Lucy Kapasi reports
"Limited understanding of what daily life was like for Arthur...protective father framing never challenged...the response to concerns about bruising to Arthur was undermined".
These are some of the key findings highlighted in a review into the death of Solihull's Arthur Labinjo-Hughes.
The six-year-old's case shocked the nation last year after a harrowing nine-week trial revealed he was subjected to a horrific campaign of abuse at the hands of his dad Thomas Hughes and his partner Emma Tustin.
Tustin was jailed for a minimum of 29 years for his murder, while Hughes was sentenced to 21 years for manslaughter.
An independent review, commissioned by the government, has now been published by the national independent Child Safeguarding Practice Review Panel.
It focuses on the deaths of Arthur and 16-month-old Star Hobson in Bradford.
The review says it "attempt to understand how and why the public services and systems designed to protect them were not able to do so".
The review also says the child protection system must be "strengthened locally and nationally".
It also highlights a need for a "clearer and sharper focus" on protecting children from significant harm.
The review did say that it "does not mean that the child protection system is broken" and said "indeed there is good evidence that, every day, many thousands of children are protected from harm by conscientious, committed and capable social workers, police officers, health, educational and many other professionals."
ITV News Central has pulled out a number of key findings raised in the review concerning Arthur's case.
Limited understanding of what daily life was like for Arthur
Professionals had only a limited understanding of what daily life was like for Arthur.
The short time for developing a relationship and engaging with Arthur in assessments and visits limited the scope to establish trust.
The report says that professionals did not always hear Arthur's voice.
Arthur’s voice was often mediated by his father in contact with professionals.
The review says too many assessments relied on his father’s perspective and did not include the views of the wider extended family or other professionals who had significant involvement with Arthur.
'Protective father' framing never challenged
Thomas Hughes was seen from the very first assessment in 2019 as a protective father.
The report says whilst this was a reasonable judgement at that time, this framing was never subsequently challenged by any professional when circumstances changed and when evidence to the contrary - such as reports from Thomas' own family that they were not sure he would protect Arthur - was available.
Family concerns not taken seriously
Arthur’s wider family members were not listened to, despite their many attempts to get agencies to look into what might be happening to Arthur.
Their views were not sought and their concerns were not taken seriously.
Family members and other connected adults can speak on behalf of the child and enable their voice to be heard.
There was never proper consideration given to the risks to Arthur arising from the move to live with Emma Tustin, despite her long involvement with children’s social care and the very significant information about her that was available.
Response to bruising concerns
The response to concerns about bruising to Arthur was undermined by the lack of a multi-agency strategy discussion, which should always be triggered when there are allegations about the suspected abuse of children.
What is really happening to children
The reviews conclusion is that a pivotal factor underpinning many of these practice issues was a "systemic flaw in the quality of multi-agency working".
The review says there was an over-reliance on "single agency processes" with superficial joint working and joint decision making. The report said this had very significant consequences.
The nature of the assessments and decisions that child protection professionals are being asked to make are extremely complex. The report said they cannot do it alone.
Robust multi-agency working is critical to the challenging work of uncovering what is really happening to children who are being abused.
At the heart of the review's recommendations is a proposal for a new approach to undertaking child protection work.
The review recommends that "Multi-Agency Child Protection Units" which are described as "integrated and co-located multi-agency teams" staffed by experienced child protection professionals, are established in every local authority area.
The report says these teams will be staffed by professionals with the "highest levels of child protection expertise and experience" and will see the key child protection agencies of the police, health and social care working together "seamlessly as a single team".
The review says that would mean "that there would be a consistent and highly skilled group of multi-disciplinary professionals leading statutory child protection practice in every local area".
The review's other recommendations are rooted in "enabling the proposed new Multi-Agency Child Protection Units to deliver excellent practice".
The review has put forward proposals for strengthened multi-agency leadership and accountability, and for better multi-agency co-ordination and system oversight from central government.
The report also says "roles and responsibilities for child protection need to be clearer nationally and locally".
Solihull Council response
Solihull Metropolitan Borough Council has released a statement concerning Arthur Labinjo-Hughes which was published on their website and YouTube on Thursday, May 26, 2022.
Nick Page, CEO of the council, said: "Arthur's brutal murder has devastated our community and there isn't any one of us that's not been horrified by this awful crime committed by the very people who should have protected and nurtured this little lad.
"Over the last few months we've had a group of national experts shine a light on what we have been doing in Solihull and understanding how we need to get better.
"And they have given us some really important areas to sort out.
"Within this they have also seen that our independently led improvement panel is doing the right thing by bringing all those different people together who have to safeguard and protect our children in Solihull. There's lots to do.
"When children talk to us they say they expect and they deserve to be safe and happy and they expect us to to be expert, dedicated and caring.
"Our social workers, they keep families together and they put families back together again as well.
"I also need to say what I see what's going going on in our communities. We have 48,000 children in Solihull and I want you to imagine that they could all get inside a big city football ground.
"And most of them, the vast majority of those children live happy and safe lives. They are doing great. But when I read reports from the NSPCC I read perhaps one in every ten children possibly are at risk of some form of abuse.
"And I look at the numbers of children we are working with and we are working with one in 25 children in Solihull.
"So imagine that football ground we are working with a lot of the children in the away end.
"When I talk about this, I'm talking about children that live with the risk of threat, violence, hate, abuse and for some a small number that's their daily grim reality.
"This needs talking about. This needs explaining.
"We have (more than) 120 social workers in Solihull and when I talk with one of the experts that's come in to help us she describes their work, social work like it's making a really difficult jigsaw puzzle with some of the pieces missing.
"Not only are they doing that difficult jigsaw, they are also doing perhaps another 15 or 20 at the same time with pieces missing as well.
"What I'm clear about is that social work, being a social worker is one of the most caring yet hardest vocations to do.
"And i'm proud that we have got expert, dedicated and caring people working with us here, but I have been concerned over the last six months because the level of abuse and even threats towards them has meant that some have had to leave their own homes with their families, with their children and their partners.
"This can't be right. So my considered view is this now is not the time for blame but it is most definitely the time for learning and sorting.
"And also we need to think long and hard about how we support those and help those children and young people live happy and safe lives."
The current independent review says that "it recognises that Safeguarding Partners in Solihull are working to address a number of the issues identified through local learning processes and have acted swiftly following OFSTED’s Joint Targeted Area Inspection".
Department for Education response
Education Secretary, Nadhim Zahawi, said: “Nothing is more tragic than the death of a child, but when that child dies as a result of abuse or neglect it is incomprehensible.
"The deaths of Arthur Labinjo-Hughes and Star Hobson appalled the nation and highlighted the urgent need for action and change.
“I commissioned the Child Safeguarding Practice Review Panel to conduct an independent national review into Arthur and Star’s deaths because the enormity of the two cases made clear that there remain some very hard questions to answer about how we protect vulnerable children, despite the improvements made since 2010.
“I would like to thank Arthur and Star’s extended families for their important contributions, under extremely difficult circumstances.
"I’m also grateful to Annie Hudson, chair of the Panel, her team and all the professionals in Bradford and Solihull who engaged with the review.
“As Education Secretary, but also formerly as Children’s Minister, I have met and worked with some of the most dedicated social workers in the country.
"Every day they protect and support families without public recognition.
"But we must be honest about where we can strengthen the system so that it helps, never hinders, good decision-making for everyone involved in child protection: the police, health services and children’s services.
“We must waste no time learning from the findings of this review – enough is enough. I will set up a new Child Protection Ministerial group, a first and immediate step in responding to these findings, before setting out a bold implementation plan later this year to bring about a fundamental shift in how we support better outcomes for our most vulnerable children and families.”
West Midlands Police response
Assistant Chief Constable Claire Bell of West Midlands Police said: “The tragic death of Arthur Labinjo-Hughes has had a profound impact on so many people. We owe it to Arthur to not miss a single opportunity to learn from what happened to him so we can better protect children in the future.
“The report by the national Child Safeguarding Practice Review Panel makes a number of important local and national recommendations that will help police and partners to work more effectively together.
“We will continue to work with our partners to act on these recommendations, building on the progress we have already made to improve safeguarding for children across the West Midlands. This includes investing additional resources into child safeguarding in Solihull, and improving the quality and management of information held on the force records management system to enable us to identify and manage risks more accurately and improve our ability to prevent and investigate crime.
“The report acknowledges the dedicated work of officers and staff who work in child protection, who face the most complex challenges. We are committed to ensuring they have the best training and support and are providing additional training across a range of vulnerability and safeguarding, including domestic abuse incidents. This will strengthen their ability to identify and protect children from all forms of cruelty and neglect.
“We know there is still more to do and we are determined to work collectively with partners to act upon the panel’s recommendations and make the changes needed to better safeguard children in the future.”
The review "sought to make sense of what happened to Arthur and Star, recognising the uniqueness of their individual lives, so that we can consider what we might do differently in the future".
The national review was initiated in the context of widespread public distress about the circumstances of the deaths of these children that followed the conclusion of the two murder trials.
A set of issues were identified in the review which hindered professionals’ understanding of what was happening to Arthur and Star.
These including weaknesses in information sharing, a lack of robust critical thinking and challenge within and between agencies, a need for sharper specialist child protection skills and expertise as well as the need for leaders to have a powerful enabling impact on child protection practice.