1. Introduction and purpose of briefing
This briefing paper provides an anonymised Executive Summary of a Thematic Child Safeguarding Practice Review (CSPR) undertaken by Jane Wiffin in respect of three separate families affected by serious incidents of child neglect. The purpose of this briefing is to share key learning, findings and considerations arising from the review without including any information that could lead to the identification of children or families.
The full CSPR identified significant opportunities for learning and system improvement. While the full report will not be published due to concerns about identifiability, this Executive Summary is intended to support transparency, accountability and shared learning across the partnership and wider safeguarding workforce.
The review focused on understanding what helped or hindered effective multi-agency practice in identifying and responding to child neglect, with particular attention to Early Help, thresholds, information sharing, professional challenge and the lived experience of children.
2. Background of the families including a summary of the incidents
The thematic review considered the circumstances of three unrelated family groups, involving nine children aged between early childhood and late adolescence at the time of the critical incidents. All families had been known to many services over time, in most cases years, where there were long-standing concerns about child neglect, intermittent professional involvement, domestic abuse and poor adult mental health and periods where the children’s needs were not adequately met.
Across the families, the critical incidents that prompted serious incident notifications shared common features:
- Children were living in unsafe, unsanitary or uninhabitable home environments, including severe clutter, poor hygiene and environmental hazards.
- There were concerns about chronic neglect of physical care, including hygiene, nutrition and living conditions including conditions for animals as well.
- Children experienced educational neglect, including prolonged non-attendance at school, elective home education without adequate oversight, or children becoming effectively unseen by services.
- Medical needs were inconsistently met, including missed appointments, failure to follow treatment plans and lack of appropriate response to known health or developmental needs.
- In each case, professional access to children and homes was restricted, either through refusal, partial access or reliance on doorstep or remote contact.
- Action escalated late, often only when a crisis occurred, resulting in emergency responses rather than early, preventative intervention.
While the family circumstances differed in composition and complexity, the review found remarkable similarity in the patterns of harm, professional response and missed opportunities for earlier protection and support. The impact of the child neglect on the children has had life changing consequences for some.
3. Summary of reflective points
Practitioner reflection events and audit activity highlighted several recurring themes:
- Children were seen but not sufficiently understood: signs of child neglect were noticed but not always named or responded to as safeguarding concerns.
- Overreliance on parental self report led to false reassurance and delayed action.
- Consent was frequently prioritised over child welfare at a practitioner level, creating barriers to information sharing, assessment and timely intervention.
- Compensatory care, particularly by schools, helped to protect children day-to-day but sometimes masked the severity and persistence of child neglect at home.
- Professional curiosity was inconsistently applied, particularly when access to homes was limited or denied.
- Children’s voices were often absent, with few opportunities for them to be seen alone or meaningfully heard.
- Historical information was not consistently brought together, resulting in fragmented understanding rather than analysis of cumulative harm.
- Practitioners reported uncertainty about thresholds, next steps and escalation when Early Help was declined or ineffective.
- Agencies could have come together to work collaboratively much earlier.
- There was evidence of challenge fatigue, with professional disagreements either not raised or not pursued in a child centred way.
- These reflections informed the review’s key findings and practice learning.
4. Summary of key findings and practice points
The review identified systemic and practice based issues that hindered effective responses to child neglect. While individual practice strengths were evident, particularly commitment and care from frontline practitioners, the system did not consistently support early, coordinated or sufficiently authoritative action.
Key findings
- Child neglect was not consistently identified, named or analysed, particularly where harm accrued gradually.
- Thresholds and pathways for responding to neglect were perceived as unclear or inconsistently applied.
- Early Help arrangements lacked clarity about purpose, expected change and consequences of non-engagement.
- Information sharing was inhibited by misunderstanding of consent rather than enabled by safeguarding responsibilities.
- Access to children and homes was not robustly challenged when parents refused or restricted entry.
- Education and health concerns were sometimes considered in isolation rather than as indicators of neglect.
- Children with additional vulnerabilities, including disability or neurodivergence, were at heightened risk without consistently tailored responses.
- The cumulative nature of neglect was insufficiently recognised, leading to repeated low-level responses until crisis occurred.
Practice points identified
- All agencies share responsibility for recognising and responding to child neglect
- Parental consent must not prevent safeguarding action
- Early Help must be purposeful, reviewed and child centred
- Compensatory care should not replace action to address child neglect
- Refusal of access must trigger professional challenge and escalation
- Professional disagreement requires clear resolution pathways
- Child neglect must be understood across physical, educational, medical, supervisory and emotional domains
- Responses must be inclusive and affirming of children with additional needs
- Children missing education, including those on part-time timetables require prompt, coordinated oversight
5. Considerations
The review identified a number of considerations for improving partnership working at a local level:
- Strengthen confidence and consistency in naming child neglect early
- Clarify understanding and application of consent when supporting families
- Improve feedback loops between referrers and decision-makers
- Review how early help refusal or drift is escalated
- Develop clearer guidance on access to homes and seeing children
- Reinforce expectations around professional challenge
- Improve identification and response to medical and educational neglect
- Ensure tools used to assess child neglect are understood and accessible
- Embed learning about children missing education and elective home education
- Ensure strategies and practice guidance for children’s and adult’s services are inclusive of neurodiversity
- Clarify safeguarding responsibility when care is delivered across multiple services or settings
- Continue to align practice with wider reform programmes to improve integration and accountability
6. What has changed already?
The Safeguarding Partnership and partner agencies have not waited for publication of this Executive Summary to begin acting on the learning from the review. A number of improvements have already been initiated to strengthen responses to child neglect:
- Child Neglect Strategy refreshed, drawing directly on learning from serious incidents and thematic review findings.
- Child neglect assessment tools relaunched, with renewed emphasis on identifying cumulative harm across all domains of care.
- Multi-agency learning events delivered, providing feedback from audits, practitioner reflections and national evidence on child neglect.
- Front Door practice strengthened, including clearer guidance on information sharing, consent, escalation and seeing children.
- Targeted quality assurance activity undertaken, focusing on thresholds, decision-making and professional curiosity.
- Increased emphasis on “was not brought” to health appointments, embedding a safeguarding response to missed medical care.
- Improved focus on children missing education, elective home education and visibility of vulnerable children.
- Alignment with wider system reform, integrating learning into ongoing work to strengthen Early Help, family support and multi-agency safeguarding arrangements.
- These changes represent early steps in embedding learning from the review and improving the system’s ability to identify and respond to child neglect earlier and more effectively.
7. What’s next? Closing the learning loop
- We will ensure that families are appraised of the findings and recommendations where they have asked to be.
- A SMART Action Plan based on the considerations of this review will be developed and monitored by the Business Group (a multiagency group of senior leaders across the partner agencies). This includes making sure, in partnership, that specific actions are assigned to particular agencies/representatives for development. A newly stood up, multi-agency Child Neglect Task & Finish Group will undertake some of this activity.
- Through their Devon SCP representatives, agencies will commit to dissemination of learning in their individual agencies.
- The partnership will conduct an audit designed to measure the outcomes of the considerations one year after the learning has been disseminated. We call these ‘Challenge Sessions’. Agencies bring evidence of impact on the lived experience of children and families, using, for example, storyboards and also data. This will be led by the Independent Scrutineer.
- Findings and best practice examples will be shared in training events that are open to practitioners across Devon and wider.
- We will share our findings and considerations with Torbay, Plymouth and other Southwest Partnerships.