Children's Commissioner says 'culture change' is needed to stop vulnerable children dying

26 May 2022, 00:17 | Updated: 26 May 2022, 19:09

The Children's Commissioner in England said child protection services need a culture change after a damning national review into the tragic deaths of Arthur Labinjo-Hughes and Star Hobson found these "are not isolated incidents".

Dame Rachel de Souza said her "heart stopped" when she read the report, which left her questioning "why" agency's so obviously failed Arthur and Star.

The Child Safeguarding Practice Review Panel said the way child protection is approached in England needs to "change fundamentally" after discovering concerns raised by wider family members were "too often" disregarded and not properly investigated.

Professionals were increasingly kept at arms length by those perpetrating the abuse, and they failed to identify a "pattern of parental disengagement and avoidant behaviour", the report also found.

It recommends dedicated multi-agency teams staffed by experienced child protection professionals be set up in every local authority area to investigate allegations of serious harm to children.

And the Government should establish a national child protection board to better co-ordinate child protection policy.

Speaking on Tonight with Andrew Marr, the Children's Commissioner said: "I think it’s really important that we just stop and reflect on the totally unnecessary deaths, the awful deaths of these two children who had everything to live for. It is seared on my heart, Arthur Labinjo-Hughes' words 'nobody loves me nobody cares for me'. "

Dame de Souza said she is "pushing hard for multiagency work" explaining: "When your read the report you can see the failures of multiagency, you can see the failures that meant these children died.

"And you read them and your heart stops, you just think why did that agency not raise that, why did that happen?

"So the report is saying no more last minute, hard stretched, pieced together multiagency work, we need to make it a priority.

"I agree with that, but don’t forget Andrew, it is only as good as how well it is implemented and that’s the challenge."

The Commissioner believes the sector "needs more than money" claiming the agencies need a culture and leadership change.

In a foreword to the report, review chairwoman Annie Hudson said the current safeguarding system is not broken, but there is too much ambiguity and inconsistency which does not serve children, their families or professionals well.

Read more: 'Evil' father and stepmother guilty of killing Arthur, six, after months of horrific abuse

Read more: Woman laughs before being jailed for life over 'cruel' murder of one-year-old Star Hobson

Distressing video sees Arthur Labinjo-Hughes struggle to pick up duvet

Existing multi-agency safeguarding arrangements "are not yet fit for purpose everywhere" she added.

The review was commissioned in December 2021 by Education Secretary Nadhim Zahawi following the deaths of Arthur and Star to look at what could be done to prevent things from going so "horrifyingly wrong" in future.

The panel interviewed just under 80 professionals in Bradford, Birmingham and Solihull; the children's family members, including Star's mother and her mother's partner; and drew on 1,500 rapid reviews of serious incidents since it was formed.

It found that child protection work is inherently complex, but the current system does not give professionals the best opportunity at cutting through this complexity "to get to the truth of what life is like for children".

It identified a reliance on quickly pulling together a team from overstretched agencies every time there is a child protection concern, which is "certainly inefficient and often ineffective".

The review noted the importance of challenging assumptions and biases relating to culture, ethnicity, gender and sexuality when safeguarding children.

Read more: Woman jailed for life for murdering baby she was hoping to adopt

It said the role of women in perpetrating abuse may have impacted on how professionals perceived the risk to children, "given societal beliefs about women as caregivers".

Arthur was murdered in June 2020 by his stepmother Emma Tustin at their home in Solihull. His father Thomas Hughes, 29, was found guilty of his son's manslaughter.

The review said a judgment seemingly became fixed early on that Mr Hughes was a "protective father", which was reasonable at the time but was never challenged when circumstances changed.

Concerns about Arthur's bruising raised by family members were not taken seriously, photographs of the bruising were not shared between agencies, his voice was not always heard and too many assessments relied on his father's perspective, it found.

Star was murdered by her mother's girlfriend at her home in Keighley, West Yorkshire, in September 2020. Star's mother Frankie Smith, 20, was found guilty of causing or allowing the youngster's death.

An explanation that concern from a family member might have been malicious and rooted in a dislike of her mother's same-sex relationship was "too easily accepted", the review found.

Read more: Couple jailed over killing of three-year-old boy whose ribs were crushed after weeks of abuse

The review found that Bradford children's social care service was "in turmoil" in 2020, with a high turnover of social workers and a high volume of work affecting quality and contributing to assessments that were "too superficial" and did not address repeated concerns from family members.

Ms Hudson concluded that there are "fundamental faultlines" in the system that need to be addressed.

She said: "We're really clear in our report that the issues that we saw there are also issues that we've seen in other instances, and that we believe that the way the system is set up, and the conditions in which practitioners are having to work and make decisions, actually makes it very difficult sometimes for them to really know what was going on and to really work together effectively to protect children."

Mr Zahawi thanked Arthur and Star's families for their contributions to the report, and said: "We must waste no time learning from the findings of this review - enough is enough.

"I will set up a new Child Protection Ministerial group, a first and immediate step in responding to these findings, before setting out a bold implementation plan later this year to bring about a fundamental shift in how we support better outcomes for our most vulnerable children and families."

Snapchat video of Savannah Brockhill from Star Hobson case

Sir Peter Wanless, NSPCC chief executive, said Arthur and Star's deaths "have left a lasting scar on the nation".

He said: "It is heart-breaking that it had to take these tragedies to shine a light on the shortfalls in the child protection system.

"Now, we must ensure the memory of Arthur and Star acts as a catalyst for the fundamental changes necessary to prevent further deaths.

"This review lays bare an all-too-familiar story of a system struggling to cope. Social workers, police, health practitioners and teachers, however hard they are working as individuals, know they cannot do this alone."

Janice Hawkes, independent chairwoman of the Bradford Partnership, apologised for the "awful circumstances" of Star's death, and said the partnership is "entirely committed to improving the safety of children across Bradford".

Star's great-grandfather, David Fawcett, 62, spoke of his anger at learning social workers' investigation into Star's case was closed a week before she died.

"Reading between the lines, they didn't have the manpower, which is why they had to close the case - it's pretty damning," he said.

"The proposals they've put forward are positive because it's communication - that's where Star was failed, a lack of communication between different authorities.

"How it was run before was pretty shambolic but I am optimistic something can be done and lessons will be learned."

Mr Fawcett said he would visit Smith in prison and talk her through the report's contents as she would be "too upset". "She's only got me to rely on at the moment," he said.

"For a lot of the family it's still too raw, a lot of them can't forgive Frankie, they think she could have done more to save Star and they don't want to speak to her at this moment.

"I spoke to Frankie on Friday and, with it being Star's birthday, she was pretty upset. It's probably the worst I've heard her.

"We were always close, me and Frankie, she was like my daughter, it's pretty heartbreaking.

"She was failed herself, really, she was abused. "What happened to Star, that's what we thought was going to happen to Frankie."

The Child Safeguarding Practice Review Panel said an early opportunity to help Smith, who was 17 when she became pregnant, was missed as no antenatal health visit took place, and that she was not offered the support of the teenage pregnancy midwife as she was over 16.

It also said that domestic abuse between Brockhill and Smith, who met when Star was five months old, was not assessed, with Smith "not given sufficient space to disclose what was happening to her".

Their trial heard that social services were contacted five times by concerned relatives and friends, with police also visiting the family.

Each time, the safeguarding panel said, the couple convinced social workers that bruising on Star was accidental or the complaints were made maliciously by friends and family who did not like their relationship.

Mr Fawcett said he felt vindicated as the report acknowledged that "Star's wider family members were not listened to".

"Savannah Brockhill said it was malicious gossip and they believed her over us," Mr Fawcett said.

His partner Anita Smith, 70, called social workers in May 2020 after family members told her Brockhill was "slam-choking" Star - lifting her by the throat and throwing her on a bed.

He said: "When we made the referral and they went to the house, they should have come to us first to understand why we'd done it.

"If we'd have been allowed to go to the house that day, I think Star would have been with us today."