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"It's everyone's job to make sure I'm alright" - Report of the Child Protection Audit and Review


"It's everyone's job to make sure I'm alright"
Report of the Child Protection Audit and Review

Executive Summary

The Child Protection Review

This report presents the findings of the Child Protection review. The central part of the review was an audit of the practice of police, medical, nursing, social work, Scottish Children's Reporter Administration, and education staff. The audit was based on a sample of 188 cases which covered the range of possible concerns about children from early identification of vulnerability to substantiated abuse or neglect.

The views of children and young people, parents and the public have contributed to the findings of the Child Protection Review which are outlined in this report. Eleven children were interviewed as part of the case audit and a further 21 children and young people with experience of the child protection system were interviewed by voluntary organisations. We included the views of 217 children and young people who discussed their experiences and concerns with ChildLine Scotland. Parents were interviewed in the audit in relation to 17 children. In addition, the findings have been informed by the views of 100 parents and other members of the public who rang ParentLine Scotland. A study of public views of child protection also contributed to the findings as did the large consultation exercise which involved parents, the public and professionals.

A literature review, analysis of child protection guidance, analysis of deaths of looked after children and information provided by speakers at a conference on child protection in other countries also informed the review.

This report outlines the findings. It presents recommendations which are based upon these findings. The recommendations are aimed at reducing child abuse and neglect in Scotland and improving services for the children who experience abuse and neglect.

The findings of the review

The circumstances of abused and neglected children

The review found that children experience very serious levels of hurt and harm and live in conditions and under threats that are not tolerable in a civilised society. Many children in the case audit and those who phoned ChildLine Scotland were experiencing serious physical abuse and sexual assault. Some children had been suffering chronic neglect for many years. Many children in the audit and those who phoned ChildLine had experienced more than one form of abuse or neglect and large numbers were living with parental substance misuse or witnessing domestic abuse on a regular basis. Sibling or peer abuse was a feature of many of the cases in the audit and was reported by many of the children who phoned ChildLine. The review findings indicate that the effects of abuse and neglect are considerable including children getting into trouble, running away from home, becoming pregnant, self harming and attempting suicide.

Protecting children

The review found that some children remained at risk of significant harm even though most children in the audit had been known to agencies for a considerable time and there had been previous referrals for many of them, There were examples of cases where neglect continued for some years and where children or their older siblings had been previously registered as being in need of protection.

Children and young people expressed mixed feelings about whether or not the child protection system had protected them. Some children who took part in the ChildLine study or who were interviewed by voluntary agencies said they were glad they had told someone about the abuse and that they now felt protected. Some children said they felt protected now they were in foster or residential care. Other children said they were more vulnerable after reporting abuse or that their position was no different. One of the reasons why some felt that the system had not protected them was because the person who had abused them had not been prosecuted. Similar views were also expressed by parents and children participating in the audit and callers to ParentLine. A small proportion of children felt they were not protected in residential care. They indicated that although they had been taken away from the person who abused them they were now vulnerable to other risks. The analysis of the deaths of looked after children indicated that in some cases agencies might have done more to protect the children who subsequently died.

The audit identified occasions when social work did not take action in response to concerns raised by health visitors and education staff who often perceived that their referrals were not taken seriously enough by social work.

Emergency protection measures were used only rarely in the sample of cases which were looked at. Social workers were reluctant to apply for Child Protection Orders unless they could demonstrate immediate risk to a child and in some cases they were concerned about appearing in court and being cross examined about their work. Other agencies were reluctant to seek an order if social work did not think one was necessary. Social workers felt there was little point in seeking exclusion orders which placed responsibility on the other adult in the household to keep the abuser out.

In some cases children were at serious risk from males who were not living in the family home but who visited the house or lived close by. In such cases Reporters had difficulty framing grounds and the hearing system was not an effective way of protecting the child. In other cases children remained at risk due to delays in the hearings system. There were delays when cases went to the sheriff court for proof; delays were also caused by late presentation of reports by social workers.

Meeting needs

The review found that children and their families do not always get the help they need when they need it. Most of the abuse and neglect experienced by children in the audit was caused by poor parenting skills and agencies responded with a range of compensatory measures to improve the day-to-day conditions for children. There was evidence of high levels of home support stabilising situations, particularly where there were problems of substance misuse. In some cases parents were greatly assisted in developing the ability to care effectively for their children. Where support to improve parenting skills was offered the contributions of family centres or nurseries were particularly impressive and in a few cases health visitors played a significant part.

Examples of meeting need included the provision of therapeutic services where children had an opportunity to work through what happened to them, come to terms with it and move towards a different future; remedial health care to address neglected problems, for example, optical or dental treatment; information and guidance about inappropriate behaviour; and change programmes that targeted entrenched problem behaviours.

In too many cases, however, the audit found that children were not receiving the services they needed and many could not access services such as health care if their parents did not co-operate. Where intensive remedial work was provided solely in the home there was little evidence of long-term success. In some cases children were living at home but virtually all the day-to-day and occasional night care was provided by a range of support services rather than by the parents. In reality the local authority was parenting the child.

A few authorities provided directly or commissioned therapeutic support from voluntary agencies and where these were offered they were valued and made a good contribution to the welfare of the children. On the whole, however, there was a shortage of skilled workers with time to offer children practical and emotional support and psychology, psychiatry and specialist counselling waiting lists were so long that children could not gain access in a reasonable timescale. Some of the parents who called ParentLine were frustrated that they could not access counselling services for children or themselves. The audit found that the needs of child perpetrators were particularly neglected, few of those in the sample had the benefit of a programme to address their sexually abusive behaviour.

The audit found that while professionals had children's 'best interests' at heart, they often did not consult with children to determine what their 'best interests' were. The views of children were often not fully considered at case conferences or were presented through third parties. Children who were interviewed by voluntary agencies complained that they were not always listened to.

The audit found examples where parents valued highly the support they were given. Some parents in the audit and those who rang ParentLine often felt they were not kept fully enough informed about what was happening. Some felt overwhelmed at case conferences. Arrangements to provide families with support were variable as was practice in ensuring they fully understood the outcomes of the meeting. Sometimes key family members, such as grandparents, were omitted from discussions. Relatives who took on the long-term care of children often felt unsupported and felt their requests for help were ignored.


The review findings suggest that many adults and children have little confidence in the child protection system and are considerably reluctant to report concerns about abuse or neglect. Many children never tell anyone they are being abused. The child protection system cannot help these children because they never enter the system and do not receive any help. Many referrals come from members of the public but the findings of the review suggest that the system is not always well understood by the public. The public attitudes study found that many adults were concerned that children would be taken away from their families if they reported abuse. Even where people were willing to report abuse they indicated that gaining access to help was not easy.

The review findings also suggest that the child protection system does not always work well for those children and adults who become involved in it. Forty children in the audit were not protected or their needs were not met following the intervention of agencies. A further 62 children were only partially protected or their needs partially met. In 77 cases children were protected and their needs met and in 24 of these cases their needs were well met.

Good practice included the provision of help to parents and children as and when it was needed, timely responses, early thought and preparation, and properly addressing the source of the risk. Sometimes agencies did all they could but outcomes for children did not improve. While some parents who received considerable support were able to improve their parenting skills and the situation improved for their child(ren), other parents were unable or unwilling to change despite high levels of intervention.

Outcomes for children were found to be highly dependent on social work doing well. Where social work performed well outcomes were generally good and when they performed less well outcomes were generally poor. While good outcomes were assisted by the work of all agencies they were less dependent on other agencies.

Where children were not protected or their needs were not met this was often the result of poor assessments and enquiries which were not sufficiently extensive. Longer-term assessments of risks were often particularly poor. Poor assessments were characterised by failure to consider the pattern of previous events; insufficient use of inter-agency information, especially health and education information; insufficient attention paid to the role of at least one key person in a child's life; lack of focus on the child and inadequate assessment of parents' ability to make use of the support on offer and to change quickly and sufficiently enough to offer children an acceptable level of care.

Practice was generally better for new babies where parents had a learning disability, mental health problem, or drug problem. In such cases health services arranged for pre-birth or pre-discharge meetings with the other key agencies. These worked well when all the key agencies attended, a multi-agency plan was made and the individual workers each played a part in implementing it.

Where, to secure their safety, children were placed successfully in foster care their circumstances, particularly material and health circumstances, often improved. Schools often noted improvements in the attitude and performance of older children following fostering. There were also cases, however, where foster carers could not cope with the behaviour of children. Occasionally children were sent back home from foster or residential placements against their will.

Good workers made a difference to the outcomes for children. In a number of instances, particularly in relation to drugs or alcohol misuse, where strong supportive relationships had been established between social workers and misusing parents, workers were able to address the problems and parents were very positive about the support they received.

Where the child protection system relied on criminal prosecution to protect children outcomes were not always good because the abuser was not always prosecuted or convicted and often remained a threat. In such cases victims were left vulnerable and felt they had not been believed.

Parents do not always feel that the child protection system is working effectively. They are not always happy with the response they receive from child protection agencies. People contacting ParentLine were often concerned about a perceived lack of activity on the part of agencies and felt they received a lack of feedback after making a referral.

The report contains 17 recommendations. The recommendations identify action that can be taken immediately to protect children and improve services as well as action that needs to take place over a longer time scale.