This Child Safeguarding Practice Review has recently been published by Gloucestershire Safeguarding Children Partnership and looks into the case of Child C who was sexually abused by their male foster carer. Please note the opening of this episode does contain a letter written by the child themselves about the abuse they faced which some listeners may find difficult to hear.
Learning themes include:
-The importance of consistent, responsive and reliable professionals
- The difference between constancy and consistency
-Speaking to children away from their homes and those that may be perpetrating abuse
-Thinking the unthinkable when it comes to foster carers abusing their position of trust
-Considering how we respond to concerns and allegations when children are watching
-Avoiding an over focus on the adults and taking note when a child retracts allegations
-Recognising that being fully compliant does not mean neglect or abuse is not present
Today’s episode focuses on a review recently published by Lambeth Safeguarding Children Partnership and refers to a family the report calls the Manning Family. This review was deemed necessary after a young boy was found with indecent and sexual abuse images of children on his phone. This formed part of some wider concerns that already existed including the potential sexual abuse, physical abuse and neglect of children with disabilities.
Learning themes include:
-Understanding the vulnerabilities of children with disabilities
-Race, ethnicity, adultification bias and cultural considerations
-Professional curiosity
-Listening and capturing the voice of the child
-Drift and delay
Bethany (aged 26) and her son Darren, better known as DJ (aged 9) were both murdered at their family home by Bethany’s former partner in the May of 2021 following a period of physical and psychological abuse. The perpetrator had a history of violence, including a conviction for domestic assault on a former partner. This episode looks at the findings from the joint Domestic Homicide Review and Child Safeguarding Practice Review published by Safer Lincolnshire Partnership and Lincolnshire Safeguarding Children Partnership.
Learning themes include:
-The importance of recognising domestic abuse harm to children
-Understanding of the Domestic Violence Disclosure Scheme (also known as Clare’s Law)
- Power and control dynamics of domestic abuse
-Understanding separation as a risk factor and the link to Dr Jane Monkton Smith’s ‘8 Step Timeline in Domestic Homicide’
- Supporting non-abusive parents and challenging abuse parents
- The importance of taking threats seriously
9 out of 10 children who are subject to Child Safeguarding Practice Reviews are previously known to children’s services. However, what about that 1 in 10 case? What lessons can be learnt? This episode will answer those questions and focuses on a review recently published by Birmingham Safeguarding Children Partnership. The review focuses on the tragic death of a three-week-old baby caused by his father, following a catastrophic breakdown in the father's mental health in the Autumn of 2022. Unlike many other Child Safeguarding Practice Reviews, prior to the baby’s death, the family were only receiving universal services and were not known to either children's social care or mental health services.
Learning themes include:
-Developing a better response when a person is in mental health crisis
-Improving access to mental health support
-The importance of passing on accurate and complete information
- Displaying cultural awareness so agencies are able to be sensitive to the way needs may present depending on ethnicity, culture and belief systems
-Considering whether community leaders such as Imams should be trained in counsel and mental health
In January 2023, Child V died at the age of 7 years old. Child V had complex health needs and disabilities and there had been significant contact with both health and social care practitioners due to her needs and concerns around neglect in the years preceding her death. This episode examines the findings of the Child Safeguarding Practice Review published by City & Hackney Safeguarding Children Partnership.
Learning themes include:
-Stepping back and thinking about cumulative harm a child is facing
-Health & Social Care working together when complex needs are present
-Insufficient management grip
-Working with resistant families
-Prioritising the health, safety and well-being of the child
-Ensuring care proceedings are timely and effective in bringing around material change
The body of Abiyah Yasharahyalah lay undiscovered in the back garden of a house in Birmingham for two years. His post-mortem was inconclusive however at the time of his death, Abiyah was suffering from several serious health conditions. His parents have subsequently been jailed for their part in his death. Last month, in June 2025, Birmingham Safeguarding Children Partnership released the Child Safeguarding Practice Review into the circumstances around his life and death. This episode of R.I.S.E brings you the key findings.
Learning themes include:
-Working with parents who live an alternative lifestyle/wish to live ‘off-grid’
-Working in a multi-cultural/multi-ethnic landscape and having the confidence to ask questions
-The critical role of assessments
-The importance of relationship-based practice
-Remaining child focused throughout work and assessments
-Enhancing access and awareness of universal services particularly to families who wish to live alternative lifestyles/’off grid’
This episode looks at the Child Safeguarding Practice Review published by Lambeth Safeguarding Children Partnership into Mara’s experiences. This review was initiated due to suspected child sexual exploitation (CSE) of a 15-year-old girl in November 2022. Mara was found with two adult males after going missing from foster care. Mara also alleged physical and sexual assault from her foster carers. Mara has a genetic condition, atypical autism and additional needs.
Learning themes include:
-Information sharing and multi-agency safeguarding responses
-Confusion around processes (ensuring Section 47 processes are not absorbed into other processes)
-The difference between strategy meetings and professional meetings
-Ensuring all relevant parties are invited to meetings and minutes are clearly recorded and stored
-Lack of suitable emergency and specialist provision
-Deprivation of Liberty – see Ofsted Guidance: Placing children: deprivation of liberty orders, Research In Practice: Deprivation of Liberty and 16 and 17 year olds,
-Voice of the child
-Missed opportunities where interventions and support don’t meet the needs of the child
Operation ACORNE was a large scale and complex multi-agency investigation into child sexual abuse in the Gloucestershire area. It developed over several years and encompassed a number of children and adults, from four families who were within a tightly controlled family network that included family friends. This episode looks at the subsequent findings from the review published by Gloucestershire Safeguarding Children Partnership.
Learning themes include:
-Quality of Risk Assessment & Decision Making
-Giving too much weight to criminal prosecution over safeguarding action
-Including the children's views and experiences in decision making processes
-Quality of partnership working
-The impact of budgetary cuts
-Professional challenge & escalation
-Understanding of Harmful Sexual Behaviour & wider Child Sexual Abuse
In February 2021, Alfie Steele was murdered at his home in Droitwich after being subject to months of abuse. His mother and her partner were subsequently found responsible and are currently serving jail time. Following his death, Worcestershire Safeguarding Children Partnership completed a Local Child Safeguarding Practice Review.
Learning themes include:
-Responding when a new partner joins a family –Unseen Men
-Domestic Abuse & Coercive Control and recognising when this is NOT present
-How realistic are expectations we put in place for children and families?
-Confirmation bias and fixed thinking
-Adults of concern who don’t meet the threshold for public protection meetings
-The effectiveness of the Core Group process
-Responding to physical abuse
-The over-reliance on children telling us what is happening to them
-Response to concerns from community members
George and Oliver were both under the age of 13 when emergency services were called to a life threatening incident at their family home. Fortunately, both children managed to get to safety. The Police immediately suspected that their father was responsible, and he had fled from the scene. He was subsequently apprehended and remanded into custody and is now serving a lengthy prison sentence. This podcast episode covers the findings of the review published by Kent Safeguarding Children Multi-Agency Partnership.
Learning themes include:
- Working with families where there is domestic abuse, coercive control and alienating behaviours
- Assessing parental mental health in the context of Private Law Proceedings
- Practitioners understanding of private law proceedings/information sharing and the impact on the children
- Risk assessments in relation to significant information and changing circumstances which may impact the safety of children.
- Assessing the children’s lived experiences
This episode looks at the review carried out by Mid & West Wales following the sexual abuse of two adolescent boys by their foster carer. Child Y disclosed the abuse in April 2020. Child X disclosed the abuse in March 2021. Adult Z was found guilty of the sexual assault of Child Y, but not guilty of the charges in respect to Child X. Both children had been subject to significant adverse childhood experiences prior to their placements with the foster carer.
Learning themes include:
-Not assuming that past trauma always explains or mitigate a behaviour or expressed concern when a child is in care
-Think the unthinkable, believe the unbelievable and imagine the unimaginable
- Understanding how recording in a certain way and using particular language and terms can feed into building a narrative of the child
-Hypothesis or confirmation bias
-Proactive management and matching of placements, of assessments of risk, and analysis of incidents or events and their implications
- Robust and clear records and the importance of Quality Assurance
- The importance of effective IROs
- Effective foster carer reviews including calling early reviews when necessary
In 2019, 14 year old Jaden Moodie was knocked off the moped he was riding and stabbed to death. Jaden was one of the youngest victims of knife crime on the streets of London at the time. This episode looks at a few of the high level findings of the review published by Waltham Forest Safeguarding Children Board.
Learning themes include:
-The importance of education arrangements
-Critical and Reachable Moments
-Co-ordination of arrangements across areas where County Lines is a feature
-Housing as a key agency to help with safeguarding arrangements
-Information sharing
-Developing a national system to respond to County Lines
-‘Rescue and Response system’
-Distrust towards authority and services by children and families
Sydney was just 13 years old when she went missing for 5 days from the Children’s Home she was living in at the time. Upon her return, she disclosed that she had been held against her will, sexually assaulted by older males and had been given alcohol and drugs. This podcast episode looks at the findings of the subsequent review published jointly by Lancashire Safeguarding Children Partnership and Devon Safeguarding Partnership.
Learning themes include:
-Sensitive and appropriate reactions to children’s disclosures
-Listening to the voice of children and families
-The usefulness of chronologies
-The impact of delayed diagnoses
-Internet Safety – see Google’s Be Internet Awesome interactive educational game for young people
-Follow up of actions, suggestions and recommendations
-Use of specialist services
-Effectiveness of risk assessments
This podcast episode highlights the key learning points from the review published by Oxfordshire Safeguarding Children Partnership for a young person, Child G, who experienced trauma and instability at an early age, including experiences of emotional and sexual abuse, and a lack of certainty about who was there to look after or care for her. As a teenager this manifested in feelings of low self-esteem, mental ill health, self-harm, running away, struggling to manage her emotions at home and at school, and some substance misuse. This led to her becoming care experienced and victim to sexual exploitation and harm in the community.
Learning themes include:
-The importance of kind and caring relationships
-Focusing on what CAN be done rather than what CAN’T be done
-Victim blaming language – see The Children’s Society Language Guide
-Recognition of emotional abuse and neglect
-Dissociative seizures – see the Mind website
-Adopting a trauma-informed approach
Leiland-James Corkhill was murdered by his prospective adopter Laura Castle in January 2021. This episode looks at the findings of the review published by Cumbria Safeguarding Children Partnership.
Learning themes include:
-Limitations of self-reporting
-Information sharing
-Disguised compliance (as referenced in the report)
-Post Adoption Depression syndrome
-Covid 19 Restrictions
-Changing dynamics of a person’s health status
For further resources on Post Adoption Syndrome please see the following:
CoramBAAF- Post Adoption Depression Syndrome
The Child Psychology Service CIC – Post Adoption Depression
Adoption UK- Post Adoption Depression- What no-one told me
Skye was 17 years old when she died after being found unresponsive in her bedroom in the commissioned residential home in Scotland that she was living in at the time. This episode covers the findings from the subsequent review published by Bath and North East Somerset Community Safety & Safeguarding Partnership.
Learning themes include:
-The importance of timely pathway planning
-The ‘Cliff Edge’ of care (see Channel 5 documentary first broadcast in 2019)
-Open and honest conversations with children
-Shortage of suitable homes for children with high levels of needs
-Cross-border placements (see Care Inspectorate Cross Border Thematic Review)
-Difference in working practices in Scotland and England
In 2020, Child Q, a Black female child of secondary school age, was strip searched by female police officers from the Metropolitan Police Service (MPS). The search, which involved the exposure of Child Q’s intimate body parts, took place on school premises, without an Appropriate Adult present and with the knowledge that Child Q was menstruating. This episode looks at the report that was published by City & Hackney Safeguarding Children Partnership.
Learning themes include:
-Adopting a safeguarding first response
-Ensuring responses to children are proportionate
-The role of an Appropriate Adult
-Racism and Adultification Bias
Emma Pattison and her 7 year old daughter Lettie were both murdered by their husband and father, George Pattison in February 2023 at their house on the grounds of Epsom College, where Emma was Headteacher. This episode looks at some of the findings from the Domestic Homicide Review published by Epsom and Ewell Community Safety Partnership.
Learning Themes include:
-Understanding of Domestic Abuse and Coercive Control
-The 8 Stage Timeline of Domestic Homicides
-The complexities of leaving an abusive relationship
-Recognising children as victims of Domestic Abuse
-The role of LADO in England
In late July 2021, Logan Mwangi was murdered by his mother, step-father and a teenage boy. This episode examines some of the findings from the Child Practice Review Report published by Cwm Taf Morgannwg Safeguarding Board.
Learning themes include:
-Considering the child’s lived experiences
-Unseen men- considering fathers
-Information sharing
-It is everybody’s responsibility to safeguard children regardless of status
-The impact of Covid-19 restrictions
In February 2023, 16 year old Brianna Ghey was murdered by two other young people, Scarlett Jenkinson and Eddie Ratcliffe. This episode examines some of the findings from the Child Safeguarding Practice Review published by Warrington Safeguarding Board into the story behind Brianna’s killer Scarlett Jenkinson.
Learning themes include:
-Use of social media and the internet
-The use of managed moves in education
-Recording of meetings
-Emotional well-being
-The importance of easy to complete referral forms
