of recent reforms (and most recently the Children and Social Work Act 2017), multi-agency safeguarding arrangements are not yet fit for purpose everywhere. This results too often in blurred strategic and operational responsibilities, creating fault lines in practice arrangements. This has major consequences for the ability of practitioners across different agencies to work together skilfully and purposively to protect children.”

Ms Hudson said the “perennial problems of sharing, seeking and using information about a child and a family persist” and this must be tackled, adding: “We cannot afford to revisit these problems again and again; new approaches are required.

“This review is focused on Arthur and Star. Yet we know from our extensive evidence base spanning all serious safeguarding incidents over the last three years that many of the issues identified during the course of this review are frequently seen in practice more broadly across England.

“Our proposal for how we change the way child protection practice is undertaken extends out towards the serious risks faced by some children and young people outside their homes, and beyond that to serious online harm.

“We hope that this review also provides a window of opportunity to enhance public understanding about the realities of child protection.

“All those professionally entrusted with protecting children must be held to public account, and this must be based on knowledge of the complexities involved.”

The Child Safeguarding Practice Review Panel is an independent body that was set up in July 2018 to identify, commission and oversee reviews of serious child safeguarding cases. It brings together experts from social care, policing, health, education and the third sector to provide a multi-agency view on cases which they believe raise issues that are complex, or of national importance.