Tags: safeguarding

Our new Safeguarding Supervision Champions Training Programme – booking now

Safeguarding supervision should provide a structured discussion between supervisee and supervisor to support and advise on specific complexities and challenges within their caseloads. For safeguarding supervision to enhance safeguarding practice, accountability and responsibility is targeted to the organisation, the supervisor, and the supervisee – with the aim to develop competent, confident, professionally curious practitioners who work across all relevant agencies to support the best interests of a baby/child/young person/individual and their families. 

This education, learning and development programme will enable participants to become Safeguarding Supervision Champions to promote the purpose of authentic safeguarding supervision, and for them to become place-based leaders in raising awareness of its relevance with peers/colleagues as well as within their organisations. 

Dr Michelle Moseley, iHV Director of Programmes, who developed our exciting new Safeguarding Supervision Champions Programme, said:

Dr Michelle Moseley, iHV Director of Programmes

“Drawing on my experience as a lead nurse in safeguarding children and as an SCPHN (Health Visitor) Educator, I have seen first‑hand the emotional and professional pressures faced by health visitors and practitioners working with babies, children and families. Safeguarding supervision plays a vital role in supporting those at the frontline, particularly in an increasingly complex and demanding working environment. It provides a protected and trusted space where practitioners can slow down, reflect, and make sense of difficult and often distressing situations.

“This education programme was developed from my own professional experiences, alongside a pilot study and my doctoral research, which took an ethnographic approach to capturing the everyday realities of health visiting practice. My PhD explored how effective safeguarding supervision offers consistent emotional and professional support for practitioners managing high‑risk and sensitive work. The research findings revealed a clear need for improved training for supervisors and for safeguarding supervision to be prioritised across organisations. Strengthening this support helps ensure health visitors feel valued, confident and equipped in their role to protect children and support families.”

Marcia Smikle, Queen’s Nurse, Head of Safeguarding Children at Homerton Healthcare NHS Foundation Trust and iHV Expert Adviser: Safeguarding, said: 

Marcia Smikle

“The Institute of Health Visiting is strengthening safeguarding supervision for health visitors through its Safeguarding Supervision Champions programme. This is in recognition of the key public health role and responsibilities that health visitors have in the early identification of need and support they provide to vulnerable children and families.  The current workload demands placed on health visitors should not be underestimated. High-quality supervision is essential and provides the opportunity for reflection on self and practice – ensuring that health visitors can make confident, well-informed safeguarding decisions.” 

The wellbeing of health visitors dealing with the complexities of safeguarding practice is paramount to prevent feelings of being overwhelmed and carrying the burden of the safeguarding of families outside of the working day. It is important that safeguarding supervisors have the necessary training to equip their supervision practice.  

Our champions model of training will allow the Safeguarding Supervisors to share best practice, evidence, research, and have a safe space to discuss their own practice experiences. Therefore, as part of this new education programme, we are delighted to set up a Safeguarding Supervision Champions Forum to meet bi-annually.  

Liz Plastow, Safeguarding Consultant and iHV Fellow, commented:

Liz Plastow

“Are you passionate about protecting babies and children from harm and suffering?If so, this training is for you!  

“It will equip you to champion safeguarding supervision in your workplace. Providing you with a range of evidence-based skills, models and strategies to strengthen safeguarding supervision, which in turn will support your colleagues to protect those in their care. You will get the opportunity to learn from others and to cascade that learning throughout your profession. 

“Do feel free to contact Dr Michelle Moseley for more details. We look forward to you joining us!“

Find out more and how to book your place on our new Safeguarding Supervision Champions Training Programme

Or contact [email protected] to find out more.

Read Dr Michelle Moseley's Voice blog: “Full to the brim” – the importance of effective safeguarding supervision education

Introducing our new Safeguarding Expert Adviser

The Institute of Health Visiting (iHV) is delighted to announce the appointment of Marcia Smikle as our new Safeguarding Expert Adviser. 

Marcia brings exceptional knowledge and experience to this role, with a distinguished career across nursing, midwifery, and health visiting. She holds a BSc in Health Studies and an MSc in Nursing and is recognised as a Queen’s Nurse for her commitment to excellence in care. Alongside her clinical expertise, Marcia is a Visiting Lecturer at City St George’s University of London, where she teaches on the Public Health and Specialist Community Nursing programmes. 

Currently, Marcia is the Head of Safeguarding Children at Homerton Healthcare NHS Foundation Trust and an active member of the City and Hackney Safeguarding Children Partnership. Her work has championed diversity and equality, including establishing a BME Staff Network and developing award-winning services. She has also served as a registrant panellist on Fitness to Practise Panels with the Nursing and Midwifery Council. 

A passionate advocate for vulnerable children whose voices are often unheard, Marcia is committed to learning, sharing knowledge, and encouraging colleagues to do the same. We feel very privileged to have Marcia join our growing group of Expert Advisers to support the work of the Institute.  

Commenting on her appointment, Marcia said: 

“Health visitors play a vital role in protecting the health and wellbeing of children, families, and communities. I look forward to championing and embedding safeguarding practice that is equitable, anti-racist, and culturally competent. Because every child deserves to grow up safe, seen, and supported. Together at the iHV, we can make a real difference in the lives of children and their families.”

Marcia will work alongside Trish Stewart, iHV Expert Adviser for Safeguarding, to strengthen the iHV’s capacity to influence policy and practice in the crucial area of safeguarding.

Opportunity to join our team as an iHV Expert Adviser for Safeguarding

The Institute of Health Visiting (iHV) is seeking the right person to join our team as an Expert Adviser for Safeguarding – a unique voluntary opportunity to shape national health visiting practice, influence public health policy, and improve outcomes for babies, children, and families across the UK. 

Our team of iHV Expert Advisers play a critical role in: 

  • Representing the experiences and challenges faced by health visitors across the UK. 
  • Providing expert guidance and insight to the iHV’s work. 
  • Supporting the development of evidence-based practice, policy, and guidance. 

All our iHV Expert Adviser positions are voluntary roles, and there are many personal and professional benefits to the role: 

  • Work with the UK’s leading professional body for health visiting: with opportunities to contribute to the iHV mission and expand your professional network.  
  • Shape iHV policy and influencing national policy: engage in national forums as a representative of the iHV and help to guide decisions using your expertise. 
  • Professional development: Expert Advisers work closely with iHV staff, Senior Leadership team and external stakeholders, offering valuable experience, shared expertise and support to enhance your development, impact and visibility.  
  • Recognition and professional credibility: you will be publicly recognised as an “iHV Expert Adviser” and may be featured in blogs, news updates and iHV media work, highlighting your contributions to health visiting and public health. 
  • Collaborating with other leading experts from across the UK: utilise opportunities to network and share best practice, evidence and research. 

What are the eligibility criteria?   

  • You are a member of the iHV based in the UK. 
  • You are a health visitor with relevant preventative public health and topic-specific expertise – you are recognised as a leader in your field of expertise. 
  • We are particularly keen to receive applications from people from all sections of the community, including people with protected characteristics.  
Please see the Terms of Reference for person specification criteria

How to Apply 

Download the iHV Expert Adviser expression of interest form

Download the Terms of Reference

iHV co-signs letter to Rt Hon Jess Phillips MP

iHV joins several leading organisations in co-signing The For Baby’s Sake Trust’s open letter to Rt Hon Jess Phillips MP, Minister for Safeguarding and Violence Against Women and Girls. The letter calls for babies and very young children to be explicitly recognised within the government’s Violence Against Women and Girls (VAWG) Strategy.

Read the letter here.

Every year, more than 50,000 babies are referred to children’s social care with domestic abuse as a factor. This is not just a statistic; it represents tens of thousands of the youngest members of our society growing up in homes where abuse can shape their earliest experiences.

Why babies must be included 

Domestic abuse does not just begin when children are older. Research shows that:

  • 30% of domestic abuse begins or escalates during pregnancy
  • This rises to 40% in the first 1001 days of life (pregnancy through to age two)
  • By the time children start school, at least one child in every class will have been living with domestic abuse since birth

Babies are uniquely vulnerable. Their brains and bodies are developing at an extraordinary speed, and exposure to abuse during this period can have devastating, lifelong consequences. Without early intervention, the ripple effects can include:

  • Delays in physical and cognitive development
  • Long-term impacts on emotional and physical health
  • Missed educational opportunities
  • The perpetuation of intergenerational cycles of abuse

If the government is to succeed in its mission to halve violence against women and girls within a decade, it must begin by protecting those who are most vulnerable – babies in their earliest days of life.

A call for urgent action  

The open letter urges the government to ensure that support for families during pregnancy and early childhood is embedded in the VAWG Strategy. This is essential if the government’s wider ambitions, including the Best Start in Life Strategy, are to be realised.

Babies deserve the best start in life. Protecting them from violence and harm is not only a moral imperative but also a vital step in breaking cycles of abuse and building a safer, healthier society for generations to come.

Read the letter

Letter Co-signatories:

Opportunity to join our expanding team as an iHV Expert Adviser

We are delighted to announce that we are looking to expand our team of iHV Expert Advisers, with a focus on two important areas of health visiting practice: safeguarding; and infant feeding. As an iHV Expert Adviser, you will use your expertise and be at the forefront of shaping the future of health visiting practice, supporting every baby, child and family to have the best possible start in life.

These appointments will join our growing team of iHV Expert Advisers who play a critical part in representing our health visiting member experiences and providing expert guidance and constructive challenge. This ensures that the iHV’s decisions and policy positions are rooted in current practice and evidence. The iHV Expert Adviser role is instrumental in addressing the increasing complexities faced by families and the health visiting workforce.

Kirsty Jacques, iHV Expert Adviser: SEND, commented:

“For me, being the iHV SEND Expert Advisor is pure pride — a chance to pour my passion into something bigger than myself. It brings joy knowing the work I do can grow from local ideas to national change, lifting up families, children, and the colleagues who stand beside them”

All our iHV Expert Adviser positions are voluntary roles, and there are many personal and professional benefits to the role:

  • Work with the UK’s leading professional body for health visiting: With opportunities to contribute to the iHV mission and expand your professional network.
  • Shape iHV policy and influencing national policy: engage in national forums as a representative of the iHV and helping to guide decisions using your expertise.
  • Professional development: Expert Advisers work closely with iHV staff, Senior Leadership team and external stakeholders, offering valuable experience, shared expertise and support to enhance your development, impact and visibility.
  • Recognition and professional credibility: You will be publicly recognised as an “iHV Expert Adviser” and may be featured in blogs, news updates and iHV media work, highlighting your contributions to health visiting and public health.
  • Collaborating with other leading experts from across the UK: utilise opportunities to network and share best practice, evidence and research.

What does an iHV Expert Adviser role involve?

The role of iHV Expert Adviser (using their area of expertise) offers a unique opportunity to influence public health policy and practice at a national level. Advisers collaborate with a network of professionals and contribute to initiatives that directly impact the wellbeing of babies, children, and families. Please see the Terms of Reference (TOR) links below for more information.

What are the eligibility criteria? 

  • You are a member of the iHV whose mailing address is in the UK.
  • You are a health visitor with relevant preventative public health and topic-specific expertise – you will be recognised as a leader in your field of expertise.
  • We are particularly keen to receive applications from people from all sections of the community, including people with protected characteristics.

See Terms of Reference (TOR) for person specification criteria:

  • Click here to view the TOR for the Safeguarding Expert Adviser role
  • Click here to view the TOR for the Infant Feeding Expert Adviser role

How to Apply

Download the iHV Expert Adviser expression of interest form

Download the TOR for the Safeguarding Expert Adviser role

Download the TOR for the Infant Feeding Expert Adviser role

Safeguarding reviews “silent” on needs of Black, Asian and Mixed Heritage children

A new report highlights failures to recognise the safeguarding needs of Black, Asian and Mixed Heritage children, revealing limited attention to race, culture and ethnicity in reviews of practice. This meant that the safeguarding needs of Black, Asian and Mixed Heritage children were often overlooked in child protection.

The Child Safeguarding Practice Review Panel (CSPRP) has published a report which focuses on 53 children from Black, Asian and Mixed Heritage backgrounds who died or were seriously harmed between January 2022 and March 2024. These children were subject to horrific abuse, including sexual abuse, fatal assault and neglect, with 27 children tragically dying as a result.

The report aimed to explore the unique safeguarding needs of children from these ethnic backgrounds and assess how agencies intervened to protect them in time. It uncovered a significant “silence” to address race and racism in child safeguarding, with many local areas neglecting to consider the impact of race, ethnicity, and culture.

The overarching aim of this report was to identify and analyse how these issues are seen and addressed to identify both good or emerging practice, and areas for learning and improvement in multi-agency safeguarding practice. The key findings from the report include:

  • Limited attention to race and ethnicity: Reflection on practice lacked necessary critical analysis, depth, and detail which meant that identifying learning and good practice was challenging.
  • Silence about racism: The safeguarding needs of Black, Asian and Mixed Heritage children and families were too often rendered invisible in both practice and the system for learning from reviews.
  • Missed Opportunities: There are too many missed opportunities in practice and in our system of learning about incidents when children have been seriously harmed or died. This can leave children vulnerable, at risk of harm, and without the support and protection that they need.

The report recognises that everyone will have their own experiences of making sense and addressing race, racism and racial bias which may affect confidence in identifying and confronting matters relating to these issues. The report highlights how we all have a professional responsibility to take ownership of developing our own confidence and capacity to address these important issues effectively. The need for good support and challenge from our teams and leaders were also recognised as being important, so that these issues can be explored together and where critical discussions are welcomed and normalised.

Georgina Mayes, iHV Health Visiting Professional Lead (Quality and Policy), said:

“This report highlights a deeply concerning silence around race and racism in child safeguarding. To ensure we protect all babies and children, it’s imperative that we acknowledge the specific risks and barriers faced by Black, Asian, and Mixed Heritage children. As health visiting professionals, it is crucial that we address racism and racial bias, and listen to families, to ensure every baby and child receives the support and protection that they need.”

The report shared some reflective questions which are helpful in prompting consideration of health visiting practice when engaging children and families from Black, Asian and Mixed Heritage backgrounds:

  1. As a practitioner, how can you feel empowered to have conversations with children and families about race and identity, particularly when you are working with individuals from different cultural and ethnic backgrounds to your own?
  2. As a practitioner, how confident are you that, when engaging with children, you consider all aspects of their identity and how these may intersect to influence risk and vulnerability? If you don’t feel confident, why might this be the case?
  3. As a practitioner, do you feel confident that you understand the impact of race, culture and ethnicity on children and families, and on their experiences? If you don’t, what may explain a lack of confidence in this area? How do you explore this with children and families and create opportunities and spaces for them to discuss its impact?
  4. How do you ensure you are self-reflective about your own biases when working with children and families from diverse cultural and ethnic backgrounds? How is this supported on an individual level, and within teams?
  5. How can you be supported to effectively respond to the diverse communication needs for children and families, particularly when considering national issues concerning the availability and accessibility of interpreters and interpretation services?

The overarching recommendations from this report include:

  • Safeguarding partners to consider the learning from this report and the reflective questions (see the report for further detail on the reflective questions from a system and leadership perspective).
  • Safeguarding partnerships to carefully evaluate their current partnership work and identify what further development is needed in learning reviews, and multi-agency safeguarding practice, to address and respond to issues of race, racism and racial bias.
You can read the full report here

Independent Child Safeguarding Practice Review Panel’s annual report 2023 to 2024

Today, The Independent Child Safeguarding Review Panel has published its annual report which consolidates the learning from serious incidents where children have died or suffered serious harm. Each case represents a child whose life was cut short or seriously harmed. Many were abused or neglected, inside and outside their families – the learning contained in this report cannot change the past, but it has the potential to change the future.

The findings and recommendations will be relevant for all health visiting practitioners, managers and system leaders – they help us to make sense of what happened to these children and consider how we can improve the ways that we work to protect children in the future.

The report identifies national patterns in practice through analysis of 330 serious safeguarding incidents (Serious Incident Notifications (SINs)) which occurred between 1 April 2023 and 31 March 2024, and 82 Local Child Safeguarding Practice Reviews considered by the Panel in this same period.

Importantly, careful analysis of multi-agency practice when things have gone so catastrophically wrong in children’s lives can shed light on the experiences of the broader group of children who need safeguarding. The analysis also highlights good practice and recognises that very many practitioners bring enormous skill and imagination to safeguard children. It also demonstrates the strains and stressors being faced by families and across the health and care sector, with diminished capacity in services that can impede our collective ability to protect children.

In addition to key data about the children and their families who are the focus of reviews, the report spotlights three themes:

  1. Safeguarding children with mental health needs
  2. Safeguarding pre-school children with parents with mental health needs
  3. Extrafamilial harm

Key findings:

In 2023 to 2024 there was an 18% reduction in the number of notifications, particularly those relating to serious harm. The drivers for this reduction need to be interrogated further, at both a national and a local level.

During the review period, almost half of the incidents were due to the death of a child, and almost half were due to serious harm. The age distribution of children was very similar to previous years, with under 1s still experiencing the most harm, representing over a third of all incidents.

Notably, in a quarter of incidents, at least one parent or relevant adult was reported to have either a physical, mental health-related, learning or developmental disability, a substantial increase from the previous year. In just over half of the incidents, at least one parent was reported to have one or more mental health conditions, and in 43% of reviews, there was a parent with an addiction to or misuse of alcohol and/or substances.

Of particular relevance to health visiting, the spotlight theme on “Safeguarding pre-school children with parents with mental health needs” reported the following findings:

  • Parental mental health was often overlooked as a potential risk factor when considering parents’ capacity to care for their children.
  • There tended to be an over-focus on visible contextual factors, such as home conditions, with less consideration of mental health, despite indicators of both historical and current deteriorating mental health.
  • Findings also identified a lack of effective communication between and within statutory and non-statutory services, particularly adult services and child services.
  • Reviews and literature identified a critical absence of support for parents with mental health needs or conditions who have children between the ages of 1 and 5, with research predominantly focusing on pre-natal and perinatal mental health.

Linked to this, some reviews identified children not being brought to their health appointments which might, in turn, have been associated with the parents’ mental health and other challenges they were facing at that time. Critically and sensitively exploring the reasons for non-attendance might have assisted in better engagement by understanding and unblocking any manageable barriers for parents.

These issues highlight the challenges for practitioners and agencies when trying to successfully engage parents in discussing the impact of these issues. Mental health needs can fluctuate between periods of stability and instability, improvement and deterioration. This, along with the presence of other stressors or vulnerabilities, means practitioners and services may need to be as flexible and accommodating as possible when working with parents in these circumstances.

Commenting on the Report, Hilda Beauchamp, iHV Mental Health Lead, said:

“The sobering spotlight on ‘Safeguarding pre-school children with parents with mental health needs’ flags the recurring need for professional curiosity, better inter-agency communication, and greater consideration of the complex intersecting factors that impact parental mental health. Some good practice by health visitors in identifying and managing risk to babies and children related to parental mental health is noted, but this report leaves us in no doubt that more can be done to protect our most vulnerable little ones.”

The Report contains key learning points for direct practice and learning for strategic leaders and managers – as well as reflective questions to assist practitioners, managers and leaders in considering practice in their area.

Read the report here

Joint Policy Position to ensure public health function of 0-19 services is not lost

The Institute of Health Visiting (iHV), School and Public Health Nurses Association (SAPHNA) and the Association of Directors of Public Health (ADPH), have published a new joint policy position on the safeguarding role of public health 0-19 services.

The statement comes following a significant rise in the number of babies, children and young people needing support for safeguarding issues who fall below the threshold for children’s social care services. To bridge this gap, health visitors and school nurses are increasingly called upon to support children and young people on Child Protection and Child in Need Plans. At the same time, child health is deteriorating, and health inequalities are widening across the nation – with an equally important call for health visitors and school nurses to utilise their specialist public health nursing skills to support the national shift from “sickness to prevention”. Meanwhile, services need to find a way to reconcile these two competing priorities.

The document, published today, highlights the impact this work is having on health visitors’ and school nurses’ capacity to carry out their public health function. It also outlines a number of measures that would support the whole sector to ensure children and families are not only kept safe from harm, but also able to access a wide range of services that promote good health and wellbeing, including:

  • Where a baby, child or young person has an identified health need, ensuring that discussions take place between health professionals and social care to determine whether a health professional is most appropriate to take on the role of Lead Practitioner and, if so, who it should be.
  • Ensuring that any public health professional’s “duty to cooperate” in child safeguarding, does not interfere with the performance of their own public health functions. In particular, when taking on the Lead Practitioner role in line with Working Together (2023) guidance.
  • Providing funding to offset the additional workforce and training costs associated with upskilling the 0-19 public health nursing service to ensure compliance with the Care Law.
  • Exploring the option of providing additional health capacity in multi-agency safeguarding hubs.

Commenting on this important policy position, Alison Morton, iHV’s CEO, said:

“Our nation faces two urgent challenges, to improve the state of our children’s health, and safeguard the most vulnerable and those at risk of harm – they both require attention and cannot be ignored. This joint policy position is intended to bring clarity to the roles of health visitors and school nurses as an important part of the solution.

“The new government has committed to shift from ‘sickness to prevention’. This will not happen by chance. It is therefore vital that we have a strong workforce with the capacity to focus on prevention and improve the health of babies, children, young people and families. With significant workforce challenges, Specialist Community Public Health Nurses need to use their skills to maximum effect – to work ‘upstream’ with families to prevent, identify and treat problems before they reach crisis point. By working together across the health and social care system, we can ensure that all children get the support they need – right person, right place, right time!”

Prof Tracy Daszkiewicz, ADPH spokesperson for children and young people, said:

“Safeguarding children and young people is, of course, absolutely essential. However, so too is public health. If we are going to deliver on the Government’s Health and Opportunity Missions, we must be able to focus on prevention and public health approaches so that our children grow up with the skills and tools they need to live happy, healthy, prosperous lives.

“Public health funding, which has seen consistent real-terms cuts over the last decade, pays for 0-19 public health nursing services, but at the moment, a huge number of professionals on the ground are saying they are unable to use their public health expertise as they are so frequently involved in safeguarding. This extra demand on an already stretched service is untenable.

“In order to support and protect our children and young people in the best possible way, the Government must not only recognise the strain these services are under but also commit to a sustained increase in public health funding.”

Sharon White OBE, SAPHNA’s Chief Executive, said:

“Safeguarding is central to the role of school nurses and is a core thread through the Healthy Child Programme. SAPHNA’s position is that school and public health nurses are most effective and impactful when able to use their specialist knowledge and skills at the promotion, prevention, and early intervention end of the safeguarding continuum.

“The cost saving benefit of public health has been shown to have significant returns on investment in the wider health and social care economy. And yet, in SAPHNA’s inaugural survey of School Nurses, The Forgotten Frontline, launched in October 2024, 71% of respondents stated that they have seen an increase in the number of children who they support on child protection plans and 67% noted an increase in children in need plans. 38% of respondents in England indicated that they spent over half of their time supporting children on child protection plans.

“School nurses shared their frustration about the impact that this has on their wider public health role. They felt that they are ‘at the table’ as the ‘health representative’ however are not always best placed to be supporting the child. SAPHNA welcome the clarification that this position policy will offer for both the workforce and partner agencies.”

Read the Joint Policy Position paper here

To cite this report, please use the link to the pdf here: https://bit.ly/3ClNbvE

 

 

New joining link for Working Together 2023 Summit – 26 April

New joining link for Working Together 2023 Summit

  • Date: 26 April 2024
  • Time: 11am – 1pm

NHS Safeguarding apologises for the technical problems that a number of people experienced joining this week’s Working Together Summit via their events platform.

To resolve these issues and ensure that you are able to hear our CEO Alison Morton’s presentation on the provider perspectives on Working Together changes 2023 (alongside the other panel of speakers from SAPHNA and NHS SEND team), NHS Safeguarding will be reverting to the tried and tested MS Teams platform for the next Summit which is being held on Friday 26 April (11am-1pm). This means that the previously shared link will no longer work.

This new way of interacting will improve your learning experience and mean greater engagement during the discussion session.

Please delete the previous links that you have received for this event and use this link instead:

Join the meeting

(Please note there is no booking for this event – just join the meeting link on the day)

Kenny Gibson at NHS Safeguarding says:

Dear safeguarding colleagues, many thanks for your on-going support with the implementation of Children’s Social Care reforms and Working Together 2023.

Please note that due to technical challenges, NHS Safeguarding has decided to change our Teams technology for Friday 26 April – this will improve your learning experience and mean greater engagement during the discussion session.

In the session you will be hearing from:

Alison Morton, CEO, The Institute of Health Visiting (iHV)

Sharon White, CEO, School and Public Health Nurses Association (SAPHNA)

Lorraine Mulroney, NHS England, SEND nursing team.

The event will include time for discussion and Q&A with the speakers and NHS Safeguarding Team.

Learning from the Child Safeguarding Practice Review Panel’s fourth annual report

In case you missed it – last week, the Child Safeguarding Practice Review (CSPR) Panel released its fourth annual report which is described as a barometer of the health of the national safeguarding system, highlighting both strengths and areas for improvement in multi-agency practice. The report provides important insights into patterns in English safeguarding practice, examining learning from incidents where children have died or suffered serious harm due to abuse or neglect.

In the Foreword to the report, Annie Hudson, the Chair of the Child Safeguarding Practice Review Panel, reminds us that, “The children at the heart of this report endured shocking, almost indescribable, violence and maltreatment. We must never become inured or habituated to this. What happened to these children cannot be undone, but what we must do is assess how well agencies responded to their needs.”

The findings presented in the 2022/23 annual report are based on:

  • serious incident notifications (SINs) during the 15-month period of January 2022 to March 2023 with a focus on the 12-month period of April 2022 to March 2023
  • rapid reviews with incidents that occurred during the 12-month period from April 2022 to March 2023
  • a sample of Local child safeguarding practice reviews (LCSPRs) produced during the 15-month period of January 2022 to March 2023
  • letters to safeguarding partnerships from the Panel used to assess the quality of rapid reviews during the 12-month period of April 2022 to March 2023.

The review also draws on evidence in the 2 national reviews and 2 thematic reviews the CSPR published in 2022 and 2023.

The Panel received 393 serious incident notifications during this period, with 37% (146) related to child deaths and 58% (227) involving incidents of serious harm to children.

Review highlights vulnerability of babies

  • Babies under the age of 12 months old comprised the single largest age group within the sample of rapid reviews (36%, n=142).
  • Over a fifth (26%, n=25) of serious incidents involving children under one year old occurred in the 10% most deprived areas compared to 15% (n=7) of children aged 1 to 5 years old.

Parental and family stressors were the most significant factor in escalating risk when it comes to safeguarding children under 12 months old. Previous reports like the Myth of Invisible Men and Bruising in Non-Mobile Infants emphasised challenges in responding to this vulnerable group. The review builds on the key learning from the inquiry into the murders of Star Hobson and Arthur Labinjo-Hughes in highlighting the importance of professionals having the time to understand the context in which babies and young children are living:

“Knowing what life is like for children, highlighting the centrality of children’s voices and experience, and those of their parents, carers, and wider family members, but also the knowledge, skill and confidence required to build a full picture of children’s lives to enable the best safeguarding, support and protection.”

Understanding the roles and risks of all adults around very young children is crucial, given their dependence on caregivers and the potential for rapid escalation. The analysis also highlighted ongoing problems in effectively assessing and managing risks involving babies, with connections to domestic abuse, where pregnancy is a recognised risk factor in such relationships, posing challenges for professionals.

Parents’ and carers’ needs

Among the 393 cases reported to the Panel, 13% (n=51) involved parents under 25 years old, and 3% (n=13) had a history of being in the care system, although identification was sometimes challenging. This indicates a potential need for additional support from services like GPs and health visitors for these parents.

Conditions in practice

One of the main messages from the review is the importance of providing practitioners with the best opportunity to identify, assist and protect children. Specifically for health visiting, the following factors were found to hinder optimal practice and safeguarding decision making:

  • Major challenges in workforce recruitment and retention, most obviously in children’s social care and health visiting, which impact on the quality of practice. The review raises concerns about the year-on-year decline in the number of health visitors.
  • Increases in population numbers and levels of vulnerability – this includes evidence from the iHV Annual State of Health Visiting survey. Alongside the decline in workforce numbers, these place significant pressures on health visiting services in meeting the scale of need.
  • Limited GP input and incomplete health records in multi-agency meetings posed a common problem in recognising vulnerabilities affecting families. Inadequate information sharing between agencies, like neonatal units, midwives, health visitors, and GPs, especially in families with young children, significantly impacts the protection of children at risk of harm.
  • There was also evidence that questions about domestic abuse were not being asked during checks with mothers if fathers were present (this learning point applies regardless of sex and gender of both parents or main carers). While including fathers in checks and appointments is essential to avoid them becoming invisible to services, this finding emphasises the need to ensure that mothers can speak to health visitors alone in case the presence of the other parent inhibits disclosure.
  • The report emphasises the importance of working upstream to prevent situations reaching crisis point.

The report concludes with a series of reflective questions for safeguarding leaders to support them in promoting the very high standards of safeguarding practice and makings sure that learning reviews drive longer term change to help children and families. These questions are organised around 6 key strategic themes:

  • Culture: creating an inclusive culture where professional challenge is promoted.
  • Clear partnership intent: ensuring clear and balanced partnership working.
  • Strategy to delivery: ensuring strategy is carried through to frontline practice.
  • Assessing effectiveness: evaluating impact of the safeguarding system.
  • Getting upstream: ensuring learning feeds into prevention, early intervention and the commissioning of services.
  • Workforce: working together effectively across agencies and promoting development.

Read the CSPR Panel report in full here