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Multi-agency weaknesses identified by inspectors in wake of Arthur Labinjo-Hughes tragedy

Children wait too long for assessments and MASH decisions are 'over-optimistic and lack professional curiosity' finds report

Published by Professional Social Work magazine, 21 February 2022

A significant number of children in Solihull remain in “unassessed and unknown risk” a safeguarding inspection carried out in the wake of the Arthur Labinjo-Hughes tragedy has found.

Children who need protecting wait too long for an initial assessment and there are weaknesses in multi-agency partnership working, governance and local safeguarding leadership.

Ministers ordered the joint targeted area inspection of safeguarding children in Solihull in December following the conviction of the killers of six-year-old Arthur.

Authorities came under criticism after it emerged Arthur’s grandmother had raised concern for his safety months before his death.

The inspection was particularly critical of the local multi-agency safeguarding hub (MASH) which it said is “under-resourced by all partner agencies”.

“This means that too many children in Solihull face drift and delay in having multi-agency decisions made to assess their need, reduce risk and provide proportionate interventions,” the report said.

It added: “For a significant minority, the decisions made in the MASH are over-optimistic and lack professional curiosity. This often results in repeat contacts to the MASH and an escalation of risk.”

When child protection concerns are identified, not all agencies are invited to attend child protection meetings, meaning decisions are being made without all the facts.

Operational challenges such as this are not being escalated to the Local Safeguarding Children Partnership, the report said.

Inspectors found social work assessments are completed swiftly, however “do not always involve all the relevant agencies”.

In cases of domestic abuse, the police “do not always capture the voice of the child well enough”, said the report.

West Midlands Police were criticised for focusing “more on compliance with process and crime recording” while understanding of safeguarding risks by operational leaders in health is “inconsistent”.

Multi-agency audits reviewed by the inspectors found “too much focus on process rather than the child and a lack of reflection and analysis and the prevalence of over-optimism”.

Areas for improvement identified by the inspection include:

  • Timeliness and quality of initial decision-making in the MASH
  • Communication between health agencies in the MASH
  • Attendance by all agencies at child protection meetings
  • Recording of children’s voices
  • Sharing learning from significant incidents with the wider partnership workforce.

In December, Arthur’s stepmother Emma Tustin was jailed for his murder and his father for manslaughter. Both were given life sentences.

Heartbreaking video footage from shortly before his death played in court showed the frail boy struggling to put bedding away in the living room of his home where he was forced to sleep.

In a joint statement following publication of the Solihull inspection, minister for children and families Will Quince, minister for Care Gillian Keegan and minister for safeguarding Rachel Maclean said: “Arthur's death was horrific and deeply disturbing. The two individuals responsible are in prison – but we must do everything we can to prevent any more cases like this. 

“His death serves as a daily reminder of the urgent need for all the agencies tasked with protecting vulnerable children to work together. That’s why we commissioned this joint inspection of services in Solihull, which has identified two clear areas where priority action is needed.   

“Each agency – police, health and children’s services – has an equal duty in this work and we are writing to all three to make clear our expectation that they participate fully in producing and delivering on a written statement of action.”

The joint inspection was carried out by Ofsted, the Care Quality Commission, HM Inspectorate of Constabulary, Fire & Rescue Services and HM Inspection of Probabtion.

A national review into the murder of Arthur and 16-month-old Star Hobson in Bradford is due to report in May.

Date published
21 February 2022

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