Intro:
Welcome to the NSPCC Learning Podcast, where we share learning and expertise in child protection from inside and outside of the organisation. We aim to create debate, encourage reflection and share good practice on how we can all work together to keep babies, children and young people safe.
Host:
Welcome to the NSPCC Learning Podcast. In this episode, recorded in February 2025, we'll be speaking with Annie Hudson and Jenny Coles from the Child Safeguarding Practice Review Panel. At the end of 2024, the Panel published two new reports: a national review into child sexual abuse within the family environment and their annual report for 2023-24.
In this podcast, we'll be talking about the key themes and learning from the reports and what this means for professionals working with children. Welcome, Annie and Jenny. Thank you for taking the time to talk to us today.
So to get us started, could you introduce yourselves and tell us a bit about the Panel and its roles and responsibilities?
Jenny Coles:
Hello, I'm Jenny Coles. I'm a member of the Child Practice Review Panel, I've been on the Panel since 2022, and my background is local authority children's services.
Annie Hudson:
Hello, I'm Annie Hudson and I'm chair of the Child Safeguarding Practice Review Panel. My background is also in children's services like Jenny. I started life as a social worker and then ultimately, like Jenny, was a director of Children's Services.
The Panel was established through the Children and Social Work Act in 2017, and had its first meeting, I think, in 2018. Essentially, it was part of the new architecture around multi-agency working in England to protect and safeguard children and it has three core roles, really.
Firstly, it provides oversight of the system of local reviews that take place at a local level by local safeguarding partners in response to serious incidents where children have been harmed or indeed died as a result of abuse and neglect. So that means we see all the rapid reviews and all the local safeguarding practice reviews that are undertaken by local safeguarding partners.
Secondly, we provide a system learning role, which, by looking at all of those reviews — and through some of the thematic reviews, including the one that we're going to be talking about, about child sexual abuse in the family environment — looks at some of the patterns in practice that have emerged from those reviews, with a view of identifying where improvements may need to be made, either at a local, regional or national level, and also where there may need to be changes in policy to better support high quality child protection and safeguarding work.
And then thirdly, the Panel has a system leadership role working with many others, including safeguarding partners and national organisations — including the NSPCC — to work together to identify what's working well in the system of safeguarding children and also where there needs to be improvement.
So in a sense, we're a... I mean, we provide a bit of a weather vane through the lens — and it is a very specific lens — of where things have gone wrong for children about how well the system that we have in place is working for children and their families.
Host:
Thank you. And you mentioned there that you work with the local safeguarding partnerships in England. Could you expand a little bit more about how you do that?
Annie:
We do that in a number of ways. So first and foremost, we receive and comment, provide them with feedback, on all of the rapid reviews and all of the LCSPRs that they undertake every year. So in the 2023-24 year, it was about 340 serious incidents which generated reviews.
And we look at those reviews and then we provide feedback on those reviews to both assist their local learning, but also to assist in their improvements in practice. We use those reviews to undertake thematic reviews. We did the one on sexual abuse. We will be producing, very shortly, a thematic analysis about, firstly, race and racial bias and racism in child protection, and also one on neglect.
So we pick topics or themes and use that local material from safeguarding partners. And in all stages we look to involve... not always all safeguarding partners, but, you know, selected safeguarding partners to really help build up national knowledge and intelligence about safeguarding practice.
Host:
So with all of this learning that you're gathering, how does the Panel share that more widely with the local and the national reviews? How do you share that and what are some of those common themes?
Annie:
We do that through reports, but we also do that through newsletters, we do that through webinars. So for example, again with the sexual abuse national review, we had two really well-attended webinars — I think they both had more than 200 people coming along for each one — as a way of not just disseminating the evidence from those reviews, but also to engage people in discussion, active discussion about some of the issues which are often very complex in nature, and therefore there aren't simple solutions to resolving some of those problems. But Jenny, perhaps you want to add to that?
Jenny:
Yeah. And I think we're learning in terms of how we're doing webinars and the latest ones on our latest review of child sexual abuse in the family, as Annie said, had a lot of participants. It was only an hour, but we got a lot of information over in discussion and we welcomed the feedback because then that adds to our learning. But we also are linked into regions — each Panel member has a region — and we do attend regional conferences, talk about the Panel, but also listen to what people are doing on the ground and what they're learning, and what they think would be a broader set of learning, whether it's at their regional level or the national level as well.
Annie:
And one other thing to add is that— one of the things we're doing at the moment is that we have commissioned from an independent organisation an evaluation of the impact of the Panel's work. We are also in a continuous learning cycle and we want to get that feedback in evidence about which of the things we do have most or least impact, because we need to go on changing our practice and the ways in which we engage with the 140-150 safeguarding partners around the country.
Host:
Yeah. And how are the local safeguarding partnerships— what are they doing locally themselves? What are they gathering and taking from the national Panel and what are they getting and gathering from elsewhere? And that will be a really interesting piece of work to see what people are saying about that.
Annie:
Yeah. And I think some of the themes that we've identified and we've majored on, either in annual reports or in national reviews, have come absolutely from the evidence and the conversations with safeguarding partners. For example, in the annual report this year, one of the three spotlighted themes was around mental health and mental health of children and young people.
And that has been a very, very consistent theme, hasn't it Jenny, from many reviews, where children, for example, have taken their own lives or where they've been involved either in harm in their own home environment or externally.
And a lot of the messaging back from safeguarding partners has been about the adequacy or otherwise of mental health services, the links between mental health services and children's services and so on. So, we try and pick up and then get some more indepth evidence around themes that also local areas are highlighting.
Jenny:
And I think to add to that, in the annual review: looking at the mental health of parents and how agencies who predominantly might work with adults, how it's really important they see that individual as a parent as well and take a holistic and family approach. This has been a fairly constant theme in reviews where mental health in parents has been present.
Host:
And I know we're going to talk about the annual report a little bit later on, but the other big report we published last year was your national review into child sexual abuse within the family environment. This report explores what is needed to enable practitioners to identify and respond to concerns of child sexual abuse, putting the needs of children first.
How did you decide within that review what areas to focus on?
Jenny:
Well, first of all, we decided to do the review because that had been a theme which has grown in evidence over the last 18 months to two years. And at the point where we did it, we had a really rich evidence body. In fact, we looked at the experience of 193 children with the Centre of expertise [on child sexual abuse] doing that fieldwork and writing that report. We felt that perhaps what had happened over the years, with absolutely the right focus on child sexual exploitation outside of the family and criminal exploitation, but that had perhaps been done at the expense of not progressing practice and supporting and safeguarding children who'd been sexually abused within their families.
And we tested that out with safeguarding partners and they said, yeah, that's an area that increasingly they were finding challenging. So, for those reasons, we decided to make this a national review.
Host:
And I know when you published the review, you called it 'I wanted them to notice'. Why did you call it that?
Jenny Coles:
So we interviewed two young people for this review, and "I wanted them to notice" was a quote from one of those young people, and we thought it really powerfully summed up what the review was about. The key finding of the review was that practitioners found great difficulty in talking directly with children around child sexual abuse. And often the feedback was that when they were in the child protection system and maybe on a child protection plan, the whole focus on evidence and verbal disclosure meant that they were often put on a plan for a broader category, like neglect.
So that was a key finding of the review and, in fact, linked in to the national and local recommendations for safeguarding partnerships about training for practitioners across the system, in terms of talking to children, having the confidence and the skills to do that.
Host:
Yeah, it is difficult. Practitioners working with children feel that they're not allowed to ask somehow, don't they? And yet what we're hearing from the young people is they do want to be asked.
Jenny:
Absolutely. And again, another key and helpful finding of the review was looking at the interface of the child protection system and the criminal justice system. And what appears to have happened over really probably, Annie, we'd say the last 20 years or more, that the criminal justice system and the focus on evidence for that has actually prevented practice developing. That's a quite a strong phrase, but it was very clear what came out of this review, and that actually the child protection system, the safeguarding system, operates on the balance of probabilities and not the threshold for criminal evidence. What we're saying here is we need a step change in how children are supported and families are supported where child sexual abuse has happened within the family.
Host:
One of the things I noticed when I read the report is that when cases were referred to the police and they decided that they were going to take no further action, then social workers or other practitioners working with the families believed that that meant that the sexual abuse hadn't happened because the police hadn't taken action.
Jenny:
And the feedback we had that people felt they couldn't take this any further; that they were worried about talking directly to children in case that prevented further investigations, when in fact the police, when they stop an investigation, if they don't feel there's enough evidence, it's for now. It doesn't mean to say that can't be reopened, and it doesn't mean to say that professionals shouldn't carry on working and supporting families and talking about the abuse to ensure that children's needs are met.
Annie:
One other facet of the review, which I think is really powerful and evidences that point that Jenny's just made, is that we still operate as a system in a very fragmented, siloed way. That was the finding, which I think many of us were quite shocked by, which was that of those 193 children that Jenny just described, in a third of the cases, the instances, family members were known to have sexually abused a child in the past, or to present a risk either because they've been convicted or they've been the subject of an allegation previously.
When you unravel that, what it highlighted was how information about people who could pose a risk — and these were predominantly men — possibly historically, possibly in another part of the country with another family, that information was not made available to the children's services, people who are working with children in the contemporaneous context.
So there's something about how we share information about people who can pose a severe risk to children, but also how we need to be thinking outside the box sometimes about the risks. So, for example, somebody who may have been the focus of a police inquiry about indecent images of children. There was sometimes an assumption that that meant that they would not pose a risk to their own children, which in many instances, some instances, absolutely not; was a very incorrect assumption.
So we really do need to bring all the agencies together who have expertise in this area, including criminal justice agencies, including probation, working together so that they get that joined up picture of risk of harm to children, that's not just about the current situation, but maybe about the historical information about key family members.
Jenny:
And although we've made national recommendations, we're really clear that safeguarding partnerships can get on and we hope that the recommendations we've made are helpful and the report's helpful for them to have an action plan — for a better word — about what to do next and improve their practice. And, you know, this is all based on the evidence that safeguarding partners have put into their local practice reviews. So it is based on real practice that's happening currently.
We hope this is helpful. We've had a lot of people on the webinars. It is an area that people have wanted us to concentrate on. So we look forward to seeing how practice has developed and we're just thinking about how we can support that, but also monitor it to make sure that with all the hard work and the responses of many practitioners and children and young people, that they can see an improvement in how children are supported.
Host:
You talked a little bit - well, you mentioned the recommendations for government and recommendations for safeguarding partners as well. Would you like to expand on that a little bit?
Jenny:
I mean, in terms of national recommendations, we're asking that there should be a national strategic plan around child sexual abuse — there is a child sexual abuse strategy, but that's quite dated now probably — and that that plan takes in some of these key findings we're talking about.
Nationally, working with professional bodies, we see a change in how practitioners are trained and get the necessary skills and guidance and a multi-agency training, but from the beginning of their professional careers, and not seeing this as a specialism; because the feedback from families, and from the experts by experience that were consulted as part of this review, is early intervention here can make such a difference in terms of lessening future vulnerability.
We also had some national recommendations for the family court justice system and Cafcass to consider what's in this report. They were met as stakeholders, in terms of formulating these recommendations, and we really hope that that will be taken on board, particularly within the court arena, and we hope this will be helpful. And particularly regarding the really important thing around health support and meeting health needs of children that have been sexually abused.
So there's very clear pathways and that commissioners are clear that services they commission within the NHS and providers can meet, and people are skilled to meet, the needs of children.
Host:
So that was a huge piece of work doing that report into child sexual abuse within the family environment and you've talked about all the different ways that you've engaged there with stakeholders and are feeding back stuff out. I wonder if we can move on now to the annual report, which was published in December 2024. So that looks at safeguarding incidents across and over the last year.
What are those key themes that were coming through last year?
Annie:
Yes, this was looking at about 330 serious incidents, which actually generated more than that number of reviews. One of the first things to note is that that represented and reflected a reduction of about 18% on the number of serious incidents notified to the previous year. We don't quite understand what that's about, and further work is being undertaken to interrogate that, because we need to understand whether that's because things are not being notified when they need to be, or whether it's actually that there has been a diminuation in certain types of abuse and harm for children.
Just in terms of top lines, I suppose the first thing to be aware of is that babies under one remain the most vulnerable group for all sorts of understandable and to be expected reasons. The other age, which is, if you like, most dangerous in terms of prevalence and propensity is 16- to 17-year-olds. Those children, it is much more in terms of extrafamilial harm. With babies, obviously it's much more likely to be particular physical abuse or neglect within the family.
There is a continuation of some of the patterns we've seen in the past in terms of children, for example, who are out of education. That is partly children who are in elective home education and also children who are not on a school roll or are not in mainstream education and missing a lot of education, and that's been a major issue of concern.
Earlier last year, we published a thematic analysis of children who had been seriously harmed or died and who were electively home educated — not necessarily as a result, because most children in EHE, of course, thrive and are very happy and are safe. But there is a small group of children who don't have that oversight of agencies in terms of their wellbeing and safety. So that education dimension is really important and just reinforces the importance of children being in school because of all the benefits of school, but also because it does mean if they are vulnerable and at risk, schools will have a much more daily ability to take the temperature on how well those children are and how safe they are.
We also look at things like whether children are known to services, whether they're on a child in need plan. Quite a number, something like just over 40% of children who are the focus of those serious incidents, were known to have been a child in need, either at the time of the incident or previously. And again, that's not that surprising because these are the most vulnerable children. So you would expect that they may well have had contact with children's services, children's social care. A relatively small number were children looked after and they had suffered harm or abuse either in placements — foster placements — or were in residential placements and then harmed outside the home.
So what you get through the annual report, I suppose, is a picture of the complexity of needs, the complexity of age, and other demographics. Something like 75% of the children were from White backgrounds. There's an under-representation compared to the population of children from Asian backgrounds, and conversely, an over-representation of children from Black backgrounds, and it's partly that that has been the driver behind a piece of work we're doing at the moment, and which we will publish shortly, about race, racial bias, racism and ethnicity in rapid reviews and LCSPRs. Because we need to understand better what is going on there in terms of under- and over-representation. But most importantly, how does practice need to change and be more responsive to the needs of those children? So that's the picture of the children.
Then what we've done this year is to build on previous analysis of some of the big practice themes that we've seen over the years around, you know, focusing on the voice and experience of children, about bringing critical analysis to assessment and so on, and looked at three particular themes: parental mental health, children's mental health, and children who have been harmed in the extrafamilial environment, and done a bit of a deep dive around that. And there are some common themes which perhaps we can talk through about what we saw in relation to those issues.
Jenny:
A key theme throughout, as you'd probably expect, is multi-agency working. We always say, there should be better multi-agency working, people work in silos; but it is really complex. And we thought these three areas illustrated that and we understand that. But what our evidence shows from these reviews that in fact agencies, even though they come together in the child protection system through core groups or various professional planning groups, they're still going away and doing their actions for their own agency in a silo rather than working together. So really, it's a completely multi-agency approach.
And, you know, it's very clear that the complexity of the challenges that families and children and young people face require even closer collaboration than probably they did ten years ago, and a flexibility to operate and consider that range of information and how other professionals or practitioners working with the family or having contact with the family are responding. And the system that assists them — so the different panels, the various risk panels, particularly for those young people at risk of extra familial harm — even though they're multi-agency, the range of arenas that they're looked at and they're considered in don't always work together.
So what you get at the end of the day, rather than a real focus, perhaps, on what is going to make the difference for this child or family, is watered down by the complexity of the system that's trying to deliver the support, if you get what I mean. That was clear on the way through.
And I think, you know, in terms of the learning — and we do get feedback from safeguarding partners about what they've done in between, because it takes some time to publish a review, particularly if there might be a criminal investigation or a court trial. It shows that people are trying to streamline what they do and they are — particularly around the extrafamilial harms — setting up multi-agency hubs, bringing professionals together. And that is learning from what's happened out of some of these serious incidents and reviews.
Host:
That must be really rewarding for the Panel: having a review taking place and then seeing what is being put into place following that. Do you get a lot of that kind of feedback?
Jenny:
Well we're encouraging partnerships to do it. And in our feedback letters we say it would have been really helpful— you know, you've made a comment that the actions we can put in place, but it would be really helpful just to know how they're going, because that all adds to our database.
Host:
Okay. Shall we pause there for now, and then we can come back in the second half for the podcast and we can look in more detail at how to translate the learning from the reports into improvements for safeguarding practice.
Outro:
Thanks for listening to this NSPCC Learning Podcast. At the time of recording, this episode’s content was up to date but the world of safeguarding and child protection is ever changing – so, if you're looking for the most current safeguarding and child protection training, information or resources, please visit our website for professionals at nspcc.org.uk/learning.