The centrality of information sharing to effective child safeguarding cannot be stressed enough. Of the 66 serious case review reports reviewed in depth, there was only one where information sharing was not specifically mentioned. All others identified issues ranging from direct failure to identify risk or protect the child to simply identifying information sharing as an area for improvement. In contrast, in over ten years of analysing serious case reviews, we have not come across a single case where a child has been killed or harmed because a professional has shared information.
It is vital that professionals for whom safeguarding is not a core responsibility, or rests within a wider range of responsibilities, are aware of the need to share information early. In the following examples, professionals were party to information relevant to
safeguarding but did not share it with those who could have assessed it from the perspective of child safety:
“The perpetrator repeatedly stated [to the Probation Trust] his intention to move into independent accommodation with the mother and the Child. However this did not prompt any enquiry or referral to Children’s Social Care to ensure that the child was safeguarded. The mother was to move to independent accommodation and the perpetrator was to breach his curfew to move in with her. Within two days he had violently assaulted both the Child and the mother… [the] Probation Trust only had information gleaned directly from the perpetrator who clearly minimised the extent of his mental health issues, substance abuse and violence, whilst the Mental Health service was aware of the extent and volatility of his behaviour.” “Mother spoke to her General Practitioner (GP) before pregnancy about domestic abuse, but this information was not included in the antenatal referral and no other professionals were aware of this as a potential concern.”
Failure to share relevant information precludes effective assessment of parental capacity and child vulnerability, as in the following case:
“The IMR Author identifies that the impact of not sharing information in a timely manner was that the information about [the mother’s] medical history was not shared and did not therefore inform assessments of her ability to care for initially two and then four additional children. [The mother] had a history of Post-Traumatic Stress Disorder since the sudden death of her husband 13 years previously and dependence on diazepam.”
7.1.1 When to share information
It is difficult to decide when to share relatives’ personal information, such as a sexual history, finances, or personal views. Nevertheless, it seems that often the default position is to not share such information unless a practitioner actively decides to do so. This
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means that no professional would have a comprehensive overview that would enable appropriate risk assessment. This was highlighted in the following case involving a 19- month-old who died following an unexplained non-accidental head injury:
“Mother shared with her GP that she wanted a termination, but she found that her pregnancy was too far advanced… An antenatal referral was made, which did not include the information regarding Mother planning a termination… consequently no other professional knew about this start to the child’s life or had an opportunity to consider its meaning for the child or Mother. Although this was an intensely personal issue, the GP should have made an assessment of whether sharing this information as part of the health response to antenatal care would be appropriate in the context of Mother and the unborn child’s wellbeing.”
An alternative position, suggested at by the quote above, would be to presume that any information that has a bearing on child welfare should be shared with other professionals unless there is reason not to. As such, the onus would be on the professional to make an active decision not to share information and to document their reasoning.
Despite the frequent issues in communication, several serious case reviews highlighted very good information sharing practice, particularly where this may be outside the usual remit of particular professionals:
“The following week, the Neighbourhood Safety Officer spoke to the Health Visitor and made another referral to Children’s Social Work, concerned that:
The child had no cot and was sleeping with [the mother]
Anti-social behaviour was continuing and [the mother] was at risk of eviction
There were complaints of parties and drug taking whilst [the child] was present
[The maternal grandmother] was reporting ongoing concerns about [the mother’s] lack of money.”
The persistence of findings relating to communication and information sharing suggests a deep, systemic issue. That information sharing is highlighted repeatedly in reports and training suggests neither a lack of professional awareness nor a failure to appreciate the importance of information sharing that is at fault. Nor can the issues be blamed on lack of guidance or systems for sharing information. All national guidance and
legislation on confidentiality and data protection supports sharing information to safeguard children and vulnerable people (Appendix B).
Our reviews of serious case reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals. The following excerpt, from a case of a two and a half year old killed by his mother who had significant mental health needs and
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issues around domestic abuse, illustrates anxiety and confusion among professionals, creating barriers to effective information sharing. Data protection legislation is viewed as a set of constraints limiting information sharing rather than a facilitative tool:
“In the absence of a system to continually assess the risk to children, universal services are best placed to raise concerns. This case has illustrated that in order to perform a child protection role effectively universal services need to be fully informed of the family ‘history’. However, data protection legislation and concerns about information sharing is leading to anxiety and confusion about when
information can be shared, and with whom, with or without consent. The culture of patient confidentiality in some organisations, such as those working within ’health’, means that the focus tends to be on protecting this right rather than on the safety of children.”
This serious case review identified a ‘culture of patient confidentiality’ prioritising the right to confidentiality over child safety. It appears that, in spite of outrage at children’s deaths, abuse and sexual exploitation, our professional, legal and political cultures continue to emphasise the right to privacy, fuelled by public fears of a ‘nanny state’, and excessive surveillance and scrutiny.
It is our view that, unless and until this culture is challenged and society accepts that children’s safety deserves a higher priority than individual privacy, information sharing will continue to be an issue whenever children die or are seriously harmed as a result of abuse or neglect.
7.1.2 Gaps in information sharing
The centrality of communication and information sharing to effective safeguarding practice was again identified in the later stages of child protection where information was missing, not sought, or withheld, compromising the effectiveness of assessments and planning, as in the following cases:
“It is clear that there were weak communications and information sharing, particularly between health and the other agencies involved. This contributed to the lack of effectiveness in the overall response to [the child’s] needs. Examples of agencies not being aware of the situation for [the child] include the police dealing with the criminal matters who were not aware of the Child in Need status or
placement being funded and supported by children’s social care, the college being unaware of the involvement of children’s social care, and the hospital diabetes team not being aware of the Child in Need/Looked After Child status or children’s social care support.”
“The review of this case has shown that there were serious gaps in information sharing both within and out with the health service which meant that the whole picture of the family’s functioning, dynamics and lifestyle remained unknown. This
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applied when the children were Children in Need and when they were subject to child protection plans.”
In contrast to those cases where there were issues around information sharing, other cases highlight how agencies can take steps to overcome these and ensure that relevant information is shared with those who know the child and are potentially in a place to offer support and care, as highlighted in relation to domestic abuse notifications in the following case:
“There are… two initiatives… that make the numbers more manageable. The first is a pilot project… whereby DV1s [the police notification of domestic violence form] were sent by Police to the normal partner agencies but also to secondary schools via [the] County Council. This appears to be sensible in as much as teachers are in an excellent position to help children and young people discuss their situation as well as giving the teachers background knowledge that may help to explain a child’s absence, poor attainment or bad behaviour.”
Effective information sharing is facilitated by clarity over the reasons for requesting information and the basis on which any request is made. This was emphasised in the following SCR:
“From discussion with the GP practice, such requests for information from the safeguarding team at the regional hospital are not uncommon and a generalised question regarding “safeguarding concerns” without knowing specifically why the question is being asked does not promote effective sharing of information
particularly if information is needed from an adult’s records. There is now an information sharing form that should be filled in and faxed to the GP surgery when information is needed.”
A key element of communication is that it must be two way. Where front-line workers express concerns or share information with child protection agencies but receive no feedback, their confidence in the process may be undermined, potentially compromising their ability to contribute to safeguarding, and inhibiting future information sharing. Thus there is a clear imperative for prompt feedback to referrers and others participating in safeguarding.
While many serious case reviews highlighted information sharing issues, few went beyond individual failings to consider deeper systemic issues underlying such failings. Some issues that were identified included fragmentation of services; delays in sending information; bureaucracy; and limited specificity in requests.
Where services are identified as fragmented, or operating from different settings or management structures, setting up clear pathways and agreements to allow effective information sharing is crucial. Delays are addressed by installing systems that ensure discharge forms are processed promptly, letters dictated and typed without delay, and,
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where there are safeguarding concerns, direct information sharing that circumvents routine processes. In sharing safeguarding concerns, including in staff-to-staff
handovers, best practice should be to combine direct verbal communication with clear documentation of the concerns. Staff need to be clear in their requests for information in terms of what is being sought and their reasoning. This can be facilitated by clear
procedures or pro-formas for information sharing.
7.1.3 Triangulating information
In addition to gathering and sharing information, information must be triangulated and verified. This involves seeking independent confirmation of parents’ accounts and triangulating information between professionals.
This concept was explored in the following accounts:
“In this case, the parents’ own version of events was often accepted by professionals without triangulating with other sources such as professional information or records. Mother was able to tell maternity services that she had accessed care and had been denied a booking in process because the Midwife did not turn up, an inconsistency that was not challenged. During the initial
assessment Mother and Father’s view about why they had not accessed midwifery care were reported without challenge, despite there being discrepant evidence regarding this.”
“[The mother] disputed information that the midwife had provided, asserting that it was the midwife that was mistaken; she gave untrue information about [the child’s] contact with their Father, saying she had organised it because she believed that it was important they developed an effective relationship and she denied having drunk any alcohol, despite smelling slightly of alcohol being the reason for the assessment. This information was recorded in the assessment without comment, or a professional view being provided.”
One approach to improving inter-agency communication, identified in a couple of SCRs, was through ‘practitioner forums’, offering support to isolated professionals and creating an arena where disagreements could be raised without families present:
“[The SCR recommends that] a forum is established by the Strategic Substance Misuse Manager to enable General Practitioners involved in delivery of shared care arrangements to come together and identify areas of concern or barriers to effective joint working and also to share current best practice.”
“The LSCB should support a framework of meetings which allow professionals involved in particular cases to meet and reflect on professional dynamics and disagreements without the presence of children and families.”
168 Learning Points
As highlighted throughout this report, effective communication is central to all safeguarding practice
All national guidance and legislation on confidentiality and data protection supports sharing information to safeguard children and vulnerable people
The Data Protection Act 1998 and human rights law are not barriers to justified information sharing, but provide a framework to ensure that personal information about living individuals is shared appropriately
Child protection agencies must feedback promptly to referrers and others participating in safeguarding
Information must be triangulated and verified. This involves seeking
independent confirmation of parents’ accounts and triangulating information between professionals
Practitioner forums may provide opportunities for professionals to discuss cases and share information in a safe environment