Sara Sharif: what the independent review really found and why it matters to social work reform

The Safeguarding Practice Review into Sara Sharif's death is difficult reading, and its findings are uncomfortably familiar. The patterns it describes (missed opportunities, poor coordination, failure to interpret risk) have been documented in serious case reviews for more than two decades. This review doesn't point to apathetic professionals. It exposes systemic failure that allowed risk to be misread, minimised and lost between agencies. Crucially, those longstanding gaps are exactly what current legislative reforms hope to finally address.

Domestic abuse was minimised

The review explicitly states that the father’s history of coercive and controlling behaviour and violence was overlooked, underestimated and not acted on across multiple agencies over many years.

This isn't unique to Sara’s case. It reflects a national failure to recognise domestic abuse against mothers as a direct child-safeguarding risk. The statutory domestic abuse practice standards outlined in the government's children's social care reforms (stemming from the MacAlister review) are meant to fix this by requiring professionals to map patterns, not incidents, and to centre perpetrator behaviour in assessments. Whether that happens in practice remains to be seen.

Elective home education removed scrutiny

Sara’s move into elective home education removed the last meaningful oversight. Professionals tried to visit but were sent to the wrong address. By the time the error was caught, she had died. While the review doesn’t criticise home education itself, it does criticise the absence of a statutory mechanism to track children who are already vulnerable. The government has now committed to a statutory register for children not in school. This review makes that harder to ignore or delay.

Information was everywhere and nowhere

The safeguarding review concluded that very substantial information existed across agencies but was not joined up. No single agency held the complete picture, and the system did not require them to. This pattern echoes past tragedies such as Victoria Climbié, Peter Connelly, Arthur Labinjo-Hughes and now Sara Sharif.

The Children’s Wellbeing and Schools Bill 2024 proposed multi-agency child protection units led by experienced social workers, designed to bring fragmented decision-making under one roof. At present, rollout is uneven and progress is slow.

Professional curiosity didn’t translate to action

Professionals did raise concerns. They questioned why Sara had suddenly begun wearing a hijab, noting that it marked a sharp change in her presentation. They noticed bruising and queried explanations. Several practitioners attempted to test the narratives they were given, but none of this cohered into coordinated action, and nothing triggered the level of professional escalation the circumstances required.

The review is clear that uncertainty around cultural interpretation played a role. Practitioners were hesitant to challenge the family’s explanations, unsure whether they were misreading cultural or religious practice or whether what they were seeing signalled significant harm. This hesitancy sat alongside a lack of confidence to interrogate whether claims of cultural expectation aligned with the wider pattern of risk.

This finding goes to the heart of one of the most difficult aspects of safeguarding practice –distinguishing between genuine cultural variation and explanations being used to mask abuse. The national reform agenda speaks directly to this tension through its emphasis on cultural competence – not as deference or avoidance, but as an ability to understand cultural context while still applying clear, evidence-based safeguarding judgement.

The challenge for practitioners is exactly where that line sits, and the challenge for the system is to ensure they have the confidence, supervision and structural backing to draw that line decisively when risk is present.

Oversight wasn’t strong enough

Delays in verifying addresses and missed home visit follow-ups that slipped between teams featured in Sara’s case. The review makes clear that these were not isolated mistakes but symptoms of structural strain – high workloads, workforce turnover, and weakened managerial oversight at key decision points. In several moments, the system simply did not have the capacity to maintain a clear line of sight on a child who was already vulnerable.

This speaks directly to the workforce element of the reform programme – the need for strengthened supervision standards, national practice expectations, and better support for complex decision-making. These reforms matter but they will not deliver their intended impact unless the workforce has the stability and space to use them.

Supervision standards cannot compensate for chronic understaffing. National expectations mean little if teams are stretched to the point of operating in permanent crisis mode. Structural reform only succeeds if practitioners have the time, managerial grip and organisational backing to do the work the standards demand.

What this review exposes

Sara’s case exposes gaps that reforms propose to close:

• Specialist multi-agency units to resolve fragmented decision-making
• Statutory domestic abuse standards to ensure perpetrator behaviour is recognised
• A national register so vulnerable children can’t disappear
• Mandated data standards to prevent siloed assessments
• A stable, skilled workforce to prevent drift

But here’s the problem: the review doesn’t identify anything new. These failures are longstanding, predictable and well-documented. The reforms point in the right direction but whether they deliver depends on implementation consistency, proper resources and measures not being allowed to drift under competing pressures.

Without that, we know what happens. Another blueprint. Another review. The same findings. Another child.

Where this leaves social work

Social workers have been saying this for years: safeguarding doesn’t fail because individual practitioners are careless, it fails when the system creates conditions for uncertainty, hesitation, delay, and fragmentation. The Children’s Wellbeing and Schools Bill offers the most significant opportunity in over a decade for a redesign to address those weaknesses. But it will only deliver change if implemented with fidelity, funded adequately and backed by political will that lasts beyond one parliamentary cycle.

Sara Sharif’s death was a predictable tragedy. The critical question now is whether the system that failed her will be transformed with the seriousness this review demands, or whether the government will allow the necessary resources and political will to fade, leaving us to read another report, with another child's name, telling us what we already knew.

Amy Eyers is an independent safeguarding consultant and former child protection chair with over a decade's experience in children's social care. She has worked across frontline, management and quality assurance roles, and now advises organisations on safeguarding practice, policy, and training