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Laming Report 2 - a missed opportunity

I have now had the time to read through all of Lord Laming's second report. The report at least recognises the increased numbers of child deaths since the first Laming Report's changes were implemented.

It was difficult for Herbert Laming to question whether the changes that were introduced following his report into Victoria Climbie were the right changes. I did have a meeting with him, but unsurprisingly the report does not go into the basics.

It does recognise some of the new problems (such as the Integrated Childrens System), but it does not make any attempt to look at the situation from the perspective of first principles or what happens elsewhere.

Basically the system is in crisis. There is good practise, but the system still concentrates on recycling children between families rather than protecting children. There is also a large amount of bad practise that is not held to account. Unless we bring in proper accoutability for practise we will not improve the outcomes.

One of the biggest problems is that of people voting with their feet. There needs to be a proper investigation into what would bring back some of the people who have left (I have my own ideas as to why) we also need to stop worrying so much about the qualifications of the workforce, but instead be more concerned as to the quality. The crisis in terms of vacancies has to be top priority. The government's proposals are likely to make this worse.

The report still seems to be something which does not challenge the direction of travel of DCSF. However, it does warrant a comment on each of the recommendations (or groups of recommendations)

1. The Home Secretary and the Secretaries of State for Children, Schools
and Families, Health, and Justice must collaborate in the setting of
explicit strategic priorities for the protection of children and young
people and reflect these in the priorities of frontline services.

This sort of thing is like being against sin. I am pretty certain that we have strategies flowing out of our ears. The problem is at the detailed level not the strategic level.
2. A National Safeguarding Delivery Unit be established to report directly
to the Cabinet Sub-Committee on Families, Children and Young
People. It should have a remit that includes:
●● working with the Cabinet Sub-Committee on Families, Children and
Young People to set and publish challenging timescales for the
implementation of recommendations in this report;
●● challenging and supporting every Children’s Trust in the country to
implement recommendations within the agreed timescales,
ensuring improvements are made in leadership, staffing, training,
supervision and practice across all services;
●● raising the profile of safeguarding and child protection across
children’s services, health and police;
●● supporting the development of effective national priorities on
safeguarding for all frontline services, and the development of local
performance management to drive these priorities;
●● leading a change in culture across frontline services that enables
them to work more effectively to protect children;
●● having regional representation with expertise on safeguarding and
child protection that builds supportive advisory relationships with
Children’s Trusts to drive improved outcomes for children and young
●● working with existing organisations to create a shared evidence
base about effective practice including evidence-based
programmes, early intervention and preventative services;
●● supporting the implementation of the recommendations of Serious
Case Reviews in partnership with Government Offices and Ofsted,
and put in place systems to learn the lessons at local, regional and
national level;
●● gathering best practice on referral and assessment systems for
children affected by domestic violence, adult mental health
problems, and drugs and alcohol misuse, and provide advice
to local authorities, health and police on implementing robust
arrangements nationally; and
●● commissioning training on child protection and safeguarding and
on leading these services effectively for all senior political leaders
and service managers across those frontline services responsible for
safeguarding and child protection.

This is Ofsted's job
Leadership and accountability
3. The Cabinet Sub-Committee on Families, Children and Young People
should ensure that all government departments that impact on the
safety of children take action to create a comprehensive approach to
children through national strategies, the organisation of their central
services, and the models they promote for the delivery of local
services. This work should focus initially on changes to improve the
child-focus of services delivered by the Department of Health, Ministry
of Justice and Home Office.

Lots of work no real changes
4. The Government should introduce new statutory targets for
safeguarding and child protection alongside the existing statutory
attainment and early years targets as quickly as possible. The National
Indicator Set should be revised with new national indicators for
safeguarding and child protection developed for inclusion in Local
Area Agreements for the next Comprehensive Spending Review.

I agree with Laming that the performance indicators have been counter productive. It is wrong of him to criticise the National Indicators as they only came into operation less than a year ago and we cannot draw any conclusions from them.
5. The Department of Health must clarify and strengthen the
responsibilities of Strategic Health Authorities for the performance
management of Primary Care Trusts on safeguarding and child
protection. Formalised and explicit performance indicators should be
introduced for Primary Care Trusts.

No that won't help.
6. Directors of Children’s Services, Chief Executives of Primary Care
Trusts, Police Area Commanders and other senior service managers
must regularly review all points of referral where concerns about a
child’s safety are received to ensure they are sound in terms of the
quality of risk assessments, decision making, onward referrals and
multi-agency working.

This is an important, but difficult point
7. All Directors of Children’s Services who do not have direct experience
or background in safeguarding and child protection must appoint a
senior manager within their team with the necessary skills and

Stating the blindingly obvious. Something that is the case almost everywhere anyway. Before saying this there should be an attempt to find out where it is the case and where it isn't.
8. The Department for Children, Schools and Families should organise
regular training on safeguarding and child protection and on effective
leadership for all senior political leaders and managers across frontline

There is a role for better understanding as to what is happening.
9. Every Children’s Trust should ensure that the needs assessment that
informs their Children and Young People’s Plan regularly reviews the
needs of all children and young people in their area, paying particular
attention to the general need of children and those in need of
protection. The National Safeguarding Delivery Unit should support
Children’s Trusts with this work. Government Offices should
specifically monitor and challenge Children’s Trusts on the quality of
this analysis.

More work to no avail
10. Ofsted should revise the inspection and improvement regime for
schools giving greater prominence to how well schools are fulfilling
their responsibilities for child protection.

Back to the Performance Management problem.
11. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to set out clear expectations
at all points where concerns about a child’s safety are received,
ensuring intake/duty teams have sufficient training and expertise to
take referrals and that staff have immediate, on-site support available
from an experienced social worker. Local authorities should take
appropriate action to implement these changes.

I cannot see how this produces an improvement.
12. The Department of Health and the Department for Children, Schools
and Families must strengthen current guidance and put in place the
systems and training so that staff in Accident and Emergency
departments are able to tell if a child has recently presented at any
Accident and Emergency department and if a child is the subject of a
Child Protection Plan. If there is any cause for concern, staff must act
accordingly, contacting other professionals, conducting further
medical examinations of the child as appropriate and necessary, and
ensuring no child is discharged whilst concerns for their safety or
well-being remain.

This is the Childrens Index issue. There is a complex issue here.
13. Children’s Trusts must ensure that all assessments of need for children
and their families include evidence from all the professionals involved
in their lives, take account of case histories and significant events
(including previous assessments) and above all must include direct
contact with the child.

Obvious, but no identification of problems
14. Local authorities must ensure that ‘Children in Need’, as defined by
Section 17 of the Children Act 1989, have early access to effective
specialist services and support to meet their needs.

Another issue not really relevant to the remit or drawn as a conclusion from the evidence.
15. The Social Work Task Force should establish guidelines on guaranteed
supervision time for social workers that may vary depending on

Another departmental task.
16. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to set out the elements of
high quality supervision focused on case planning, constructive
challenge and professional development.

This could be good.
17. The Department for Children, Schools and Families should undertake
a feasibility study with a view to rolling out a single national
Integrated Children’s System better able to address the concerns
identified in this report, or find alternative ways to assert stronger
leadership over the local systems and their providers. This study should
be completed within six months of this report.

ie do nothing about one of the biggest procedural problems that exists. There is no sense of urgency here.
18. Whether or not a national system is introduced, the Department for
Children, Schools and Families should take steps to improve the utility
of the Integrated Children’s System, in consultation with social
workers and their managers, to be effective in supporting them in
their role and their contact with children and families, partners,
services and courts, and to ensure appropriate transfer of essential
information across organisational boundaries.

This has to be driven by practitioners and almost certainly won't be.
Interagency working
19. The Department for Children, Schools and Families must strengthen
Working Together to Safeguard Children, and Children’s Trusts must
take appropriate action to ensure:
●● all referrals to children’s services from other professionals lead to an
initial assessment, including direct involvement with the child or
young person and their family, and the direct engagement with,
and feedback to, the referring professional;
complete list of recomendations
●● core group meetings, reviews and casework decisions include all
the professionals involved with the child, particularly police, health,
youth services and education colleagues. Records must be kept
which must include the written views of those who cannot make
such meetings; and
●● formal procedures are in place for managing a conflict of opinions
between professionals from different services over the safety of a

This would completely seize up the system. It happened in Birmingham over DV referrals. This is a "systems" thing. If there are too many referrals and too much time spent on triage then there is too little time for the work needed to deal with the more serious issues.
20. All police, probation, adult mental health and adult drug and alcohol
services should have well understood referral processes which
prioritise the protection and well-being of children. These should
include automatic referral where domestic violence or drug or alcohol
abuse may put a child at risk of abuse or neglect.

Apart from the fact that this tends to happen with MARAC it also is one of the bigger problems causing the system to fail.
21. The National Safeguarding Delivery Unit should urgently develop
guidance on referral and assessment systems for children affected by
domestic violence, adult mental health problems, and drugs and
alcohol misuse using current best practice. This should be shared with
local authorities, health and police with an expectation that the
assessment of risk and level of support given to such children will
improve quickly and significantly in every Children’s Trust.

That would be good if we could stop silly referrals.
22. The Department for Children, Schools and Families should establish
statutory representation on Local Safeguarding Children Boards from
schools, adult mental health and adult drug and alcohol services.

23. Every Children’s Trust should assure themselves that partners
consistently apply the Information Sharing Guidance published by the
Department for Children, Schools and Families and Department for
Communities and Local Government to protect children.

Here we need to do proper research to find out what the problems are.
Children’s workforce
24. The Social Work Task Force should:
●● develop the basis for a national children’s social worker supply
strategy that will address recruitment and retention difficulties,
to be implemented by the Department for Children, Schools and
Families. This should have a particular emphasis on child protection
social workers;
●● work with the Children’s Workforce Development Council and
other partners to implement, on a national basis, clear progression
routes for children’s social workers;
●● develop national guidelines setting out maximum case-loads of
children in need and child protection cases, supported by a
weighting mechanism to reflect the complexity of cases, that will
help plan the workloads of children’s social workers; and
●● develop a strategy for remodelling children’s social work which
delivers shared ownership of cases, administrative support and
multi-disciplinary support to be delivered nationally.

"shared ownership of cases" - this is dangerous as it makes cases someone else's job.
25. Children’s Trusts should ensure a named, and preferably co-located,
representative from the police service, community paediatric specialist
and health visitor are active partners within each children’s social work

26. The General Social Care Council, together with relevant government
departments, should:
●● work with higher education institutions and employers to raise the
quality and consistency of social work degrees and strengthen their
curriculums to provide high quality practical skills in children’s social
●● work with higher education institutions to reform the current
degree programme towards a system which allows for specialism in
children’s social work, including statutory children’s social work
placements, after the first year; and
●● put in place a comprehensive inspection regime to raise the quality
and consistency of social work degrees across higher education

However, we start with a recruitment crisis which is not solved by making things worse.
27. The Department for Children, Schools and Families and the
Department for Innovation, Universities and Skills should introduce a
fully-funded, practice-focused children’s social work postgraduate
qualification for experienced children’s social workers, with an
expectation they will complete the programme as soon as is

Again undermining the problem with capacity.
28. The Department for Children, Schools and Families, working with the
Children’s Workforce Development Council, General Social Care
Council and partners should introduce a conversion qualification and
English language test for internationally qualified children’s social
workers that ensures understanding of legislation, guidance and
practice in England. Consideration should be given to the appropriate
length of a compulsory induction period in a practice setting prior to
formal registration as a social worker in England.

A sensible idea, but making the job one attractive for English Social Workers is better.
29. Children’s Trusts should ensure that all staff who work with children
receive initial training and continuing professional development which
enables them to understand normal child development and recognise
potential signs of abuse or neglect.

Sounds a surprising novelty.
30. All Children’s Trusts should have sufficient multi-agency training in
place to create a shared language and understanding of local referral
procedures, assessment, information sharing and decision making
across early years, schools, youth services, health, police and other
services who work to protect children. A named child protection lead
in each setting should receive this training.

Sounds a surprising novelty.
31. The General Social Care Council should review the Code of Practice
for Social Workers and the employers’ code ensuring the needs of
children are paramount in both and that the employers’ code provides
for clear lines of accountability, quality supervision and support, and
time for reflective practice. The employers’ code should then be made
statutory for all employers of social workers.

This would be an improvement as the code tend to concentrate on employment accountability.
32. The Department of Health should prioritise its commitment to
promote the recruitment and professional development of health
visitors (made in Healthy lives, brighter futures) by publishing a
national strategy to support and challenge Strategic Health Authorities
to have a sufficient capacity of well trained health visitors in each area
with a clear understanding of their role.

I am not sure that national strategies are the real solution.
33. The Department of Health should review the Healthy Child
Programme for 0–5-year-olds to ensure that the role of health visitors
in safeguarding and child protection is prioritised and has sufficient
clarity, and ensure that similar clarity is provided in the Healthy Child
Programme for 5–19-year-olds.

An attempt to go back to a better past that is sensible.
34. The Department of Health should promote the statutory duty of all GP
providers to comply with child protection legislation and to ensure
that all individual GPs have the necessary skills and training to carry
out their duties. They should also take further steps to raise the profile
and level of expertise for child protection within GP practices, for
example by working with the Department for Children, Schools and
Families to support joint training opportunities for GPs and children’s
social workers and through the new practice accreditation scheme
being developed by the Royal College of General Practitioners.

An odd thing on the back of Baby P which was not a GP issue. Rather than having a list of nice ideas there should be an attempt to identify patterns of failure and deal with those.
35. The Department of Health should work with partners to develop a
national training programme to improve the understanding and skills
of the children’s health workforce (including paediatricians, midwives,
health visitors, GPs and school nurses) to further support them in
dealing with safeguarding and child protection issues.

This is important and applies also in social work. However, the nature of the training is key.
36. The Home Office should take national action to ensure that police
child protection teams are well resourced and have specialist training
to support them in their important responsibilities.

The police tend to do quite well compared to local authorities
Improvement and challenge
37. The Care Quality Commission, HMI Constabulary and HMI Probation
should review the inspection frameworks of their frontline services to
drive improvements in safeguarding and child protection in a similar
way to the new Ofsted framework

I am not sure that there has been an identified problem for this solution.
38. Ofsted, the Care Quality Commission, HMI Constabulary and HMI
Probation should take immediate action to ensure their staff have the
appropriate skills, expertise and capacity to inspect the safeguarding
and child protection elements of frontline services. Those Ofsted
Inspectors responsible for inspecting child protection should have
direct experience of child protection work.

One of the advantages of Ofsted has been having a fresh look at the work of those in child protection. I would not wish to lose this.
39. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children so that it is explicit that the
formal purpose of Serious Case Reviews is to learn lessons for
improving individual agencies, as well as for improving multi-agency

Surprising that this is not already the case.
40. The Department for Children, Schools and Families should revise the
framework for Serious Case Reviews to ensure that the Serious Case
Review panel chair has access to all of the relevant documents and
staff they need to conduct a thorough and effective learning exercise.

Surprising that this is not already the case.
41. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to ensure Serious Case
Reviews focus on the effective learning of lessons and implementation
of recommendations and the timely introduction of changes to protect

Surprising that this is not already the case.
42. Ofsted should focus its evaluation of Serious Case Reviews on the
depth of the learning a review has provided and the quality of
recommendations it has made to protect children.

This is a bit silly. Unless the Serious Case Review is rigourous then the other things cannot be achieved.
43. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to underline the importance
of a high quality, publicly available executive summary which
accurately represents the full report, contains the action plan in full,
and includes the names of the Serious Case Review panel members.

That is sensible
44. Local Safeguarding Children Boards should ensure all Serious Case
Review panel chairs and Serious Case Review overview authors are
independent of the Local Safeguarding Children Board and all services
involved in the case and that arrangements for the Serious Case
Review offer sufficient scrutiny and challenge.

This is right, but more importantly they should be appointed by someone independent of the LSCB.
45. All Serious Case Review panel chairs and authors must complete a
training programme provided by the Department for Children, Schools
and Families that supports them in their role in undertaking Serious
Case Reviews that have a real impact on learning and improvement.

Not a bad idea
46. Government Offices must ensure that there are enough trained
Serious Case Review panel chairs and authors available within their

47. Ofsted should share full Serious Case Review reports with HMI
Constabulary, the Care Quality Commission, and HMI Probation
(as appropriate) to enable all four inspectorates to assess the
implementation of action plans when conducting frontline

The full reviews need to have a wider audience even if not being published.
48. Ofsted should share Serious Case Review executive summaries with
the Association of Chief Police Officers, Primary Care Trusts and
Strategic Health Authorities to promote learning.

If they are published then this becomes possible
49. Ofsted should produce more regular reports, at six-monthly intervals,
which summarise the lessons from Serious Case Reviews.

There is merit in this, but what matters is looking for patterns of failure
Organisation and finance
50. The Department for Children, Schools and Families must provide
further guidance to Local Safeguarding Children Boards on how to
operate as effectively as possible following the publication of the
Loughborough University research on Local Safeguarding Children
Boards later this year.

A bit obvious.
51. The Children’s Trust and the Local Safeguarding Children Board should
not be chaired by the same person. The Local Safeguarding Children
Board chair should be selected with the agreement of a group of
multi-agency partners and should have access to training to support
them in their role.

I am not sure that this matters and it could be counter productive.
52. Local Safeguarding Children Boards should include membership from
the senior decision makers from all safeguarding partners, who should
attend regularly and be fully involved as equal partners in Local
Safeguarding Children Board decision making.

There is a challenge if you take up too much senior management time.
53. Local Safeguarding Children Boards should report to the Children’s
Trust Board and publish an annual report on the effectiveness of
safeguarding in the local area. Local Safeguarding Children Boards
should provide robust challenge to the work of the Children’s Trust
and its partners in order to ensure that the right systems and quality
of services and practice are in place so that children are properly

I am not sure this will make any difference. Most annual reports merely say how well some organisation is doing. We need challenge instead.
54. The Department for Children, Schools and Families, the Department of
Health, and the Home Office, together with HM Treasury, must ensure
children’s services, police and health services have protected budgets
for the staffing and training for child protection services.

They already have budgets. How much they are ring fenced is another issue.
55. The Department for Children, Schools and Families must sufficiently
resource children’s services to ensure that early intervention and
preventative services have capacity to respond to all children and
families identified as vulnerable or ‘in need’.

That is a real challenge for government.
56. A national annual report should be published reviewing safeguarding
and child protection spend against assessed needs of children across
the partners in each Children’s Trust.

As long as it means something.
57. The Ministry of Justice should lead on the establishment of a systemwide
target that lays responsibility on all participants in the care
proceedings system to reduce damaging delays in the time it takes
to progress care cases where these delays are not in the interests of
the child.

This is a big mistake. We need to review the process whereby care proceedings and care plans operate. In many ways a child's care plan does need continual review. One big problem is getting children out of care. A rush to a court judgment is not necessarily good for the chidlren. If we could get more cooperation whereby the system cooperates with families then there would be less of a need for coercion. This particular area is one what needs a really detailed review and gets almost no attention.
58. The Ministry of Justice should appoint an independent person to
undertake a review of the impact of court fees in the coming months.
In the absence of incontrovertible evidence that the fees had not
acted as a deterrent, they should then be abolished from 2010/11

Personally I don't think the court fees issue is a key issue. Court fees are perhaps 5% or less over time of the total costs of taking a child into care.


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