My first reaction to reading the Serious Case Review into the case of the brutal attack by two young brothers in Edlington in 2009 was one of anger. Children's services clearly had no understanding of its moral imperative to rescue children at greatest risk. This included social workers working in the Duty and Assessment Team (DAS) who were supposed to be at the front line of safeguarding children. The catalogue of failures amounted to more than incompetence; there was a consensus of indifference to children at risk.

What is particularly shocking is the warped thinking around the use of the Common Assessment Framework. Assessment had become a bureaucratic exercise serving the organisation, not children in need. A chilling example is the following use of an initial assessment to avoid taking any action (paragraph 199):

'... an internal mangement review of the family's case within DAS results in a decision to close the case. The reason for closure is recorded and is based on wrong assumptions. It is made without undertaking any enquiries. The reasons given for closing the case are that all the issues are self reported by mother; the main issues are anti social behaviour; the reported injuries have not been seen by the GP; the injuries are reported to be self inflicted by children at the time of the initial assessment; the reports of domestic violence reported by mother are not current and there are no historical reports of domestic violence to the police. This last criterion is factually incorrect.'

This lack of engagement by children's services with the family put enormous pressure on other services to provide assessment and support. The input from the Youth Offending Team was considerable and on many occasion workers from this, and other agencies, put pressure on the Duty and Assessment Team to be become involved, but to no avail. It recognised that the boys presented a high risk of offending, introduced many schemes to tackle the problems and held frequent planning meetings dealing with anti-social behaviour. Though well-intended, much of the work reeks of desperation, with workers soon realising they had an impossible task and wanting to refer elsewhere. The family dysfunction persisted; the boys were not getting the controls they needed and their behaviour deteriorated.

Parental resistance to working with social workers was a significant factor throughout. It was never established that the parents wanted supportive services except on their own terms. Consequently, any kind of therapeutic relationship that workers may have tried to establish with the family was doomed to failure.

When children's services finally agreed to care it then made the unfortunate decision to place the brothers in a foster-home near the father who had been harming them. Social workers assumed that the boys simply needed care, ignoring the fact that they had been showing an escalating pattern of violence over several months and needed close supervision. Ideally, social workers should have separated the boys and provided placements in a more secure setting, for the protection of others.

Prior to the attack the system had ignored all the warning signs that the boys were a serious risk to other children. Afterwards it was forced to place them in a Secure Unit but it should have put controls in place earlier, when the boys started to assault others. This case has shown the need to rebalance children's services in favour of the victims of violent children.

From my experience of working in children's services during the 1980's and 90's I am convinced that much practice wisdom from the past has been lost. Social workers now seem less confident in the use of authority and more uncertain about how to identify risk and carry out risk assessments. A professional culture has emerged where assertive social work is regarded as oppressive and socially inclusive practice implies that all children must remain with their families. Previous practice wisdom has been replaced by this new orthodoxy. It has skewed thinking about children's needs, created bewilderingly complex guidance and resulted in scarcely any shared agreement between professionals on what risk means.

This Review covers the period from 1995 to April 2009. This was a time when child protection procedures were well established and social workers should have been clear about their statutory duties. From the very moment in 1995, when a child protection conference decided that medical evidence of non-accidental injury to a child did not justify registration, social workers sent a message to the family that it was not serious about protecting children from abuse.

There are many more examples of poor social work practice throughout this period. These included failures in: recording, carrying out statutory duties, arranging child protection conferences, creating a child protection plan, making assessments and identifying risks. The Review states that there was 'endemic non-compliance with procedures'. However, the absence of any critical analysis in this Review is alarming. Furthermore, the fact that the profession remains in denial about serious shortcomings in child protection work does not inspire confidence.

Lessons to be Learned

There is no evidence in the Doncaster Review that social workers had the necessary social work skills in carrying out formal investigations (section 47 of the Children Act 1989) - which are often fateful moments to intervene. The Review suggests there was often uncertainty about who had managerial responsibility for overseeing this work, how it was carried out and what the outcome was. Other agencies found this confusing and the general ambiguity about who was doing 'safeguarding' work was clearly a problem. On one occasion it was assumed that a section 47 enquiry had been completed, which was incorrect.

Social work assessments were poor - as many other Serious Case Reviews have also found. Unfortunately, the skill base of the profession has become so impoverished by the introduction of bureaucratised practice that there may not be enough skilled social workers to support a move back to practice in which social workers have the confidence to use their professional judgement and make sound, well-balanced assessments.

The introduction of the social work degree in 2003 was meant to address these problems but in fact it has made them worse. There are now serious concerns that many newly qualified social workers are not equipped for practice and yet children's services are employing them because they have no alternative. It is madness that the profession has allowed a situation to arise where the least experienced social workers are often doing the most complex and emotionally demanding work.

Legal Context of Social Work Practice

The Children Act 1989 was the first piece of legislation to set out the duty of councils with regard to child protection and provides an excellent framework for practice. However, failings in child protection investigations apparent in the Victoria Climbie case were not addressed by the Laming Inquiry 2003 and continuing poor practice in this area contributed to further child abuse scandals. These problems were exacerbated by the introduction of the term 'safeguarding' in the Children Act 2004. The Act was poorly written and made it difficult to know when councils were failing to comply with the law. The official guidance 'Working Together', which attempted to clarify the law, was not fit for purpose because it included too much non-statutory guidance which inadvertently obscured important information about statutory requirements.

Formal Investigations into Abuse and Neglect

The social services department is the lead agency with regard to formal child protection investigations. It co-operates with the police if there are grounds for a criminal investigation but also has a duty to be proactive in gathering evidence of significant harm to a child and deciding whether there are grounds for care proceedings.

Top priority must be given to improving the system for dealing with child protection referrals. The root of the problem is the integration of the child protection investigation into the Common Assessment Framework. Difficulties often arise because of uncertainty about how to combine the dual roles of investigation and assessment of need.

Although much social work combines protection with support an investigation requires a different mindset on the part of the social worker similar to that for detective work. The style of working is very different from support work. It requires a greater level of detachment, a more probing approach and considerable skills in terms of tact, perceptiveness and sound judgement.

Not all social workers are suited to child protection investigations. It therefore is makes sense to give this work to experienced social workers who are comfortable with doing this type of work and are appropriately selected, trained and supported. The competence with which the investigation stage is handled will crucially influence the effectiveness of subsequent work.

Risk Assessment

Good assessment is a complex activity and includes the ability to understand the child's developmental needs while also being alert to concerns about potential harm to the child that may need further investigation. The introduction of the Common Assessment Framework was an attempt to develop a needs-led approach but unfortunately this has skewed social work practice away from thinking about the assessment of risk.

In my experience, risk assessment is an ongoing process, often based on 'evidence' gathered informally from working with the family over a period of time. However, it is sometimes appropriate to carry out a structured risk assessment after the creation of a child protection plan or during legal proceedings. An assessment guide can assist in this task by providing a comprehensive list of all the circumstances of the child and family that need to be explored, though it can be misused by social workers who simply treat it as a questionnaire. Intuitive understanding and logical reasoning are important social work skills in this work. At the end of the assessment the social worker should have a clear understanding of what is wong, what needs to change and how this might be achieved.

Tackling Anti-Social Behaviour

The Youth Offending Service provides a range of support services to tackle anti-social behaviour. However, when working with children who are very disturbed and repeatedly reject whatever help is offered there is a limit to what can be achieved. The underlying aim is to meet the developmental needs of the child and help parents establish more effective controls over the child's behaviour. If the family cannot be engaged in any meaningful way social workers may need to raise the tariff, using written agreements which spell out the consequences of failing to co-operate, and, if this fails, bring matters to court. However, as the age of criminal responsibility is ten, children under this age cannot appear in a youth court and no other sanctions are available.

In effect the system for dealing with anti-social behaviour in young children in Doncaster at that time was dysfunctional. The assault on two boys was preventable. The system lacked the authority to take the necessary action to remove the brothers from their home to a secure place for the protection of others. It is also evident, with hindsight, that the system was ineffective in meeting the brothers' needs for apropriate care and control.

In the past, social work approaches to preventing youth crime used a range of services, including residential care but now it seems impossible for workers to get outside the current orthodoxy which strongly opposes residential care. The education service rarely offers residential provision for the most disturbed and out of control children.

Further Analysis

Doncaster council made the mistake of regarding multi-agency work as 'safeguarding work' when social workers in these teams did not have a sound grasp of their legal duties and responsibilities. There was a blind faith in the benefits of various schemes to improve parenting and to promote the children's welfare.

The Munro Report made a similar mistake in wanting to shift the balance in social work from 'investigation' to 'support' without realising that serious failures have come from failures in 'investigation'. There should be greater recognition that some families will never respond to support and social workers should be more concerned with gathering evidence that may be used in court proceedings. Munro does not acknowledge that a formal investigation requires a very different way of working from that which social workers learn on their university courses.

Finally, questions must be asked about the huge expenditure involved in work that ultimately failed. A vast range of different projects and agencies worked with this family - e.g. the Family Intervention Project, Youth Inclusion Support Service, Youth Mentoring Scheme, Parenting Programmes, Safer Neighbourhood Team, and so on. If this money had been diverted to a more appropriate service, such as residential schooling, the outcomes would possibly have been better.

A pdf file of the Doncaster Safeguarding Children Board's Serious Case Review on the 'J' children can be downloaded from here.

Hilary Searing

A more detailed account of what is needed can be seen at:

The Urgent Need for Reform of Child Protection

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