In 1973, Maria Colwell, a seven-year-old girl from Whitehawk, was violently beaten by her stepfather sustaining severe internal and external injuries from which she died. She had been in foster care from age one until about fourteen months prior to her death when she was returned to live with her mother and subsequent killer.
The case caused obvious, national outcry and a public inquiry followed. That found, amongst other issues, there was poor inter agency working, sub-standard information sharing, inadequate procedures, lack of professional curiosity and not hearing the voice of the child. This tragedy was seen as the catalyst for an intended huge change in child protection procedures in the UK, including The Children Act 1989, which was designed so that such events should rarely, if ever, happen again.
However, in 2000, Victoria Climbié, an eight-year-old Ivorian girl living in London, was tortured and murdered by her great-aunt and her great-aunt’s boyfriend. Again, this triggered a public inquiry which found, among other issues, a “catastrophic” failure in inter-agency communication, a failure to follow basic child protection procedures, a lack of professional curiosity and not hearing the voice of the child. Again, this tragedy was to have led to better procedures, stronger multi-agency working and oversight and a non-negotiable emphasis on seeing and hearing from the child. New legislation, The Children Act 2004, was to have enshrined this.
Why then did a report into the murder of a Surrey ten-year-old girl, Sara Sharif, in August 2023 published last week highlight, among other failures, the same raft of issues: poor information-sharing and assessment, failures in front-door (referral) processes, suboptimal professional curiosity and not hearing the voice of the child?
Legislation demands that when a child dies or is seriously harmed, and abuse or neglect is known or suspected, a Child Safeguarding Practice Review (CSPR) should be held. These, like their counterparts in other safeguarding arenas, are intended to examine the procedures, their application and the multi-agency working that preceded the death/ harm to see if lessons can be learned. They should not apportion individual blame nor do they replace trials or inquests but they should discover systemic faults and, through their recommendations, fix broken systems.
In my previous roles as chair of Brighton and Hove Local Safeguarding Children Board (as was) and the Safeguarding Adults Boards of both Brighton and Hove and East Sussex, as well as an independent reviewer undertaking similar reviews here and abroad, I can confidently say, well-meaning as these reviews and those involved are, they do not work.
In their 2023-2024 Annual Report, the Child Safeguarding Practice Review Panel (the CSPR oversight body) found “a lack of a co-ordinated, multi-agency approach when working with children and families”, picked out that, “many reviews reflected how missed opportunities for effective information sharing impacted on having a clear and rounded understanding about the child, family and their needs,” and noted “frequently missing evidence of the voice of the child being heard, especially from those with mental health conditions or those who were being harmed outside their homes, despite these children often being adolescents.”
We can continue to review all these cases, and they can’t be ignored, but often it is possible to pre-write the findings before the first page of evidence is read. The system has been tweaked, re-shaped and rebranded while governments and various oversight bodies have come and gone yet, since the mid-seventies when we started to look at the child safeguarding system through the lens of Maria’s death, the same chasms in working together remain.
Professionals at all levels want to do everything they can to stop children coming to harm, they really do, but all the time we have disparate organisations working to different priorities, funding arrangements and government departments, all we will hear, as we have for over half a century is the same hollow rhetoric. ‘Lessons will be learned’, ‘this will never happen again,’ and ‘fundamental changes have been made.’ In my experience the answers to those assertions are, ‘no they haven’t,’ ‘yes it will,’ and ‘shifting the deckchairs is not fundamental change.’
Why don’t we start again, create a national single Child Safeguarding Body under bespoke leadership, reporting to one, not multiple, Secretaries of State and make a generational change of how we protect all children, like they deserve?
I originally wrote this for my weekly column in The Argus, published on Monday, 24 November 2025.
