Persistent safeguarding themes from the CSPR panel

The Child Safeguarding Practice Review Panel has published a new set of 10 persistent themes drawn from national learning where children have died or suffered serious harm through abuse or neglect.

These themes reflect issues that appear repeatedly across safeguarding reviews, are recurring challenges across safeguarding practice and are not new but they are impossible to ignore:

• the child’s lived experience

• understanding the whole family

• naming and understanding harm

• understanding and responding to risk

• information sharing and triangulation

• positive and skilled engagement with families

• consent and responding when it is absent

• when cases become ‘stuck’

• stepping back safely

• culture, leadership and practice conditions.

Individually, none of them are surprising. Safeguarding professionals will spot them immediately as topics in their work. Yet they continue to be highlighted in serious incident reviews.

It is repeated time and again that good safeguarding depends on more than knowing procedures. A practitioner may understand the importance of the child’s voice but still find that professional meetings become dominated by adult accounts. A setting may have excellent information-sharing procedures, yet important pieces of information can still sit separately within education, health, police or children’s social care without anyone bringing them together.

The Panel describes effective safeguarding as depending on understanding what life is actually like for the child day to day. It also stresses the importance of understanding the child within their whole family, their relationships, circumstances and the wider environment. What is life actually like for this child? Who cares for them? Who lives in or visits the home? What relationships affect them? What has changed? What do other professionals know? It is essential that the whole family is part of the assessment and knowledge base.

Safeguarding practice can become centred on the main adults but there are other important people such as fathers, partners, siblings, extended family members or adults regularly present in the home and part of the child’s life that are often less visible. That does not mean that every adult represents a risk but how do you know who is relevant if they aren’t considered as part of the child’s life?

The Panel’s wider learning emphasises that harm rarely arises from one issue alone. Children affected by serious safeguarding issues may also have several overlapping pressures and vulnerabilities, cumulative harm. Another theme asks professionals to recognise, understand and clearly name harm.

Language matters. Terms such as chaotic family, difficult parent, poor engagement or challenging behaviour can describe a situation without saying what the child is experiencing. Repeatedly describing individual incidents without considering their cumulative effect can make significant harm appear less serious than it is. This means asking not only what happened but also what does this mean or look like for the child or children in living that situation.

Risk is not a static event. A family may cope very well for long periods and then experience bereavement, unemployment, relationship breakdown, worsening mental health, substance misuse, homelessness or another significant event. Apparent improvement does not mean risk has disappeared. Understanding and responding to risk requires an ongoing analysis, working with professional curiosity and consideration of changing circumstances. Safeguarding assessments cannot be something completed then filed. They need to change when the child’s circumstances change.

Sharing information is important, but safeguarding becomes stronger and effective when professionals bring information together and collectively ask what is happening. A nursery may know that attendance has changed. Health may know that appointments have been missed. Police may have attended the home. Housing may know that the family is facing eviction. Any of those pieces of information might seem manageable in isolation. Together, they may well be a very different story. Triangulation means using information from different sources to build a fuller understanding of the child’s circumstances and needs, to form a better picture of what the child’s life is like.

Good safeguarding depends on skilled and effective relationships with parents and carers and working with families without losing sight of the child. Most families experiencing difficulty need support rather than judgement. Respectful engagement can help practitioners understand family strengths and vulnerabilities. It does not mean agreement, and it does not mean that safeguarding action depends on parental consent. One of the Panel’s persistent themes is specifically concerned with consent and how to act when it is absent. A lack of consent does not remove safeguarding responsibilities. Decisions must focus on the child’s welfare, safety and level of risk. Practitioners should work openly with families wherever it is safe to do so, while remaining clear about their responsibilities to share information and act when a child may need protection. It’s not just about informing parents of things but also checking their understanding of what is happening and why.

What happens when cases become ‘stuck’? Sometimes concerns are present for months or years without the child’s situation improving. They may dip and out of services without any improvements. Where there are repeated referrals, ongoing assessments, regular meetings and plans, individual incidents may be dealt with, but does anybody stop to ask whether the situation is changing? Cases can often become stuck when concerns continue without better understanding, further assessment or collective response, allowing uncertainty and harm to become normalised especially when things drift, staff change and families move.

When professional involvement is reduced do they step back safely? Improvement at this moment does not necessarily demonstrate sustained change. Decisions to reduce or end support should be based on clear evidence that the child’s lived experience has improved and risk has reduced. For education settings, this is relevant in situations where attendance improves, parental engagement increases or a child appears happier. Those changes are positive, but practitioners still need to understand whether improvement is or can be sustained.

Safeguarding does not happen in a vacuum. It depends on a good strong culture, robust leadership and effective practice. Workforce pressure and instability, difficulties accessing services, leadership changes, inconsistent thresholds, fragmented responsibility and ineffective multi-agency working are all factors in the systemic challenges experienced by professionals and families.

Effective safeguarding is enhanced by good supervision, analytical reflection, established relationships between agencies, professional curiosity, constructive challenge and organisational cultures where practitioners feel psychologically safe to ask questions or to disagree. If staff are overloaded, unsupported or afraid to challenge decisions, then the best procedures may not translate into effective safeguarding practice.

These themes are intended to support and encourage reflection and discussion among practitioners, managers, leaders and safeguarding partnerships. They can be used in supervision, team meetings, learning actions and partnership discussions.

Some straightforward questions to check can be:

• Do we really understand the lived experience of the children we are worried about?

• Do we know the whole family and wider context?

• Are we naming harm clearly?

• Are we bringing information together rather than considering individual incidents separately?

• Are any of our cases becoming stuck?

• When we step support down, what evidence tells us that life has improved for the child?

• Do our culture, workload, supervision and leadership arrangements enable staff to be curious, challenge professionally and think?

As we are learning from previous tragedies, these are the questions we need to be asking about the children we are working with today.