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"It's everyone's job to make sure I'm alright"
Report of the Child Protection Audit and Review

Chapter 7: Findings from research and consultations

Comparing our findings with research findings
Lessons From elsewhere
Child deaths
Deaths of children and young people who are looked after
How children and young people could be better protected
Child Protection Committees
The Consultative Group
Key messages

7.1 So far in this report we have outlined the findings from the case audit and have considered the voices of children, parents and the public. In this chapter we draw together other elements of the review and summarise the findings.

Comparing our findings with research findings

7.2 Our sample of cases was comparatively small. It covered a wide range of issues from more minor concerns about a parent's temporary difficulties in coping with their child's behaviour to serious life-threatening cases of abuse and neglect. In drawing conclusions from these cases we have paid particular attention to how our findings fit with what is known about abuse and neglect from research and other reviews.

7.3 The reasons why children were not protected in our sample were similar to the reasons why children were not protected in other research studies. Many of the children in our sample and in previous studies expected the criminal justice system to protect them by convicting the abuser and delivering justice, but only a very small proportion of identified cases of abuse or neglect lead to a prosecution and even when cases do proceed to court there may not be a conviction (Wattam, 1997; National Commission of inquiry into the prevention of child abuse 1997; Grubin 1998; Scottish Executive Justice Department, Justice Statistics Unit court proceedings database). The small number of children in our sample who were involved in the court system indicated, as have children in other studies (Keep 1996; Goodman et al 1992) that the court process has a damaging effect on them. Where the abuser is not found guilty they feel they have not been believed and have endured a distressing experience 'for nothing'.

7.4 We found, as have previous studies and inquiries (Munro 1999; 1998; Social Services Inspectorate 1997; Department of Health 1991; Brandon et al 1999; Hill 1990; Greenland 1986; Ibbetson 1996; Sinclair and Bulloch 2002):

• lack of information sharing across and between agencies;
• poor assessment processes;
• ineffective decision making;
• poor recording of information; and
• lack of information on significant males;

contributed to many children not being protected.

7.5 We also found, as have other studies that some children experience further neglect or abuse after they come to the notice of child protection agencies (Department of Health 1995; Hobbs and Hobbs 1999; Hamilton and Browne 1999; Waterhouse et al 1998). Where children are known to child protection agencies and are 'in the system' there is still no guarantee that they will get the help they need. Only a quarter of children in our case audit received such help and this appears to be a widespread problem (Gray et al 1997; Sharland et al 1995; Farmer and Owen 1995). It is possible, however, that the outcomes for children might have been worse without child protection involvement. It might also be that, through contact with child protection agencies, children are more readily identified a second time as having been abused or neglected than if they had never had any contact.

7.6 The lack of confidence children have in the child protection system is UK wide. Children are more likely to speak to friends and relatives than professionals when they need help (Cawson et al 2000; Cawson 2002).

7.7 In line with other research studies (Green and Mason 2002; Gray et al 1997), we found that the needs of child perpetrators are particularly neglected. Like other studies (Sharland et al 1995; Cleaver and Freeman 1996; Platt 1996; Shemmings and Shemmings 1996; Thorburn et al 1995) we found that parents' needs were not always met in that they felt they were not kept sufficiently informed of the progress of the investigation or case. We found that the systems of support for foster carers, particularly family carers, were weak. The Sykes et al (2002) large scale study of foster carers came to similar conclusions.

Lessons From elsewhere

7.8 In order to assist our thinking about what might be the best way to improve services for children who have been abused or neglected we commissioned a seminar of international speakers. A number of papers were presented on different approaches to dealing with abuse and neglect. An overview of the issues highlighted and discussed at the seminar is provided in Appendix B.

7.9 Whilst different countries approach child abuse and neglect and child welfare differently, there are two distinct approaches emerging in the Western world. One approach is exemplified by Canada and Australia (and also the United States and England) and the other by Sweden, Belgium, France, Italy and Germany.

7.10 The Australian/Canadian approach distinguishes between children who are at risk and those in need. There is a strong emphasis on establishing whether an incident is abusive and who the perpetrators are so there is much evidence gathering, investigation and assessments of risk.

7.11 There is a presumption of protecting family life and parents' rights but, in high-risk cases, child protection is the primary concern and this is achieved through high levels of intervention or removal from home. The harm or risk threshold for intervention in a family's life tends to be high. Systems and procedures have been developed to manage this approach including the development of risk assessment tools as the means to screen children away from statutory intervention. The courts have a significant role in decision making and the court system follows an adversarial tradition.

7.12 Children who are in need but are not considered to be at risk are generally provided for on a voluntary basis, often by the voluntary sector, and there are programmes of early intervention to prevent child maltreatment. The services in this sector are increasing.

7.13 The continental Western European approach tends not to differentiate so strongly between risk and needs. Children and their families are provided with help as part of the state's package of welfare to all children and families who need it. There is no child protection system as such, rather, families in difficulty are encouraged to seek voluntary help and there is a strong commitment to birth family preservation. For example, adoption for older children does not exist in France as an option if children cannot be cared for by their parents. The system is reliant on the skilled helping relationship between the professional (social worker, doctor, child psychiatrist) and children and their families. There are few systems or processes to be followed and meeting need or protecting children is dependent on individual professional judgement. Where cases of abuse or neglect are investigated, this is a role for the police and there is a clear separation between this and the helping role of the social worker or medical practitioner. Those parents that cannot or will not change will come within the more formal court-based systems. These are inquisitorial and conducted by specially trained children's judges. The focus on consensus and negotiation remains and removal of children from their families is not generally considered.

7.14 Children can receive services in their own right. Professionals can work with children in confidence. They are not required to pass on information about abuse and parents do not need to be told that their child has requested or is seeking a service.

7.15 There are benefits and disadvantages to the two approaches. The Australian/Canadian approach enables greater consistency between practitioners and means families are able to care for their children without interference unless it is necessary to protect the child. It also enables some attention to be given to prosecuting abusers and thereby protecting other children. It does not, however, focus attention on meeting children's needs and the thresholds of intervention are so high that there may be significant harm caused before help is provided. Some of these problems are offset by the provision of voluntary help. The system is stigmatising and parents do not willingly become involved in it. Staff turnover is high and there are indications that staff find the approach unfulfilling.

7.16 The continental Western European model is highly dependent on good professional skills and consistency is achieved through training rather than guidance or procedures; practice, therefore, may be variable. Practitioners continue to work in a negotiated way with families and abuse may continue whilst this approach is being pursued. Offenders may not be prosecuted and may be free to offend again within their own family or with other families. Whilst the system is avowedly child-focused the needs of the parents are given particular attention and children's needs may get lost in resolving parental problems. In those cases where parents cannot or will not respond, alternative arrangements are needed and measures of compulsion may be required. Families in difficulty view the approach as helpful, and abusive or neglectful parents more willingly accept help and change behaviour. More children and families are offered and accept help. Staff working in the field of child care are well motivated, are held in high esteem in their communities and turnover and 'burnout' is low.

England and Wales

7.17 The approach in England and Wales is consistent with the Australian/Canadian approach although there are some significant differences.

7.18 In England and Wales the 'Quality Protects' programme of improving services to children is at the centre of reducing abuse and neglect. As part of the programme for modernising and improving services for children a 'Framework of the Assessment of Children in Need and their Families' has been developed and has been implemented in every local authority. The Framework is intended to be a multi-agency tool for assessing the needs of children and responding to them, bearing in mind the needs of the child, the child's environment and parental capacity. Along with the framework, training and research findings have been produced in order to encourage a more evidence-based approach to practice.

7.19 A further development in England and Wales has been the development of 'Serious Case reviews'. As part of the Quality Protects initiative, the previous 'Part 8' child protection committee reviews of deaths of children on the child protection register were redeveloped under new guidance as Serious Case reviews. New guidance was issued in 1999 on the conduct of reviews of child deaths and serious injuries in cases of suspected abuse and/or neglect. The focus of the reviews is an analysis of agencies' practice and lessons learned.

7.20 More recently guidance has been issued on the conduct of criminal investigations into abuse, particularly in complex cases. New inter-agency guidance has been issued. The guidance states that in complex cases such as cases of sexual abuse occurring in schools or care homes, a multi-agency approach to the investigation should be put in place from the outset involving the police, social work and appropriate experts such as lawyers and psychologists. The planning and process of the investigation should conform to certain standards and there should be a consistent approach which protects the welfare of children and vulnerable witnesses but also takes account of the need to protect the rights and privacy of alleged abusers. The guidance covers the approach to investigations and their management, managing and sharing information, dealing with the media, support for staff and legal issues. Whilst the police and social work have always undertaken the joint investigation of certain cases, this guidance strengthens the approach and takes a multi-agency strategic approach to the investigation from the outset.

7.21 In Scotland, Lothian and Borders Police, in partnership with other agencies, has developed guidance for local use on historic abuse and this is currently being considered by ACPOS and ADSW for use nationally.

Child deaths

7.22 During 1999 there were a total of 57,799 deaths in Scotland. Of these 231 were boys under 16 and 216 were girls under 16 years of age. The majority of these deaths were health related (358), however, a number related to road accidents (25), fires (7), suicides (24) and Sudden Infant Death Syndrome (33). ⁵

7.23 While the UK's overall road safety record is good, our record on child pedestrian safety is one of the worst in Europe, with a death rate that is double Germany's. More than 130 children die in Great Britain each year and over 4,500 are seriously injured while walking or cycling, and two thirds of all accidental deaths for the 5-19 age group are due to road accidents. Children from more deprived homes are more likely to be killed as pedestrians than those from wealthier households.

7.24 In the year 2000, 20 male and 13 female children were recorded as dying from Sudden Infant Death Syndrome in Scotland. A small number of these deaths may have been caused by maltreatment or very poor care. High profile prevention campaigns have been effective in reducing such incidents.

7.25 Death by fires or drowning are sometimes a consequence of leaving children unattended and parents being under the influence of drink or drugs can be a contributory factor in deaths by fire.

7.26 Young males are twice as likely as young females to commit suicide; and many more children attempt suicide or harm themselves deliberately.

7.27 Clear information about the deaths of children is difficult to obtain as statistics are collated and classified in a number of different ways by different bodies:

• information about Fatal Accident Inquiries (FAI) in Scotland, some of which relate to children, is held on 40 local databases;
• some statistics are recorded on a United Kingdom basis, for example, deaths involving fire; other statistics relate only to children under the age of 16 rather than 18; and
• the International Classification of Diseases (ICD) System for coding all deaths does not identify possible child abuse or neglect cases. For example, malnutrition is noted as a cause of death but not how it occurred. Deaths of very ill children may also be identified only as dying from causes relating to their illness whilst, in some cases, abuse, neglect or inappropriate restraint may have been a contributory factor.

7.28 Some deaths of children are reviewed in Scotland. The Procurator Fiscal is responsible for the investigation of all sudden, suspicious, accidental, unexpected and unexplained deaths. The deaths which must be reported to the Procurator Fiscal include : any death of a child from suffocation including overlaying; any death which may be categorised as due to sudden death in infancy syndrome or sudden unexplained death in infancy (SUDI); and any death of a foster child, a child in the care of a local authority or on an "at risk" register.

7.29 If a death is notified to the Procurator Fiscal, he or she will decide whether to make any further investigations into the circumstances surrounding the death. Once these further inquiries have been carried out the decision may be taken to raise criminal proceedings or to request a Fatal Accident Inquiry (FAI).

7.30 An FAI is a public inquiry into the circumstances of a death, where evidence will be lead by the Procurator Fiscal and any interested parties may appear or be represented. At the end of the inquiry, the Sheriff will make formal findings setting out: where and when the death and any accident from which it resulted took place; the cause(s) of the death and any accident from which it resulted; the reasonable precautions, if any, whereby the death and any accident from which it resulted might have been avoided; the defects, if any, in any system of working which contributed to the death or any accident from which it resulted; and any other facts which are relevant to the death. The Sheriff has no power to make any finding as to fault or to apportion blame.

7.31 Suspicious deaths are investigated by the police and may result in a prosecution of those thought to be culpable. In some cases there are public inquiries, internal agency reviews or reviews commissioned by Child Protection Committees into the role of professionals following the death or serious injury of a child. The Scottish Executive reviews the deaths of all children who are looked after by local authorities.

Child death review teams

7.32 Elsewhere in the world, most notably in Australia and North America, there are systematic reviews of all child fatalities including deaths from road traffic accidents and health-related causes. The aim of such reviews is to learn from them and develop methods of reducing child deaths, from whatever cause. The teams identify hazards that may place other children at risk from neglect, abuse, violence or unintentional injuries. The teams comprise representatives from medicine, law enforcement, public health, social services, education and other relevant agencies. This information is used to prioritise and focus prevention activities and not to establish blame.

7.33 Evidence of their effectiveness is noted in the NSPCC Report Out of Sight 2001, the level of preventable deaths reducing by as much as 16% in some states. The report noted that the risks to children in America are similar to those in Great Britain although deaths from firearm incidents are at a much higher level in the United States.

7.34 In England and Wales Child Protection Committees have a statutory responsibility to undertake reviews of the role of professionals in cases of child deaths or serious injury where there are concerns about possible abuse or neglect. Some Child Protection Committees in Scotland have developed guidance and pilot arrangements for reviews of child deaths where abuse or neglect may be a contributory factor.

7.35 The purpose of Child Death Review Team reviews is to:

• establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children;
• identify clearly what these lessons are, how they will be acted upon, and what is expected to change as a result.

In the UK child death reviews, where they occur, are not investigations into how a child died or who is culpable. Those are matters for Fatal Accident Inquiries and the courts. Similarly, any disciplinary action against staff is a matter for individual agencies.

Deaths of children and young people who are looked after

7.36 The review team carried out an analysis of the circumstances of 50 looked after children who died between 1997 and the end of 2001. Children and young people are looked after by local authorities when they are provided with accommodation, subject to a supervision requirement or subject to a legal order, such as a child protection order or a parental responsibilities order from Scotland or another UK country. When a looked after child dies local authorities are required to submit a report to the Scottish Executive within 28 days. The report is expected to cover the medical and social history of the child and an account of the circumstances of the death. The Scottish Executive is empowered to:

• examine the arrangements made for the child's welfare when the child was looked after;
• assess whether action taken or not taken by the local authority may have contributed to the child's death;
• identify lessons which need to be drawn to the attention of the authority and other agencies; and
• review legislation policy, guidance, advice or practice in the light of a particular case or any trends emerging.

7.37 Young people who are looked after have revealed to researchers that they do not always feel safe. They have revealed that they are at risk of physical, sexual or racial abuse, or at risk of misusing alcohol or drugs, self-harming behaviour or prostitution (Who Cares Scotland). Looked after children have a higher mortality rate than other children. In 2000 there were 478 child deaths out of a total child population in Scotland of 1,062,140, a mortality rate of 0.04%. In the same year 15 looked after children died out of a total population of 11,309, a mortality rate of 0.13%.

7.38 Nearly half (24) of the 50 children whose deaths were analysed were accommodated at the time of their death, most living with foster carers, and 11 of the children had been on the child protection register at the time of their death. In six of the 50 cases the cause of death was related to pre-existing life-threatening illnesses and in a further 14 cases the cause of death was primarily health-related (although two cases were determined to be the result of Sudden Infant Death Syndrome (SIDS) and a further two were related to the young person's drug use and were self-harm related.

7.39 Of the remaining 30 deaths:

• 11 were suicides;
• 10 were drug, solvent or alcohol-related (often as the result of inhaling stomach contents);
• 6 resulted from road accidents;
• 2 were caused by drowning; and
• 1 was a murder.

7.40 The analysis of the social work and health reports undertaken by the Social Work Services Inspectorate and medical advisors indicated that in some cases more could have been done to protect the children. There were some concerns about medical practice. The lack of mental health services for children and young people with challenging behaviour who demonstrated high levels of reckless or self-harming behaviour was also noted.

• In one case of hanging, preventative measures had not been put in place following a previous suicide attempt.
• In an alcohol/drug-related death, poor home leave planning, lack of residential staff skills in this area of work and issues of staff cover when shifts were changing were noted.
• A young child who drowned was in the care of an elderly temporary carer who was unable to 'keep up' with the child. There was no prospect of the child being returned to his birth family and suitable long-term arrangements were needed.
• In the case of one child who died of SIDS, a child protection case conference held pre or post birth would have addressed the parenting capacity of the child's family.

How children and young people could be better protected

7.41 Children and young people, parents, other adults and professionals presented to the review team their views on how children and young people could be better protected. Their views are outlined in Figure 8.

Child Protection Committees

7.42 A review of Child Protection Committees (CPCs) was undertaken in 2000 (Scottish Executive 2000b). The report concluded that CPCs were viewed by members as being effective when:

• identifying and promoting inter-disciplinary training;
• ensuring inter-agency liaison;
• promoting and developing inter-agency guidelines; and
• promoting good inter-disciplinary practice.

They were less effective in:

• inter-agency reviews of local child protection practice;
• assessing case enquiry issues;
• development of local preventative strategies; and
• reviewing availability of expert advice.

7.43 The findings of this review indicate that the situation remains broadly the same. Child Protection Committees continue to focus on training, co-operation and guidance and pay less attention to quality or practice issues. Recently, a few committees have developed and implemented programmes for community awareness raising and preventative strategies. Others have developed mechanisms for reviewing cases and inter-agency work and two committees have begun to develop approaches to reviewing the deaths of children.

7.44 The review of Child Protection Committees noted that lack of specific resources and lack of senior representatives on the committees were seen as major barriers to taking work forward. A number of respondents felt the committees had little impact on practice although the indirect benefits of training were recognised. Few respondents wanted radical changes to CPCs, other than that they be placed on a statutory footing with more stable funding. The review concluded that improvements could be made within the current structures and guidance should be revised to strengthen the role of CPCs without placing them on a statutory footing. Some work on revising the guidance commenced but has since been suspended awaiting the conclusion of this review of child protection.

7.45 During our work we met with the chairs of Child Protection Committees. They saw a significant role for committees in the future. Child Protection Committee chairs saw scope for:

• a more systematic review of practice;
• better supervision for case workers across agencies;
• improved communication over children at risk with Accident and Emergency departments
• a training budget;
• a national campaign to improve public understanding of child protection;
• further guidance on confidentiality issues.

7.46 They thought that improvements were needed in the services provided for particular groups of children - those affected by drug using parents, neglect, disability and those in need of psychiatric help.

7.47 There were concerns about the lack of national consistency in respect of child protection guidance and also other matters such as training and awareness raising. Each committee acted independently of each other following their own agendas but valued the opportunity to discuss issues together on a national basis. This review has been the major focus of the group's discussions during the past year and their early contributions informed the process of the case audit.

7.48 Some Child Protection Committees have initiated inquiries when children known to statutory agencies or children on the child protection register have died or have been caused serious injury. A small number have also recently established local procedures and guidance in order to undertake such inquiries should the need occur. Chairs of CPCs have indicated that they would welcome a statutory responsibility for inquiries into incidents of concern and guidance on how these might be properly conducted.

The Consultative Group

7.49 The consultative group tackled, in a structured way, a number of difficult inter-agency issues.

Confidentiality

7.50 Mixed views were expressed about confidentiality. Some members of the Consultative Group, usually those working in the statutory sector, thought all allegations of abuse and neglect should be passed on to statutory agencies to deal with. Some thought there should be 'mandatory reporting' in Scotland as there is in some other countries. Others, most often those working in the voluntary sector, thought that increasing access to confidential services would enable more children and their parents to get help.

7.51 It was acknowledged that confidence in the statutory sector might be improved if referrers, children and parents had more control over the timing and type of child protection investigations and proceedings. There was some support for professionals taking 'a space for negotiation' - pausing after receiving a referral to consider the best way forward for the child, taking account of his or her views and, where appropriate, the views of parents.

7.52 This would allow parents who were harming their children or thought they were at risk of doing so to negotiate with agencies who could help them, through counselling or change programmes, a period of help without their children being automatically reported as being in need of protection. Similarly some professionals would like a 'space' in which to consider with other colleagues from their own or other disciplines how to approach certain problems without automatically following a child protection route.

7.53 Organisations representing children and young people advised us that young people were extremely concerned about the extent of information sharing between agencies and the erosion of their privacy whilst those working in the statutory sector advocated greater sharing of information about children and their family circumstances.

Race and cultural issues

7.54 The consultative group felt that the statutory agencies and a number of the voluntary agencies did not serve the needs of children or families of minority ethnic origin well.

7.55 Practitioners were concerned that they did not always understand different child-rearing practices and they were unsure whether some behaviours such as physical chastisement, care of young children by older children, and under-age marriage/pregnancy were abusive. They were also concerned about the lack of culturally and racially appropriate services and the lack of people with sufficient knowledge of both minority ethnic issues and child welfare and protection in Scotland to provide appropriate training for organisations. Access to appropriate interpretation services was identified as a particular issue of concern.

Empowerment and 'whistle-blowing'

7.56 The consultative group were concerned that less senior staff in organisations, for example, cleaners in hospitals and dinner staff in schools might not be properly trained to deal with concerns or suspicions that they might have about a child. They felt that better information for the general public about child protection processes would improve understanding of what happens after referral and perhaps enable people within organisations to feel more confident about making referrals. They felt the public also need information about action taken after a referral is made so that they could be assured their concerns were being taken seriously.

7.57 The consultative group felt that staff might be dissuaded from raising their concerns about agency or individual practice due to an existing culture of 'not seeing' abuse or because they were worried about what might happen to them or to a child if they disclosed abuse. They felt some staff might not feel able to report more senior colleagues or might not be aware that some behaviour they witnessed constituted abuse because they may not have had any training on the matter. The group felt that positive guidance on how concerns should be addressed and which explained the systems of support available to 'whistle-blowers' would help to create a culture that was child-focused and did not support abusive behaviour.

Performance indicators

7.58 The consultative group asked whether 'protecting children' was about:

• Reducing the number of children who died or were seriously harmed and did this include all children, for example, those killed in car accidents?
• Reduction of abuse and neglect across the whole population or in cases where this had already been identified?
• Improvement in the wellbeing of all of Scotland's children or those who had been identified as being 'in need'?

7.59 They felt that objectives for child protection should be built into children's services plans and be owned by all the agencies with a responsibility for improving the welfare of children. They thought it was important to have national goals and objectives as there was a danger that individual agency objectives might not be in the interests of children overall. There was some support for process performance indicators, for example, the length of time taken for a case to be finalised at a Hearing or court, but it was felt that such indicators should be secondary to establishing whether outcomes for children had improved. They felt that quality indicators such as the new National Care Standards and the How Good is Our School? indicators could help raise the quality of practice and felt similar indicators should be developed in child protection work.

7.60 There was concern that some performance measures were unhelpful. For example, the group pointed out that if an aim is to reduce the number of children on the child protection register this might lead to children being taken off the register prematurely. The need to reconcile different objectives was also pointed out. For example, a successful child protection agency might be one that generates high levels of child protection referrals while a very successful national child protection strategy might reduce overall levels of abuse and neglect and referrals to agencies.

7.61 The consultative group felt that existing targets which relate to the physical and intellectual wellbeing of children, for example:

• reductions of deaths on the roads;
• reductions in infant mortality;
• increases in educational attainment; and
• reductions in levels of poverty

might better indicate the extent to which children are being protected and their needs met than indicators specifically relating to child protection.

Key messages

• The findings of the case audit bear close resemblance to the findings of research studies and other reviews which have looked at child abuse and neglect.
• No country has found the solution to child abuse and neglect but there is much that can be learned from how other countries tackle the issue.
• More could be done to improve the safety of looked after children.
• Members of the public, children and professionals all believe that everyone has a part to play in protecting children.
• Professionals working in the field of child protection have identified a number of areas where improvements could be made.

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