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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


In Scotland each year, about ten children are killed by a parent or parent substitute. Following the report by Dr Helen Hammond into the death of one child, Kennedy McFarlane, the (then) Minister for Education, Europe and External Affairs, Jack McConnell, ordered a review of child protection across Scotland. This report presents the findings of the review.

The Work of the Child Protection Review Team

Aims and remit

A multi-disciplinary team was established to carry out this audit and review of child protection. The team included professionals from education, the police, medicine, nursing, the Scottish Children's Reporter Administration and social work. This multi-disciplinary review was able to build on previous multi-disciplinary work, including in particular the multi-disciplinary review of support for vulnerable families which informed the work of the team and is being published simultaneously. The review aimed:

  • to promote the reduction of abuse or neglect of children; and
  • to improve the services for children who experience abuse or neglect.

The team's remit was:

  • To review, throughout Scotland, the practice of medical, nursing, social work, police, Scottish Children's Reporter Administration, education and other public, voluntary and private sector staff to examine how well these:
    • identify those children who may be being abused or neglected;
    • reduce such abuse and neglect;
    • meet these children's needs; and
    • make plans for the future wellbeing of these children.
  • To review how well agencies work together and public and professional confidence in these services.
  • To review how well professionals work together and public and professional confidence in the way they work.
  • To identify best practice.
  • To learn lessons from international developments in this field.
  • To report and make recommendations to improve professional working and the regulatory framework within which professionals operate.

The review was managed by a Steering Group chaired by the Chief Social Work Inspector, with representatives from HM Inspectorate of Education, HM Inspectorate of Constabulary, Scottish Executive Health Department, Justice Department and Education Department and the Scottish Children's Reporter Administration. The team was assisted by a consultative group which represented a range of organisations concerned with child protection in Scotland. The group's expertise was essential to the success of the project and regular meetings were held. The team was also supported by the Chairs of the Child Protection Committees and a number of other organisations and individuals were consulted on specific issues which were covered in the review (a full list of people involved in the child protection review can be found in Appendix A).


In order to achieve the aims of the review the team set out to answer a number of questions:

  • What is the extent of child abuse and neglect in Scotland?
  • What help is available to children who have been abused or neglected?
  • What help is available to parents and others who care for children?
  • What do children and young people, parents, the public and professionals think about the services designed to help or protect children who have been abused and neglected?
  • How well are children protected and what is the quality of work?
  • What might we learn from other countries?
  • How well does the system work?

In order to answer these questions, the review team undertook a range of tasks presented in diagrammatic form in Figure 1. Reports on a number of projects were prepared and some of these are available on the review website: www.scotland.gov.uk/socialwork/-childprotection2 .

Figure 1: The Child Protection review components

fig 1

Case audit of practice

Central to this review was a case audit of child protection practice. It included the work of medical, nursing, social work, police, Scottish Children's Reporter Administration, education and other public, voluntary and private sector staff. The field work was carried out between January and March 2002. This multi-agency approach to case audit was new to both the Scottish Executive and those whose work we inspected.


We wanted our sample to cover the range of possible concerns about children, from early identification of vulnerability to substantiated abuse or neglect. We asked education, health, police and social work to identify:

  • children who had been referred to the police or social work services because of concerns about abuse or neglect in the week beginning 3 September 2001;
  • children whose names were on the child protection register on 7 September 2001;
  • children whose names were on health visitors' 'cause for concern' lists in the week beginning 3 September 2001; and
  • children who had been referred by the education department because of concerns about abuse or neglect in the week beginning 3 September 2001.

In addition, all agencies were given the opportunity to submit one or two cases where they identified particularly good practice.

In total, agencies identified 5,045 cases. We included children on health visitors ''cause for concern' lists because we wanted our sample to include children about whom agencies had concerns but where these concerns had not necessarily led to child protection referrals. The sheer numbers of children on the health visitor lists (2,666) indicated that health visitors carried a considerable weight of concern about vulnerable children. Only 19 children were referred to social work from education during the identified week.

Although we had included children on health visitors' 'cause for concern' lists, we recognised that we would still miss abused children whose abuse had not yet come to the attention of any statutory agency. It was not possible to consider such children in the case audit but they were included in our ChildLine study which is described below.

From a total sample of 5,045 cases we selected 188 children for in-depth examination across all the agencies involved. To preserve anonymity, agencies were asked to submit only a child identifier unique to the agency. They were also asked to provide date of birth, gender, ethnic origin and the nearest town of residence. This information enabled us to select a sample which reflected the geographical and socio-economic conditions of Scotland and was representative of the age and gender of the childhood population. Particular attention was paid to including cases from the small number of those of black or minority ethnic origin which were submitted.

Inter-agency arrangements

The arrangements for the case audit were made locally by the relevant agencies, and in consultation with each other. We asked that each agency complete a recording document about their involvement with the child and to make available to us, in respect of each child, all the relevant paper work and staff on specified days. The response of different agencies to the task was illustrative of the complexity of inter-agency working and highlighted some of the difficulties. Those involved in the organisation of the visits reflected to us that the process of setting up the interviews and gathering files provided them with insights into their local inter-agency communication and systems for achieving joint tasks.

What we were looking for

We wanted to examine education, health, police, Reporter and social work practice and to assess how well the agencies worked separately and together. The principal focus was on the outcomes for children.

In all 188 cases, we examined detailed information provided by the relevant agencies. In 103 cases we also undertook a detailed examination of case files and conducted interviews with key staff. We carried out in-depth interviews with a total of 438 professionals:

  • 136 from social work services;
  • 130 from health professions;
  • 70 from education;
  • 64 from police; and
  • 38 Reporters.

In many instances, the same professional was involved with more than one child.

All interviews were structured in the same way so that we would obtain the same information from each and to make the process of analysis easier. Use of the inspection recording document ensured that we were able to record data in chronological order and were also able to give interviewees the opportunity to say what they wanted. Almost all interviews were conducted by pairs of inspectors, with one of the pair being from the discipline being interviewed. The observations we formed from reading the files were also noted on the inspection document. A separate inspection document was filled in for each agency involved in a case.

Issues arising during the case audit process

In most of the areas we visited we saw the health files and spoke with the relevant health staff. Often this was at short notice, as health authorities did not always know who the relevant personnel were in respect of each child. Access to health records and staff was affected by the way the issue of confidentiality was interpreted locally. This lead to different approaches:

  • records were only available with parental consent;
  • health professionals anonymised the records before we saw them;
  • health professionals spoke to records and we did not see them;
  • no records or interviewees were made available; or
  • all records and staff were freely available (the majority of cases).

Overall very few medical staff (GPs and Paediatricians) were available for interview. There was excellent health visitor attendance.

Whether attending school or not, all children of school age are the responsibility of education services. However, in a few authorities, for some children of school age, no arrangements were made for staff to be interviewed or records seen, and we had to request this information. Social work, Reporters and the police knew which staff were involved and were generally able to present both staff and files promptly. All those who attended for interview, of whatever profession or agency, fully co-operated with the team.

All agencies were asked to consider how best to offer families an opportunity to speak to us. Eight local authorities, generally through social workers, made arrangements for such meetings, though some parents and children cancelled the appointments on the day. Eleven children met with us, and a parent or parents spoke to us in relation to 17 children. In some areas, families were not informed of our visit, or given the opportunity to meet with us. Health visitors were unable to approach many of the parents of children on their cause for concern list because either the parents did not know they were on such a list, or if they did, the term 'child protection' had never been used with them.


Once we had looked at files and interviewed professionals we brought all the information together about each child to assess:

  • how well each agency had individually met its responsibility to the child; and
  • what the overall outcome had been for the child as a result of the efforts of all the agencies.

The review team discussed each case in detail as soon as possible after the interviews had been carried out so that the information remained fresh in our memories. We considered the information contained in the recording and inspection documents and pieced together all the information we had about a particular child. These discussions normally took around two hours and ended with the team rating the performance of each agency according to agreed criteria. The criteria covered both adherence to guidance, but also outcomes for the child. There was a final evaluation of the outcome for the child as a result of the efforts of all the agencies. Cases were described as 'Very Good', 'Strengths Outweighing Weaknesses', 'Weaknesses Outweighing Strengths' or 'Poor'. Very good cases conformed to accepted standards of good practice, the child was protected and their needs were met. At the other extreme, poor cases were those where children remained unprotected and their needs were unmet.

The review team comprised people from a number of different professional backgrounds and experiences. Our expectations of agency behaviour were also different and what was accepted as good practice by one team member might be seen as only adequate or even poor by another. Our discussions about these issues were the cornerstone of our understanding of the findings. It revealed the extent to which there is not a consensus about:

  • the best ways of protecting children and who has responsibility for taking action;
  • what good communication means; and
  • how much sharing of information is appropriate without breaching confidentiality or intruding upon family integrity.

In almost all cases, however, it was possible, through detailed discussion, to arrive at a shared agreement on the overall evaluation of the case. Even where differences of opinion might remain over the individual contribution of agencies to cases, there were few instances where the team were in any doubt about the overall outcome for the child.

Once practice had been scored the information from each case was entered into a database for quantitative analysis. All the demographic details supplied on the recording documents and obtained during the case audit were included. The ratings were also entered so that the database allowed identification of individual cases for more detailed assessment.

The views of children

The review team were very keen to hear children and young people's views on child protection. We recognised, however, that obtaining young people's views on such a sensitive issue would be problematic. It is difficult to carry out research with children and young people, it is especially difficult when the subject is such a distressing one as child abuse and neglect. We told agencies that we wanted to speak to children and young people during the case audit of practice but out of a total sample of 188 children we were only able to speak to 11 (6%). Many children were too young, others did not want to speak to us or agencies did not ask them to take part because they did not feel that it was appropriate.

In anticipation that it would be difficult to talk to young people about such a difficult issue, we developed a number of methods to, cumulatively, ensure the voices of children and young people could be heard.

Messages from young people

We carried out a study in conjunction with five voluntary agencies - Aberlour, Barnardos, Children 1st, Who Cares? Scotland and Women's Aid. These organisations agreed to interview children and young people on our behalf and to pass the information to us for analysis. In recognition of the potential problems of interviewing children and young people we established a number of principles to guide the process including:

  • all participants were given a confidentiality statement;
  • no young person was asked to recount direct experiences of abuse or neglect;
  • all participants were provided with an information letter about the review;
  • a young person was able to withdraw from or terminate a discussion at any point;
  • a young person was provided with support during and after taking part in the consultation exercise; and
  • informed, written consent was obtained from each young person taking part. For young people under 12 and for all young people with a clinically diagnosed learning disability or mental health problem additional written consent was sought from the parents or carers with parental responsibility for the young person. For children over 12, parents were informed of the consultation exercise.

The staff who carried out the interviews received a detailed list of our areas of interest and a checklist for collecting young people's views. The checklist was used flexibly and tailored to the needs of the young person so that the areas of discussion were not restricted and young people were able to comment on any aspect of the child protection system they wished. The areas of interest were:

  • Describe the experience of being involved in formal child protection proceedings and what it felt like for you.
  • Working through the events, what were the most helpful things that happened?
  • Working through the events, what were the most unhelpful things that happened?
  • Thinking about all the different people who may have been involved in the investigation/proceedings, was it clear who they were and what their jobs were?
  • Are there things that need to change that would improve the situation for other young people going through similar experiences?
  • Do you have any other comments or suggestions about what would help to protect children and young people?

Agencies were confident that many young people would be prepared to take part. However, some agencies were able only to interview a small number of children and young people. They found that children did not want to take part, their parents did not want them to take part, support workers did not feel that taking part would be in their interests or investigations were ongoing or court cases pending and interviews, therefore, could not be carried out. Between them the agencies did succeed, however, in carrying out 21 interviews. The information they collected from the interviews was analysed by the review team and a report of the findings was produced. Although the interviews are based on interviews with only 21 young people, we are confident that the findings of this project are similar to those of previous research studies which have spoken to young people about their experiences of the child protection system. We have used direct quotes from the young people who were interviewed to illustrate points made in the report.

ChildLine research

In order to obtain the views of those children and young people who had been abused or neglected but had not necessarily come into contact with child protection agencies we carried out a project with ChildLine Scotland. We undertook an analysis of calls made to them and letters sent to them on the subject of child abuse and neglect. We analysed ChildLine's statistics over a two-year period and also carried out a more qualitative analysis of all the calls (216) and letters (1) which ChildLine Scotland received on abuse issues over a two-week period in November 2001. All the information passed to us was anonymous. Much of the information was in the form of direct quotes from children and young people and some of these quotes have been used to highlight points made in this report. A report of the findings of the analysis of the ChildLine calls was produced by the child protection team.

The views of parents, members of the public and professionals

The review team also wanted to hear parents' and members of the public's views about child protection. Agencies were told that we wanted to speak to families during the case audit of practice but out of our total sample of 188 children we were only able to speak to parents in relation to 17 children (9%). In many instances practitioners judged it inappropriate to contact parents because of the nature of the ongoing circumstances. We were, however, able to obtain further information about parents' views and those of other family members, neighbours, and concerned citizens from the exercise we carried out with ParentLine Scotland.

ParentLine research

Children 1st run a helpline - ParentLine - which is for parents and other adults who have concerns about children and young people. We carried out an analysis of the calls ParentLine receive on the subject of child abuse and neglect in order to find out something about why some people do not choose to contact official agencies about their concerns. It was also expected that some callers would have had experience of contacting child protection agencies and we aimed, therefore, to obtain information about the nature of this contact. We carried out a quantitative analysis of ParentLine Scotland's statistics over a two-year period. We also carried out a more in-depth analysis of 100 calls which ParentLine received on child abuse and neglect over a five-month period dating back from September 2001. The information ParentLine passed to us for analysis was anonymous. Some of the information which callers provided has been used to illustrate points which have been made in this report. The child protection team also produced a report outlining the findings of the analysis of calls to ParentLine.

Public perceptions, understanding and views about child protection in Scotland

MORI Scotland were commissioned to undertake a study to assess:

  • levels of public knowledge and understanding of the child protection process;
  • expectations about the role of individuals, communities and public agencies in child protection; and
  • views about the degree to which they, as members of the public, should take responsibility or become involved.

In November and December 2001 MORI conducted eight focus groups (each comprising eight to 10 people) at a range of locations across Scotland among a cross section of the general public. The discussions focused on the following issues:

  • life in today's society;
  • awareness of the child protection system;
  • scenarios;
  • perception of areas of responsibility;
  • information needs; and
  • key priorities for the Scottish Executive review team.

MORI produced a report of the key findings of this research. Much of the information in the report was in the form of quotes and some of the quotes have been used in this report.


The views of the public and professionals were also obtained through a consultation exercise which comprised two principal elements:

  • a questionnaire that was circulated to a wide range of statutory and voluntary sector agencies involved with, and concerned about, matters of child protection; and
  • a website that was available to members of the general public, including children, to record their views and comments about matters relating to child protection.

A total of 1,219 questionnaires were sent out to:

  • Academic bodies 50
  • Statutory agencies 801
  • Voluntary agencies 222
  • Private individuals 17
  • MSPs 129

The website was open from 20 November 2001 to 31 January 2002. The questionnaire and the website were structured around three questions:

  • What helps the protection of children?
  • What hinders or prevents the protection of children?
  • What would improve the wellbeing and protection of children in Scotland?

A total of 110 completed questionnaires were submitted as formal responses on behalf of statutory or voluntary sector agencies, academic institutions or professional bodies that are involved with child protection. A total of 176 individual responses were recorded on the website or on completed questionnaires. An independent analyst provided an analysis of all the responses received from the consultation process and produced a report outlining the key findings of this process.

Other projects

A range of other projects were carried out to inform the work of the review team and to provide further information about child protection:

Lessons from elsewhere

In order to find out more about child protection practice elsewhere an international seminar was held in Edinburgh on 20 March 2002 at which the following speakers informed conference members about the systems in place in Australia, Belgium, Canada, France, Germany and Sweden:

Adam M Tomison
Australian Institute of Family Studies

Professor Andrew Cooper
The Tavistock Clinic and University of East London

Dr Catherine Marneffe
Medical Director of the Paediatric Centre
'Clairs Vallons',France

Evelyn Khoo
Umeå University, Sweden

Lennart Nygren
Umeå University, Sweden;

workshops allowed further discussion of the issues which were raised by the speakers. Professor Malcolm Hill (University of Glasgow) chaired the event and produced a report based on the findings from the seminar. This report can be seen in Appendix B.

Analysis of Guidance

All available national and local inter- and intra-agency guidance on child protection procedures was analysed, as was guidance from the Armed Forces and faith groups. A sample of guidance used by sports clubs was also looked at.

In analysing agency guidance, consideration was given to the layout, tone and accessibility of the guidelines, and to the extent to which various areas were covered. There was a focus on the extent to which the following were covered:

  • the legal background;
  • the definitions and descriptions of child abuse;
  • roles played by the various agencies;
  • degree of emphasis on inter-agency working;
  • agency or organisation procedures to be followed when a case arose;
  • the role of parents;
  • involvement of children in the proceedings; and
  • additional advice for more complex situations such as abuse of a child with special needs.

Through such an analysis, it was possible to determine the extent to which, within an area, the guidelines used by different agencies were consistent, showed an awareness of possible complexities and promoted:

  • a focus on the child's needs;
  • partnership with parents; and
  • effective inter-agency working.

In looking at the guidance provided by faith groups and sports clubs, particular attention was paid to the readability and clarity of guidance, appointments procedures for staff and volunteers and the degree of emphasis given to referring disclosures of child abuse to the statutory agencies.

Literature review

The literature review was designed to provide an overview of the ideas and research evidence on child abuse and child protection. The research evidence was presented in three parts: definitions and information; identification and assessment; addressing the problem and 'what works'. A wide range of national and international journal articles and publications were consulted in the process of producing the literature review. The literature review is published as an accompaniment to this report.

Deaths of Looked After Children

An analysis of the deaths of the 50 Looked After Children (LAC) who died between April 1997 and December 2001 was undertaken. In the event of a death of a child who is looked after local authorities are required to notify the Minister. Information, obtained from all reports, to the Minister about all children and young people who died between these dates was collated on a database. Information from reports which are notified to the Minister after this date will also be collated on this database and it is anticipated that the database will be used to record and assist the analysis of future reports of deaths of looked after children. A report outlining the findings of the analysis of reports of children who died between April 1997 and December 2001 was produced by the review team.

Deaths of children

National statistics and a range of publications were used to provide an analysis of the deaths of all children in the community. A report was produced which outlined the findings of this analysis.

Legal aspects of child protection

Professor Kathleen Marshall was commissioned to advise on the legal issues for all the agencies involved, surrounding child protection. She produced a paper, which outlined the Scottish and European legal framework for agency decision making, relevant to potential child protection cases.


Statisticians from the Scottish Executive Education Department worked closely with the child protection team in order to provide statistical support.

The structure of the report

Chapter 1 provides an overview of current knowledge about child abuse and neglect and its extent.

Chapters 2-4 present the findings of the case audit. Chapter 2 describes the circumstances of the children in the sample. Chapter 3 considers how well the children in the sample were protected and chapter 4 assesses whether their needs were met and what the outcomes for children were.

Chapter 5 considers what leads to success in child protection and discusses the issue of accountability.

Chapter 6 discusses how well the child protection system works according to the views of those who have most need of it - children, parents and members of the public. It draws on the ChildLine Scotland, ParentLine Scotland, messages from young people and MORI studies which were undertaken specifically for the review.

Chapter 7 draws on other elements of the review - the literature review, lessons from elsewhere, deaths of looked after children and consultation responses.

Chapter 8 looks to the future. In the light of the key findings, it sets out what needs to change and makes a number of recommendations which are intended to bring about these changes.