In the weeks running up to the end of 2021, the stories of two children who died because of child abuse hit the headlines. Many members of the children’s workforce, including many of those I support through training and supervision, were upset, and concerned, and have closely examined their own knowledge and practice as a result. There will be a national inquiry by the Child Safeguarding Practice Review Panel, a Joint Targeted Area Inspection of all the agencies involved, and the police service are also carrying out their own internal investigation. No doubt there will be, in the fullness of time, specific recommendations made regarding improving the practice of safeguarding because of their deaths. As both cases have come into focus in my work with professionals, even with limited and partial information at hand, I thought it would be worthwhile to explore some key themes that have emerged.
What happened to Arthur and Star?
Six-year-old Arthur Labinjo-Hughes lived with his father Thomas Hughes and his father’s partner Emma Tustin at her home in Solihull in the West Midlands. There, over a period of less than three months, he was shaken and routinely beaten, poisoned, kept isolated in the home, starved, dehydrated, and emotionally abused. A camera was installed to monitor Arthur which recorded the abuse. On 16 June 2020 Arthur was severely beaten by his stepmother and he died the following day from his injuries. After his death, Arthur was found to have 130 injuries all over his body and to have been poisoned with salt. Tustin was convicted of murder and Hughes found guilty of manslaughter. Both were convicted of child cruelty charges.
Sixteen-months-old Star Hobson lived with her young mother Frankie Smith and her mother’s partner Savannah Brockhill in Keighley, West Yorkshire. During the 10 months they lived together, Star was physically and emotionally abused. The couple would record the abuse on their mobile phones. Star died on from a punch administered by Brockhill on 22 September 2020. After her death, Star was found to have bruising, tearing of her major organs, bruising and fractures, caused by deliberate twisting of limbs, punching, stamping or kicking over a period of time. Brockhill was found guilty of murder, and Smith was found guilty of causing or allowing the death of a child, just eleven days after Arthur’s abusers were convicted.
Some important themes have emerged from the early reports of these cases.
Disguised compliance and false optimism: In April 2020, just a few weeks after moving into his stepmother’s home, Arthur disclosed to his paternal grandmother that he was being badly treated. She saw serious bruising on Arthur and reported her concerns to social services. Referrals were also made by Tustin’s own parents and by Arthur’s uncle. Social workers visited the home and were told that his bruises were down to boisterous play which they believed to be true. Numerous friends and family members called social services to express concerns about Star during her short life; the first referral was made in January 2020 by her babysitter. The referrals included photographic evidence of physical abuse and social workers visited Star’s home on four different occasions. But Star’s mother fobbed off social workers, persuading them the referrals were malicious as she was in a lesbian relationship. Afterwards, the Bradford Partnership apologised for missing warning signs that could have led to firmer statutory enforcement action to protect Star.
Multi agency working: In April 2020, Arthur’s uncle spoke to West Midlands police about bruises on the boy’s back. He sent the photos to an officer but never heard back. Police later closed the log believing it required “no further role for force response” as social services were involved. The police visited Star’s home once and arranged for Star to be medically examined at a hospital, with seemingly no follow-up.
Physical abuse: Both Arthur and Star showed grave signs of physical abuse which were photographed by some of the people making referrals on their behalf. We don’t currently know why these signs were not fully registered by social workers or police and await more information on this from the inquiries.
Video evidence: in contrast to other historical high profile child abuse cases, the abusers of Arthur and Star left a trail of documentary evidence, filming it using their mobile devices and CCTV, and even, in Star’s case, sending to friends for their amusement. One attack of Star was filmed by the CCTV at Brockhill’s place of work at a recycling plant. This incontestable evidence has led to high public outrage and concern being expressed.
Lockdown: Arthur’s was sent to live with his father and paternal grandparents after his mother was convicted for murder in February 2019, during which time he seemed to be happy and well. Arthur’s abuse escalated markedly as soon as he and his father moved in with Tustin at the start of the first lockdown in March 2020. The abuse of Arthur and Star carried on behind closed doors at a time when everyone was isolating, and face-to-face meetings were rare. This increased the isolation of Arthur and Star and their vulnerability to abuse. According to data published by the Child Safeguarding Practice Review Panel, lockdown brought a 27 percent increase in serious incident notifications relating to children.
Children with family members in prison: Arthur’s mother had herself been convicted for murder in February 2019, and he had only been in his father’s sole care after her imprisonment. His maternal grandmother said Hughes had stopped her from seeing Arthur since 2019, adding to his isolation. Children with parents in prison, especially if that parent is their mother, are regarded as having been exposed to an adverse childhood experience, but they are not currently seen by safeguarding services as necessarily children in need or at risk.
Children missing in education: After his father assumed sole care of him in February 2019, Arthur started at a new school. From March 2020 in lockdown, he was now out-of-school. In April 2020, Arthur’s grandmother telephoned the school to say she had made a referral about him. After the visit to the home by social workers, the school’s Designated Safeguarding Lead (DSL) was contacted to be told there were no concerns. The school DSL agreed to check in with the family on a weekly basis to provide support during lockdown after social workers dropped the case. During the weeks of telephone contact, Hughes would tell teachers that Arthur was playing out in the garden and that he couldn’t come to the phone. Arthur’s school reopened on 8 June 2020, but Hughes did not send his son back, initially claiming the boy hadn’t slept well and would return the next day. Over the following days he reported to the school that Arthur was losing weight, wasn’t eating and might faint. Without the opportunity to see Arthur daily, the school could not witness for themselves his alarming decline in health. Arthur died 9 days after the start of term.
Keeping Children Safe in Education gives us a useful reminder of the main themes arising from serious case reviews: ‘73. It is important for children to receive the right help at the right time to address risks
and prevent issues escalating. Research and serious case reviews have repeatedly
shown the dangers of failing to take effective action. Examples of poor practice
- Failing to act on and refer the early signs of abuse and neglect;
- Poor record keeping;
- Failing to listen to the views of the child;
- Failing to re-assess concerns when situations do not improve;
- Not sharing information;
- Sharing information too slowly; and
- A lack of challenge to those who appear not to be taking action.’
The NSPCC offer an evidence based resource on how to spot and challenge disguised compliance, learning from case reviews, succinct and to the point: Disguised compliance: learning from case reviews | NSPCC Learning
Please review your local safeguarding partnership policies, including those concerned with professional challenge and escalation, which come into play when you disagree with the safeguarding decision of another professional.
This interesting blog post by a social worker in Bath is something everyone should read to help them gain a sense of perspective whilst encouraging us to really understanding the challenge and complexity of working with families who abuse. Read it and let me know what you think. 5 points about the tragic death of Arthur Labinjo-Hughes (we are unlikely to hear in the media) – Richard Devine’s Social Work Blog (richarddevinesocialwork.com) Here are the key points in summary:
- This case and others like it are extreme and rare. No system could be designed to eliminate severe child abuse and death. On the other hand, excessive vigilance to child abuse could increase the likelihood of over-and-misidentifying risk, thus leading to unnecessary (and harmful) state intrusion into family life and the traumatic removal of children from their families (Fox Harding 1997).
- Focus on extreme cases and mistakes made can lead to hindsight bias ‘the worse the outcome, the greater the hindsight bias’ (Munro 2019, p.50).
- The evaluation of social work decision-making needs to be made in the context in which they were made – sometimes in the face of parents and carers who may be going out of their way to be extraordinarily deceptive.
- Child maltreatment is being investigated more than ever, but this has not increased the identification of and reduction of child abuse (Devine, 2015). Conversely, there is accumulating and powerful qualitative evidence illustrating the harmful effects of social work involvement on the lives of children and families, sometimes disproportionately effecting poor, female, and ethnic minorities (Featherstone 2018, Bywaters et al 2016, 2019, 2020).
- Extreme anger may prevent us from being able to understand the interpersonal and psychological functioning that underpinned the behaviour of the abusers, which is worth understanding in our work to protect children.
A Guardian article challenges the notion of social workers displaying ‘false optimism’. For the writer, the issue is more along the lines of helplessness based on the stresses of the profession: ‘My years of practice and research into child protection social work suggests that far from being optimistic, when faced with such aggressive and manipulative parents, social workers’ states of mind are often closer to helplessness. They are outmanoeuvred and overcome by the suffering and sadness in the atmosphere of such homes and in the children’s lives.’ The death of Arthur Labinjo-Hughes raises hard questions – we must address them all | Harry Ferguson | The Guardian
The ‘Baby P’ effect, what can go wrong in the face of tremendous public outrage over the death of a child from child abuse: Baby P 10 years on: social work’s story (communitycare.co.uk)
My final advice to everyone reading this is to ensure that you are getting the support you need to practice safeguarding effectively. Both cases are extremely upsetting and hearing and reading about them takes its toll upon us. Safeguarding supervision for safeguarding leaders is crucial. In addition, practice self-care seriously and with real intent. Do whatever you need to do to look after yourselves. Ultimately the children you work with – as well as you – will benefit.
Want to discuss more? Sign up to one of my open safeguarding courses I deliver in partnership with Delegated Services. You can read about all my training in my current brochure.