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What is a Child Safeguarding Practice Review (CSPR)?

A Child Safeguarding Practice Review (CSPR), is undertaken by the Safeguarding Children Partnership Board when

  • Abuse or neglect of a child is known or suspected; and
  • Either – the child has died; or the child has been seriously harmed and there is cause for concern as to the way the authority, their board partners or other relevant persons have worked together to safeguard the child. (Working Together,2018: 84)

Professionals from a wide range of agencies working with a child and family contribute their experiences and perspectives to; learn and explore what could have been done differently to improve the outcomes for the child and to provide future guidance for professional practice.

Following the referral to the CSPR Subgroup and completion of a Rapid Review, accepted by the Child Safeguarding Practice Review Panel, it was decided that a local CSPR should be initiated. This review concerns the death of a baby boy who we shall call Stephen to protect both his and his family’s anonymity. He lived in the family home with his mother, mother’s partner, and older half siblings. Stephen died from head trauma at the age of 12 weeks old. His post-mortem showed evidence of historical injuries including fractures, reflecting physical abuse over time. Stephen’s mother’s partner (who was not Stephen’s biological father) has been found guilty of his murder.

In the case of Stephen all agencies were required to provide Independent Management Reviews (IMRs) and a chronology of their involvement with Stephen. Due to the unprecedented impact of COVID 19 panel meetings and consultation with practitioners and mangers were undertaken virtually. Additionally, Stephen’s mother was contacted and both Stephen’s biological father and the father to his half siblings were liaised with via virtual means for the purpose of the CSPR.

Changes in Practice Identified within the CSPR since Stephen’s death

  • A new maternity e-records systems enables maternity staff to be made aware of changes to partner/putative father details. The system for managing copies of Domestic Abuse Stalking and Honour Based Violence (DASH) assessments and police notifications has been improved to enable community midwives, and hospital-based staff, to have a timely awareness of women who may be at risk from domestic abuse.
  • Cambridgeshire Constabulary report they are ‘confident that they were now in a better place’ regarding response to domestic abuse incidents and ensuring the welfare of victims and children in the household. There is a ‘vulnerability focus desk’ in the two geographical divisions to enhance the support and supervision of frontline practice as part of ongoing developments.
  • The designated paediatrician for child safeguarding has introduced improvements in clinical practice for infant growth monitoring including a review of the systems used to record, share, and evaluate children’s measurements within the parent-held, clinic and general practitioner (GP) electronic health records.
  • Children’s social care services current framework for undertaking child and family assessments places a greater emphasis on multiagency planning at the outset of an assessment, and clarification of the contribution of agencies and professional expertise in the process.
  • The safeguarding children partnerships board multi-agency safeguarding training includes training on ‘working with parents who are difficult to engage’. Professional briefings following CSPRs (where there is evidence of parental disguised compliance or confrontational behaviour) are available as is training for practitioners in helping to support families through strategies for positive change.

Key Learning Points for Professionals

Areas for Improvement Identified within the CSPR

  • Mother’s partner was presenting as, and was believed to be, Stephen’s father. A change of partner in pregnancy is a pivotal event. Such changes should engender professional curiosity and enquiry regarding the background, role, and status of men in the household.
  • A clearer understanding of men in the family and household by all involved agencies may not only have better protected Stephen, but also offered an opportunity to explore the potential role of his father (and the father to his siblings) in the children’s care, welfare, and protection, particularly at the point of statutory assessment.
  • The initial responses to concerns of domestic abuse and the welfare of the children (i.e., the offer of early help) were not sufficiently robust. Agencies accepted mother’s explanation of neighbours’ reports being ‘malicious’, that the arguments were verbal, and that her partner was supportive.
  • The response to neighbours’ escalating concerns about the children was not sufficiently robust, reflecting previous findings from a national study that ‘insufficient weight is given to concerns raised by neighbours’ (Brandon et al., 2020:70) and the ‘hierarchy of referrer’ described in a more recent review (Shropshire Safeguarding Partnership, 2021). Agencies appear to have accepted mother’s explanation of neighbours’ reports being ‘malicious’, that the arguments were verbal, and that her partner was supportive
  • Had a statutory child and family assessment been commenced at an earlier stage (and/or there had been consideration of the application of the multi-agency pre-birth protocol) this would have enhanced multi-agency working, provided key insight into the daily lived experiences of the children. Providing a timely opportunity to support the family in addressing the known risk from the partner, including the application of the domestic violence disclosure scheme
  • Stephen’s mother and the mother’s partner exhibited cumulative incidents of ‘disguised compliance’ towards agencies giving selective bits of information to different practitioners. Both minimalised and denied the seriousness of reported domestic violence incidents to agencies and professionals.  They also refused to engage with agencies by not accepting Local Authority community support services (i.e. early help) provision and were resistant towards professional intervention when requests were made to speak to the children alone. The maternal grandmother was seen to collude with her daughter when challenged; and then conceding to the professional view.
  • There was no communication between the Community Rehabilitation Company and the outside providers involved in mother’s partner’s probation programme. Had the agencies liaised with each other this may have prompted a discussion about the pregnancy and new relationship and a call to children’s social care before the period of probation ended. This would have also highlighted the fact that rehabilitation activity requirements of his court order had not been fulfilled. There were other examples of a lack of communication between children’s social care and health partners; and the timeliness of pre-school reporting and recording of concern. Sharing information in terms of risk and protective factors between agencies who are working with a family is essential to safeguard the child(ren).
  • Once referrals were received a decision was made for LA community support services to be offered to the family instead of pursuing a section 47 inquiry. Critically, these decisions were not challenged by other services party to the information on the initial police notification and DASH and of whom were working with the family at this time. There must be respectful challenge whenever a professional or agency has a concern about the action or inaction of another. The aim must be to resolve a professional disagreement at the earliest possible stage, always keeping in mind that the child and young person’s safety and welfare is paramount
  • Child safeguarding practice balances protective factors with emergent risk before invoking procedures that may entail compulsory intervention in family life. This was evident in this case. However, there is the ever-present risk that positive findings may contribute to professional optimism that all is well.
  • Children’s social care reported that the delay in speaking to the children alone was in part due to the issue of gaining parental consent to do so, with a half-term school holiday adding to this delay. This meant that the assessment was not completed in the expected timescales.
  • Disclosing that the mother’s relative’s children had recently been subject to proceedings, may have presented an opportunity for an authoritative discussion on her own safety and that of the risks to her children in the context of the statutory assessment and known risk from domestic abuse (Department of Health and Social Care, 2017). This was also an opportunity for the practitioner to suggest to the mother that the input of children’s social care be viewed as a positive for the protection and welfare of her children, rather than being punitive.
  • The mother booked late for her maternity care, reporting that she had undertaken a pregnancy test six weeks previously which was positive. Late booking may be an indication of risk to the mother and/or the unborn child (National Institute for Health and Care Excellence, 2010)
  • Stephen was not weighed and measured at the 6–8-week developmental check within primary care. This would have identified Stephen’s ‘faltering growth’ which could have been an indicator of neglect.  It could have also assisted in the identification of other potential physical injuries.

Areas of Good Practice Identified within the CSPR

  • The police officer who attended the first call out for domestic abuse exercised good judgement in completing a DASH assessment, as well as an F101 (Police Child Safeguarding notification). The DASH assessment, which was circulated to agencies, gave the risk of domestic abuse as ‘medium’ and recorded mother’s partner’s history of previous police call outs involving an ex-partner and noted he had ‘previous convictions for assault.’
  • Initially agencies identified both the risks and the protective factors within the case. Both the school and health agencies recorded positive factors in relation to their observations of the children and it was noted that previously there had been no historical concerns in relation to the family.
  • The review highlighted that health professionals actively enquired with Stephen’s mother about potential domestic abuse. It was noted, within the review that a Health Visitor illustrated good ‘authoritative practice’ by having a ‘frank and open discussion’ with Stephen’s mother about their concerns. Consent for information-sharing was also sought and given. This practice should be commended and modelled elsewhere.
  • The school, where Stephen’s siblings attended, made good observations in relation to the children’s appearance and demeanour whilst noting any changes in their behaviour.
  • The social worker whilst on a home visit observed the partner’s ‘controlling’ and ‘confrontational’ behaviour and recorded this on file and influenced the assessment process.
  • The review author noted that for both health and social care agencies there was good management oversight of the case and ongoing supervision with case workers.


  1. The Board seeks assurance as to the way in which agencies record and update the details of family/household members. This may include completion of a genogram (or equivalent record of family make-up) and recording of current address. The recommendation applies to those providing services to children and to adults who are parents/carers. Such services should be required to demonstrate compliance with their wider responsibilities in child safeguarding.
    Consideration should also be given as to whether a change in intimate partner during pregnancy be added as a risk factor to section two of the pre-birth protocol in its next revision.
  2. The Partnership Board requires the National Probation Service to ensure that services commissioned to support offenders’ rehabilitation activity requirements (RAR) are provided with relevant information about the nature of the offending, risk management, and the expected outcome of their involvement. Information sharing includes the evaluation of progress in achieving the goals of the RAR.
  3. The Partnership Board seeks assurance that concerns, and referrals, are not processed based on a hierarchy of referrer (giving less weight to concerns from neighbours or family members). The response should be proportionate to the reported lived experiences of children and others potentially at risk within the household.
  4. The Partnership Board requires Cambridgeshire Constabulary to provide assurance that stated improvements to internal system checks ensure correct allocation, grading and sharing of DASH/F101 notifications with other agencies are in place, with evidence of impact. Partnership agencies should also seek to progress and support improvements in the management of domestic abuse notifications to ensure the identification and prioritisation of high-risk cases.
  5. The Partnership Board requires Children’s Social Care to provide assurance that children are both seen, and spoken to, within the expected protocol and timescales of a child and family assessment. Those with parental responsibility who are not resident in the family home should be made aware of agency involvement and enabled to contribute to the assessment.
  6. The Partnership Board requires health partners to report on progress in the embedding of improvements in growth monitoring of infants, with evidence of impact through quality assurance of practice.
  7. The Partnership Board undertakes quality assurance activity to assure members that the work it has undertaken to enhance practitioners’ understanding of authoritative practice has been embedded and resulted in a positive impact on practice.


Department of Health and Social Care (2017) Domestic Abuse: a resource for health professionals

HM Government (2018) Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children London: DfE.

National Institute for Health and Care Excellence (2010) Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors; Clinical guideline [CG110] London: NICE.

Further Information:

April 2022


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