The child protection minefield

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Tuesday 20th March 2007.

Chair: Beverley Beech, Chairwoman of The Association for Improvements in the Maternity Services

Improving practice: protecting the child without damaging a family.
Dr Liz Davies (LD), Senior Lecturer Children and Families, London Metropolitan University

I am really worried about the loss of child protection in the UK as our procedures and protocols are lost and our systems are being destroyed.

This graphic

This graphic shows how children in these days may be surrounded by protectors and abusers. The more dependent a child is the more of these adults are around her; abusers get to a vulnerable child by pushing her protectors away. Unfortunately at present there is very little focus on the world of the abuser, or on targeting the perpetrators of serious crimes against children. "Childism" is an attitude, discrimination against children, which sees children as potential offenders, rather than the victims of child abuse. We contravene the United Nations convention on the rights of the child by placing more young people in custody for longer periods than ever before and for less serious crimes. There is disproportionate interference by the state in family life, with a focus on the control of children and not on the protection of the vulnerable children or justice for them. We have the state surveillance of children, a database for all children (ContactPoint), and a Common Assessment Framework to assess concerns in approximately 1 in 3 children. The abolition of the Child Protection Register will have a very serious impact on professional ability to protect children and what was needed was a national child protection register and a register of missing children to focus on children at high risk of significant harm. The abolition of the register will mean that professional attention will be distracted from children at high risk and the alerts to emergency services will no longer be in place.

We can justify a database of all children at risk of abuse but not a database of all children; such a database would in any case be a security risk. Schools are listed so that pupils at a Muslim or other faith school could be targeted. A national strategy - a broad outcomes approach for all children not focusing on those at risk of harm - just shifts the focus from dealing with the consequences of difficulties in children's lives to preventing things from going wrong. With its aim of reducing referrals to statutory services it will flood the workloads of all professionals; children at serious risk of abuse will be lost among the mass of those with low level concerns. Being located within the needs of the family and within socially disadvantaged families it ignores the essential investigation of the massive industry in child abuse and the fact that all forms of abuse occur across the socio-economic spectrum.

For the government safeguarding children means tnat all reasonable measures to ensure that the risks of harm to children's welfare are minimised and that agencies take appropriate action to address concerns (Department for Education and Skills, Department of Health and Home Office 2003 Keeping Children Safe ). This standard does not satisfy me, and 'concerns' is a vague ill-understood definition compared with 'significant harm', which has had a meaning for us over many years. On the other hand ' Working Together ' works. Children whose names were placed on the Child Protection Register, and where multi-agency planning to protect was in place, were rarely among those who died from abuse. Those who die are mainly children who, from the time of initial referral to social services, have not been defined as children in need of protection. Victoria Climbié is a painful example of this. Her referral indicating the likelihood of non-accidental injury was labelled as a child in need, so that no child protection assessment was performed (Reder P and Duncan S (2004) Making the Most of the Victoria Climbié Inquiry Report. Child Abuse Review 13:95 114:104). The multiple indicators of possible abuse gave 'reasonable cause to suspect actual significant harm' and should have lead to a Section 47 referral. The obvious lesson was not learned.

A myth of prevention is replacing protection. The hundreds of child abuse inquiry recommendations since 1945 provide our knowledge base of exactly how to protect children; no more inquiries were needed. Child protection has to be proactive, involving joint - including police - investigation of Section 47 referrals, the investigation of organised crime in this area and a focus on justice for the child. Prevention is useless without protection; the former requires strategies to teach the public and professionals to recognise and report abuse, creating a network of protective adults in the community. Then appropriate reporting enables professionals to prioritise, investigate, intervene and act to protect.

At present only about 2% of referrals result in the conviction of an abuser. Real prevention would increase the number of child protection referrals, given the known incidence of child abuse and how this is not reflected in the numbers of investigations made or convictions obtained. It would focus on systems to remove abusers from the lives of children and increase resources for the investigation of serious crimes against children. The former DfES, now Department for Children, Schools and Families, cast doubt on the value of responsive child protection work; but abused children need a response, they need frontline intervention to protect (Joint Chief Inspectors July 2005 2.19 p8 CSCI).

The 2003 Laming report on the death of Victoria Climbié recommended the exclusion of the police from joint investigations, and noted that social services staff feel a pressure to reduce the number of Section 47 inquiries, driving down child protection conferences and the number of children whose names were placed on the Child Protection Register; despite this Laming recommended the abolition of the Register. Victoria's social worker Lisa Arthurworrey reported that on the advice of her managers she was following a family support model of social work. "Child protection was only for emergencies". She stated that there was a 'No Police' notice in her office, and she supposed wrongly that she was making a Section 47 referral (L.Arthurworrey's witness statement to Employment Tribunal. 2004.64). And so she was not wearing the essential child abuse spectacles.

The Framework of Assessment has marginalised Working Together. It is not integrated with risk assessment, and Section 47 referrals are not now seen as an activity parallel to initial assessments, leading to delay (Ch 1 in Calder M (2003) Assessment in Child Care. RHP). There may be pressure to terminate assessments after a week, but some of my investigations have taken up to two years. Targets are undermining professional judgment and form-filling reduces client contact time. The safety of children is increasingly dependent on technology rather than professional judgement, which is undermined by a tick box 'conveyor belt' culture.

Although they are sometimes parallel processes, Working Together now wrongly identifies investigation as the same as assessment. Government performance targets now demand core assessments of all children and their families in every case of alleged child abuse, a huge waste of time diverting precious professional resources from high risk cases, while joint investigation by police and social workers is minimised, turning the clock back and introducing a serious gap in protective systems. At the point of initial referral, how are we to know if we are dealing with a crime?

The policy shift away from protection is reflected in the massive reduction in the numbers of children's names on the Child Protection Register. Comparing the figures for 2005 with those for 2001, physical and sexual abuse entries were almost halved; one London borough had not a single child on the register in the category of child sexual abuse, while another had two. Performance targets led to pressure to keep numbers low. Safeguarding Children inspection reports have noted inappropriately high thresholds in responding to referrals and taking action to protect. Again and again serious case reviews showed that professionals had not realised that the trigger for child protection had been reached (Jayarajah Dent:2004 Executive summary. www.haringey.gov.uk); with cases treated in isolation and closed too quickly (Kelly (2004) p.35), connections were not made and the wider picture ignored.

Lisa Arthurworrey's case exemplified the usual reasons for professional non-compliance with correct procedure and law: lack of experience and training, high workload, inadequate supervision and poor management and a bullying culture. The move away from local control of children's services to increasingly centralised structures has seriously limited essential checks and balances. Victims who have reported their abuse to numerous professionals have been labelled as nuisances and inventors of allegations, and defined as children in need of care placements rather than protection. These children were not heard, were blamed for their abuse and expected to solve it themselves. The abusers were not investigated and child protection procedures were not implemented.

In the '80s and early '90s we achieved prosecutions and children were protected. Young people and professionals were speaking out. This was resource intensive and lead to compensation and negligence claims; organisations and people with high profiles were being exposed. Proactive practitioners began to be labelled over zealous, and the mythology developed that too many children were entering the child protection net. Government directives to shift away from multi-agency joint investigation followed (Messages from Research (DOH 1995) and Framework of Assessment (DOH 2000)). Family support was framed as opposed to child protection (Letters: Community Care; Robertson 21.01.1996), and prevention presented as the opposite of interventionist policies; this allowed restructuring of the service, the centralisation of child protection work and increased privatisation (’DfES ECM next Steps p.30, 2004).

As a self-confessed whistle blower I have written the book "Protecting Children", and jointly with foster carer Kate Cairns have set up the online courses "Introduction to Child Protection".

Suggested reading

Davies L (2007) Protecting Children. Gloucester. Akamas

Davies L (2007) Responding to the needs of traumatised sexually abused children. Chapter 10 in Hosin (Ed) Responding to Traumatised Children. Hampshire. Palgrave Macmillan

Davies L (2004) The difference between child abuse and child protection could be you. Creating a community network of protective adults. Child Abuse Review 13: 426-432

Davies L (2006) There are too many Becky's. Society Guardian online 29.08.06

Davies L (2006) Data also needs protection. Society Guardian online 13.09.06

Davies L (2007) Our children have less protection now than did Victoria Climbié. Society Guardian 28.02.07

The author asked Liz to supply a note of changes in child protection since the date of the meeting. She wrote:

The main difference since 2007 has been the abolition of the child protection register in April 2008.

She also listed the following publications in 2008:


Davies, L (2008) In the shadow of a tragedy. Society Guardian online 28th January 2008

Davies, L (2008) Reclaiming the language of child protection, in Calder, M (Ed) Contemporary risk assessment in safeguarding children. Dorset. Russell House

Davies, L (2008) Reforms have been imposed at the expense of protecting children. Society Guardian online 2nd December 2008

Davies, L and Duckett, N (2008) Proactive Child Protection and Social Work. Hampshire, Learning Matters

Davies, L and Townsend, D (2008) Investigative Interviewing of Children: Achieving Best Evidence. Dorset, Russell House (Training Manual)

Davies, L and Townsend, L (2008) Joint investigation in Child Protection. Dorset. Russell House (Training Manual)

Legal representation - a modern minefield?
Mr Trevor King (TK), Solicitor and member of the Law Society's Children's Panel

Lawyers used not to be allowed to attend child protection conferences in Cornwall where I practise; I organised judicial review, took the local authority to the High Court, and the permission to attend was granted. At that time Working Together in Cornwall specified that parents could be accompanied to a conference by a friend, and "lawyers have no friends". Clients who failed to attend case conferences were denied copies of the minutes. Nowadays lawyers attend most such case conferences, and their input is appreciated, particularly by parents (and by children who attend as they are allowed to do if they wish), as they are usually bemused by the proceedings. They believe that the conference is a conspiracy which will reach a decision to remove a child from the family, whereas its purpose is to collate material. They suppose that they are deemed to be guilty until they prove themselves innocent.

A case story. The family believed that the conference would discuss whether to take their case to court, whereas the local authority had already decided to do so and the hearing was to be the following day. The mother was served with court papers that same evening, and solely because the family was from Kenya the police came to her home and removed her child the next morning. He was placed in foster care by the next day.

Child protection is indeed a legal minefield. Emergency Protection Orders (EPOs) were issued quite frequently until recently, when a judge laid down the circumstances justifying their use.

Case story. One hour following a case conference the child was admitted to hospital; the social worker, who had no medical background, presumed that this might be a fabricated fictitious illness - Munchhausen's syndrome by proxy - and within two hours had made a successful application in court for an EPO based upon no proper evidence. It took a three-week hearing 14 months later before that child was returned to the family, none of the allegations against the mother having been substantiated.

Yes, every child is vulnerable, needs protection, but how far do we go? EPOs should be issued by courts on 48 hours notice; an efficient local authority will have a social worker attending with a statement which may run to 40 pages or more; how is a lawyer called to the court without notice properly to represent his client? If you don't challenge the statement the client may reasonably accuse you of failing to represent her best interests; if you do challenge it the client, who already presumes a conspiracy against her, may become entrenched and thereafter is not seen to be co-operating with the local authority. There is no opportunity to test evidence in the available time, and the situation becomes irretrievable.

Case story. The mother's first child was removed because of a skull fracture, known to be non-accidental, but where the perpetrator could not be identified. The second child, by another partner, was allowed to remain in the home under a care order, which passes control to the local authority. This child was also removed by reason of the mother's limited capacity and the poor home circumstances, but by then the mother was pregnant again. Now the agreed plan was to place mother and baby in foster care together, but as a result of delays in the judicial system the newborn baby was removed alone, despite there being no cause for concern; a week passed before the case could be heard in court, and by then mother and baby fostering was no longer available. The local authority applied for a recovery order, enabling them to take the second child into their care, but then they varied the care plan without consulting the parents. This was successfully reversed on the ground that the order contravened the child's human rights. Subsequently the local authority had the second and third children removed from the family, since when the parents have been rehoused into good conditions.

The Human Rights Act as accepted by the government has huge value in these and other cases, but it must be said that it comes into conflict at times with the Children Act. The only other recourse available to parents is to apply for the original care order to be discharged, even when they accept its validity. It is difficult to convince the legal system that the cost in time and money justifies a court hearing in such cases, where the chance of reversing the care order is very low; the best that can be hoped for is that the court will order the local authority to change their care plan.

If a court determines that the child has suffered or is likely to suffer significant harm it may, in considering disposal of the case, make an order for the care deemed appropriate. The Children Act recommends that courts make no order at this time, but they frequently do so, particularly when it becomes known that a family member is capable of and willing to undertake a child's care on behalf of the parents. A supervision order, usually for one year and renewable, places the child in the family's care, usually when the perpetrator of the abuse has been permanently removed. And there are the options to order long term fostering or to institute a care order, giving the local authority shared care with the family.

All children need protection, including those within the care system, where abuse is sadly not unknown. Only with the advent of the Children Act in 1989 did legal aid become available in these cases; it is now possible that fixed fees will be required. But in this minefield some parents in some areas are unable to find any legal representation.

Evaluating the risks of intervention.
Jean Robinson (JR), Former Chair of the Patients' Association, lay member of the General Medical Council and committee member, Association for Improvements in the Maternity Services (AIMS)

AIMS has been at work for 40 years, gathering and evaluating evidence, taking and expressing a critical view of the healthcare professions, taking part in NICE consultations and giving evidence ourselves when appropriate. We have long experience of child protection issues, criticising the medical profession, social services and where necessary standards of care. We also support clients and lawyers in negligence cases.

We take on board whatever comes our way in confidence, and this enables us to react with an early alert system addressing significant problems. Without choosing to do so we gradually became involved in child protection cases about 10 years ago. The trickle of reports from mothers whose newborn babies had been taken from them by social services became a flood. We suspected that this was being encouraged by the Social Service Inspectorate to meet government targets for adoption. Supporting mothers at case conferences and in the family courts we came to see social service files and medical reports and were horrified by the Kafkaesque process to which they were subjected, and how helpless, unprepared, and inadequately defended they were.

For some years I sat on the disciplinary and professional conduct committees of the General Medical Council. Professional misconduct verdicts were handed down with the level of evidence 'beyond reasonable doubt'. In the family courts I was appalled by the the quality of the evidence accepted and the draconian decisions made 'on the balance of probabilities'; on legal aid the parents were getting nothing to equal the legal support available to doctors from their defence societies. We have at times been surprised how bullish and unscrupulous lawyers acting for local authorities and guardians can be. The least damaging outcome for the child may not result; interviewed recently children in care have said that they should only have been removed from their families as a last resort, and that every family member should first have been considered as a carer. Social services were playing safe, and children were losing touch with their families.

Doctors may be involved in family court proceedings because they are responsible for the child's medical care or as medical experts; as is now well known some erroneous opinions expressed by experts have had disastrous results, and have lead to the regrettable threat from the Royal College of Paediatricians that paediatric evidence might in future be unavailable.

There has since been a recognition that complaints arise from the genuine concerns of parents, that there is uncertainty in diagnosis; however parents still find that the pursuit of complaints is frustrating and stressful. A forthcoming study of parents' views will be welcome.

It has been a matter for concern that complaints themselves may sometimes lead to accusations of child abuse. Any health care worker's suspicions of abuse will usually lead to the involvement of other agencies, and the whole family is now involved in a process the outcome of which is unpredictable, and over which the originator may have little or no control. The expressions of concern may be put to unanticipated uses by professionals who have different cultural backgrounds, ethical standards - particularly on confidentiality - and knowledge bases which may be unproven. The agenda and professional language can also differ.

Multi-agency working is not as simple as it has been made out to be; in particular the responsibility of the doctor may loom largest in the public mind, when opinions, particularly those of psychiatrists, can be difficult to prove or disprove. Because of the secrecy of family courts doctors are unaware of each other's evidence, and so they are unable to criticise it as is the case in negligence procedures. Anonymity for family members may be welcomed, but professionals should not be allowed to hide behind it. Social workers with a limited understanding of them may accept the labels applied to family members by psychiatrists; these labels are permanently on record and can have a lifelong effect.

Doctors should be aware that their evidence may be merged with data of doubtful quality, and that the agenda of other involved professionals may be based on targets such as adoption. Paediatricians have complained that they are left in ignorance of the outcomes of family court hearings. They should demand to know if a child has been removed from the family and be made aware if this has a damaging result. Concealment of such information from or its alteration in social work records is not unknown. There is a tendency for medical experts to be selected whose opinions can be predicted and will be welcome; it cannot be overlooked that their work then and sometimes subsequently is lucrative.

It is my experience that the advent of the generic social worker has resulted in a lamentable fall in the the quality of their reports. With my encouragement clients have acquired the minutes of conferences which I have attended in support of them, and the accounts I have read have sometimes been sadly inaccurate and misleading. Accordingly I urge expert witnesses to treat this type of material with caution.

The adverse effects that can result from some child protection decisions have been serious and prolonged; some of the families we have followed up have removed their children from school and placed them in private education to avoid the surveillance culture to which they were being subjected. They may change registration from their general practitioners to alternative practitioners; they are afraid to take their children to accident and emergency departments.

The largest cause of maternal death in the postnatal period is suicide, leaving many children as orphans. The formerly reliable means of detecting suicidal mothers at this time, the Edinburgh Postnatal Depression Scale, has been reported by two researchers to be unreliable because some women completing the questionnaire are lying. The reason they give us - again - is the fear, known on occasion to be justified, that their babies will be removed to meet the adoption target if they are identified as depressed. And so the effective treatment of prolonged depression is evaded, and suicide may result.

Are we now really protecting children, or doing more harm than good?

Discussion.

Responding to the question 'Would it not be possible to resolve matters without the need for a court hearing?', TK explained that the protocol for care order proceedings requires them to be completed with a final hearing within 40 weeks; during this time after the initial interim order there are reviews which can lead to 28-week orders until the case is completed. Aside from the legalities it should be understood that both parents and children want their day in court before a judge, a person with a wig. And it is the opportunity, badly needed by parents, to have their say, to dispute matters in person, but not least to enable them to tell their child later in life that they fought their corner in person. LD: Bear in mind that 96% of these cases result in the the family remaining intact following calm discussion at length. However we are now seeing social workers being pushed into one-week assessments leading to hasty decisions sometimes based on what may seem to be hard evidence, but which is not relevant to the question being asked. Now that the child alone is usually the subject of assessment the valuable tool of residential assessment is no longer available.

A gynaecologist asked for advice for cases in which a mother, aware of sexual abuse within her family, is unwilling to provide evidence. JR: Apply to social services or the police child investigation team. The mother may plead for confidentiality, but this must take second place where significant harm to a child is concerned and a Section 47 investigation is required. Police involvement is essential to avoid a social worker being left with sole responsibility. A delegate recommended applying first to the child protection team, people with expertise, which exists in every NHS hospital.

JR confirmed that AIMS preserves confidentiality absolutely, but will when appropriate advise the caller which steps to take. Occasionally we contact health care professionals, but only with consent. Sadly in today's culture of fear people are giving doctors and health visitors less and less information; team working in the healthcare system aggravates this. A woman whose pregnancy results from rape may want the opportunity to adjust in a healthy way in her relationship with the baby, but she worries that if she tells a midwife it will be reported to social services. Such a baby was temporarily removed from the mother, who was never left in peace thereafter, her bond with the baby seriously disturbed. A mother subjected to violence by her partner hesitates to report it to the police, for fear that her children will be removed under a misapplied protection order. Social workers are protecting themselves rather than the children, staying in their comfort zone while a child is safely adopted.

A lawyer working for Cafcass (Children and Family Court Advisory Support Service) referred to the independent Local Authority Circular (LAC) review procedure whereby officers with the oversight of cases of all looked-after children are tasked with trying to resolve disputes or potential breaches on the part of local authorities; if unsuccessful the matter is referred to Cafcass who can invoke judicial review against the authority. It is a matter for great concern that we have received no such referrals whatsoever, which is the subject of inquiry by DfES. Why is not greater use being made of family group conferences which are intended to involve the wider family and so to obviate the need for statutory intervention? TK is unaware of authorities making use of such conferences other than on an informal basis, and his experience of LAC reviews is that they are rare. LD: Excellent as family group conferences can be when a child is known to be safe, in replacing child protection conferences they can blur the issues and it is unsurprising that parents are reluctant to come forward in circumstances where children are being thrown to the wolves. The presence of an abusive parent at a group conference is clearly unacceptable.

A delegate working in the Official Solicitor's office expressed concern at the cancellation of the Child Protection Register. JR, sharing that concern, explained that the inclusion of children 'in need of a protection plan' on the national database throws unwarranted suspicion around them, whereas it should only be the inclusion of a child in the Register that should imply the suspicion of serious harm. This important meaning, understood by families and authority alike, will be lost. We won't have the same system of flagging in Accident and Emergency and Police departments that we have now, and the important post of Custodian of the Register, held by an experienced social worker, will be replaced by individuals running information technology searches.

JR: Confidentiality in the interests of children is essential, and there is now no basis for it in ContactPoint actions, and it is unsurprising that parents are reluctant to come forward in circumstances where children are being thrown to the wolves.

A midwife: The lack of continuity of carer leads to mistrust between mother and midwife and the failure of the important communication of suspicions of harm. We are advocates for the unborn, and we are placed in a very difficult position when we are present when a newborn baby is removed. Workers in the risky business of child protection need courage and support, as Lord Laming said. Blaming healthcare professionals helps nobody, especially the children. JR: The requirement for everyone who has a suspicion of harm to report it has resulted in a flood of such reports, many from midwives which are not substantiated. Where do midwives get training in this matter, and where are social service departments to find the significant needles in the haystack? The system has gone wrong because of goals imposed without thought or investigation. An example reported to AIMS was that of a father who discussed with a schoolteacher the possibility that his eight year-old son was now of an age to walk alone to school. The teacher reported this to social services as a suspicion of harm, and the suspicion was of course rejected. Because of the way in which child protection has been oversold people anxious to avoid taking risks are making faulty judgements.

Jacqueline Dunkley-Bent, Professor of midwifery, Faculty of health and social care, London South Bank University: Being an asylum seeker does not automatically trigger a social service referral. I have reported 47 cases where women were pregnant as a result of rape; they were advised and supported appropriately, it was clear that they did not represent a risk to their babies, and child protection procedures were not considered.

Responding to a question from Gill Aston, Lecturer in midwifery and women's health studies, on the status of domestic violence in child protection cases, TK confirmed that it is recognised as a major concern for child welfare which often triggers investigation by local authorities. Financial and psychological issues commonly co-exist, and children exposed to such violence are damaged; parents often acknowledge that they need help in the form of anger management or psychotherapy, but sourcing funds for this is a major difficulty in the judicial process. JR: A sad and shameful effect of the removal of children from a scene of domestic violence is that the professionals, reassuring a mother that the baby is now safe, ignore the fact that some of these mothers are suicidal.Responding, the lead midwife for domestic violence and child abuse at the Radcliffe Hospital Oxford described the scheme in which midwives working in the local area are trained and supported in the skill of direct questioning of parents where there is domestic violence. TK: Typical is the case of a client for whom I worked. After a lifetime of verbal abuse by her father she refused to report him to social services. "He's the only Dad I'll ever have".

A delegate reported the reluctance of disabled clients to apply for needed services for fear of their being labelled inadequate parents resulting in the removal their children. JR lamented the culture of blame in our social service profession and compared it unfavourably with the supportive culture among European services. Children are put at risk if the healthcare professions are seen to have a policing and surveillance role. LD: Working Together to Safeguard Children has eliminated the term 'social worker' from its vocabulary; it sees that sort of work as something anybody can do, and the vital skills of assessment for child protection are being lost. Over- and under-interventions are rife, and both will lead to tragic outcomes. Training for police child protection teams has been reduced to a parlous level in London.

A lecturer in child health at City University: With one to two children dying weekly from abuse what will be the value of the Child Death Reviews which are now being piloted? LD: Such enquiries should be undertaken independently to prevent coverups, with as much as possible being made public; this is not the case for most Serious Case Reviews, so that we cannot learn from them.