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Everyone is to blame

Published 20 November 2008

Boundary wrangles between social services lie at the heart of the Baby P case, argues Marian Brandon, a leading government adviser on child abuse

With hindsight, the death of Baby P was preventable

The brutal circumstances of the death of Baby P are hard to bear, and made more harrowing still by the publication of photographs of him, showing the toddler as an icon of childish vulnerability. Gordon Brown says such deaths must never happen again, but the truth is that even if best practice were the norm, it would not be possible to prevent all children dying from abuse.

Our recent study, commissioned by the Department for Children, Schools and Families and carried out by a team from the University of East Anglia and the National Society for the Prevention of Cruelty to Children, examined 161 serious case reviews of child death and grave harm through abuse and neglect in England between April 2003 and March 2005. We concluded that the wealth of factors which raise or lower the risk of harm to the child was in most cases too complex for death or serious injury to have been predictable. In the current climate of moral outrage and panic, however, it seems this finding is unacceptable.

Rates of physical and sexual abuse appear to be falling in most high-income countries, including the UK, although not rates of neglect or psychological abuse. However, much abuse goes unrecognised (and hence not reported) and most abused children do not get help. Unlike Baby P, almost half of the children we studied were not known to the children's social care services, but their families were in contact with health visitors and midwives. Many families were also known only to specialist adult services for which the well-being and safety of children were not priorities (an omission, which must change). We found that many older, often suicidal, young people had histories of abuse and neglect. They were challenging to help but were failed by a range of agencies that squabbled over whether they had met their criteria for services. A recent Barnardo's study highlighted the demonisation of adolescents, whose vulnerability goes unnoticed.

Learning the lessons of the "worst cases" can lead to misinterpretation and bad decision-making. Although domestic violence, substance misuse and mental ill-health among parents were common, we found no cause-and-effect relationship between this and child death or serious injury. Repeat attendance at accident and emergency departments for babies with minor injuries, or hospital admission (as in Baby P's case), does, however, appear to be a marker of abuse, according to study evidence. Many families live in great adversity, which increases the risk of harm to children, but it is important to remember that most children do not suffer serious abuse in these circumstances.

With hindsight, the individual death of Baby P was preventable. He should have been protected because there were already heightened concerns for his safety. He was the subject of a multi-agency protection plan and had been seen on numerous occasions. The responsibility for protecting him was, appropriately, shared between many agencies, although blame is falling as usual on children's social care. This is wrong: the Children Act 2004 makes clear that all agencies are responsible for safeguarding minors. The reviews we studied reflected a preoccupation with boundaries and wrangles over which professional group was "responsible" for the child. It is a function of the new Local Safeguarding Children Boards to agree thresholds and ensure referrals. The extent to which the boards can achieve this will be a measure of their success.

Chaotic families, in which neglect often happens, tend to have complex histories and are confusing and overwhelming for practitioners. In Baby P's case there was not even a clear understanding of who was living in the household. The child is often "lost" in the midst of parental needs, hostility or even apparent co-operation. An assessment that this is a simple "neglect" case shuts off critical thinking and makes it hard to spot the combination of physical danger and other forms of abuse, as well as risks from others in the household, particularly new partners. Social workers should be (and evidence from audit studies says they usually are) approaching complex cases rigorously. Careful collection of information about the child, together with the parents' profile and history, should help them understand the stresses the parents are under - and what makes them, as well as new partners or visitors in the household, tick. It should also answer the question: "What's it like to be a child in this household?" What stops social workers thinking and acting systematically is the triple pressure from families, employers and bureaucratic demands. Work overload, a target- driven culture and poor support make workers stressed and ill or paralyse them into inactivity. Good support and supervision should not be solely about meeting performance indicators such as a reduction in numbers of children in care. This highly responsible role is crucial, but supervisors are not adequately trained or resourced. The vitriol attracted by high-profile child deaths will do nothing to bring good candidates into child protection work.

It may be that the threshold for removing children who are suffering chronic neglect is set too high. When social workers bring these cases to court they are often sent back to "start again" with the family; sometimes the consequences can be grave. Most child protection policy is effective, and when failings happen they are caused by human error. However, there is also a lack of guidance about acceptable standards of adequate parenting. This is a problem, not only for social workers, but for families themselves.

When the firestorm of the Baby P case is over, social workers and other professionals who protect children will need to be able to trust each other enough - and be trusted enough by the public - to start challenging their own practices and decisions.

Marian Brandon is a senior lecturer in social work at the University of East Anglia and lead author of a new study for the Department for Children, Schools and Families into child deaths from abuse and neglect in England

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5 comments from readers

Carl Jones
20 November 2008 at 16:57

Marian, Haringey has double case load. A whistle blower was gagged and FOUR government ministers were sent warning letters....I fear this last point is being buried by the establishment/MSM.

As a generalisation, Britain is a warped nation when it comes to children. According to a recent poll, half of all UK adults believe our children are akin to feral animals.

The state/establishment are hell bent on destroying the family. Dragging children into childcare, or school at an earlier and earlier age so they can be programmed.

It is all very sad and the current financial crisis will ensure that Britain continues to hate and mistreat its children for a very long time to come.

Jonny Mac
21 November 2008 at 09:27

That headline is the most offensive and wrong-headed example of leftist 'We are all guilty'-ism I have yet seen. Good work, NS subs.

http://www.jonnymacsplace.blogspot.com/

swatantra nandanwar
21 November 2008 at 16:36

The very state the house was in, the stench and the squalor should have alerted the social workers. The incapacity of the parents should have set alarm bells ringing. Its the cultre of not wanting to interfere in families even though they are dysfunctional which is at the heart of the problem. They let the child remain.

hellen
24 November 2008 at 11:04

What's up with this country? I'm disgusted and utterly shocked in this day and age a child has died in these horrific circumstances after supposedly being under the supervision of social workers and child protection, every single person that was involved in baby p case had a helping hand in causing his death..and should have to justify their actions and be dealt with accordingly. Something has to be done to protect all children that suffer at the hands of their abusers on a daily basis a message needs to be sent out that we as a society are not prepared to stand by and let these animals carry on with the fear of nothing more than a laughable (in most cases) short sentence in a prison wing away from other prisoners for their own safety to boast and swap stories then be put on a register when they come out allowing them to live in our neighbourhoods mixing and going virtually unnoticed without us having a clue about there past, once again protecting their safety. have people given up on society as a whole? where some are more concern with being so P.C that we have to watch what we say. only a few months ago prisoners being realised from barlinie prison were awarded compensation as they had to" slop out " and it was ruled to be against their human rights, what about there victims how must they have felt when hearing the news yet again let down by society..baby p cried constantly yet nobody did anything about it, neighbours must have heard his screams I wonder if it had been a dog constantly barking would they have lifted the phone to complain or try and seek a hasbo for noisey neighbours..makes u wonder I only hope after all the shouting and buck passing will baby p be just another statistic brushed under the carpet until another child dies this way, after all were we not promised after Victoria clymbie death this would never happen again....

maria
25 November 2008 at 18:24

This innocent and blameless child did not deserve to die in the way it did. I am appalled and shocked that local authorities did nothing and rather allowed this to happen and even delayed an apology. When the case of Victoria was uncovered, hoped that such an incident would not repeat itself. It a shame that once again I say that I hope and indeed pray that such an incident does not happen again to another child.