1.1. In Scotland we want all children and young people to be safe from abuse and neglect throughout their childhoods. We want a society that can protect, nurture and value our children and young people. For the majority of children and young people, parents and primary carers provide the love and care that children and young people need. Being a parent can be hard and some parents can face challenges in their lives that impact on their ability to care for their children. Research indicates that the majority of abuse and neglect of children occurs within families (Gilbert et al., 2009). We know that children and young people living with parental substance misuse, domestic abuse, parental mental health and parental learning disabilities can face greater adversities and are more likely to require the wider support from families and professionals. Unemployment, poverty, discrimination, poor housing, ill-health and disability also adversely impacts on children and young people's outcomes. For some children and young people, physical, sexual and emotional abuse occurs out with the family; for example, by an adult in a position of trust known to the child or young person (such as a teacher, nursery worker, youth worker, cleric, residential worker), a person within the community and, to a lesser extent, 'stranger' abuse. There is an increasing awareness about children and young people who are being sexually exploited and abused via the internet. The Scottish Government and professionals working with children and young people are committed to understanding children's lives as a whole and have, through a growing evidence-base, recognised the importance of early intervention to tackle the root causes of risk and social disadvantage to ensure that every child and young person has the opportunity to grow and flourish.
1.2. The Children and Young People (Scotland) Act 2014 is a key part of the Scottish Government's strategy for making Scotland the best place in the world for children to grow up. By facilitating a shift in public services towards the early years of a child's life, and towards early intervention whenever a family needs help, this legislation encourages preventative measures, rather than crises responses. Underpinned by the Scottish Government's commitment to the United Nations Convention on the Rights of the Child 1989 ( UNCRC), and a national approach to improving outcomes for children, known as Getting it Right for Every Child ( GIRFEC), the Act also establishes a new legal framework within which services will work together to support children, young people and families. This national collaborative approach is critical in providing the right help, at the right time, from the right people. The right help, the timing of that and the people best placed to provide it will be different for every child and young person. The support that most children need will come from their families and communities and the universal services, such as mainstream health and education services. However, some children and young people will need the help of additional support and specialist services; and a minority may need compulsory interventions by the state to keep them safe, help them overcome the impacts of adversity and reduce the risk of serious harm (see Figure one, Child at the Centre).
Figure One: Getting it Right for Every Child: Child at the Centre (Scottish Government, 2014)
1.3. It is everyone's job to keep children and young people safe, and professionals in health, education, police and social work have specific responsibilities when they become aware that a child or young person is being subjected to harm, or is at risk of significant harm. The scale of the task faced by the myriad of professionals in health, education, police, social work and third sector organisations in identifying children and young people at risk and developing plans to effectively protect each of them cannot be underestimated. It is estimated that less than a tenth of those children and young people who experience abuse or neglect are known to formal child protection agencies and many children and young people who experience abuse and neglect may not be detected, reported or recorded within formal child protection systems (Gilbert et al., 2009). A UK-wide study based on self-reporting of child maltreatment found almost six per cent of children under the age of 11 and 18.6 per cent of 11-17 year olds had experienced severe maltreatment during their childhoods (Radford et al., 2011). For those children and young people who do disclose abuse, it is most likely to be to a mother or friend, rather than a professional. Some children report disclosing abuse and neglect, but remain 'unheard' and no action is taken (Allnock & Miller, 2013). Disclosure in itself can be problematic, as experiencing neglect on a day-to-day basis can be more difficult to disclose than a specific incident (Vincent et al., 2004). In a review of children and families' access to services where neglect had occurred, children stated that what they were looking for was 'somebody to notice that they are unhappy and ask them why' (Burgess et al., 2014: 25).
1.4. In the worst-case scenarios where there is neglect or abuse, children and young people can die or suffer seriously adverse outcomes. A triennial review of Significant Case Reviews in Scotland (1 April 2012 to 31 March 2015) included eleven child fatalities: five were infants or pre-school children and six were young people aged 15-17 years old. A further twelve children had been significantly harmed or were at risk of harm. The fatalities included drowning, physical injury, drug overdose, suicide, accidental death from falling when intoxicated and Sudden Unexpected Death in Infancy ( SUDI) (Care Inspectorate, 2016). In Scotland, the five-year average rate of child homicides has decreased by 44 per cent over the last decade (Bentley et al., 2016:17). Decline in fatalities is one indication of progress in child protection; however, 'studies have indicated that the number of child deaths where abuse or neglect is suspected as a factor is higher than shown in the police-recorded homicide figures' (Bentley et al., 2016; see also Brandon et al., 2012).
1.5. In Scotland, there has been significant progress in recognising that everybody has a responsibility for protecting children following the publication of 'It's everyone's job to make sure I'm alright': Report of the Child Protection Audit and Review' (Scottish Executive, 2002) and the subsequent reform programme (2003-2006). A process review found that the subsequent guidance, Protecting Children and Young People: Framework for Standards (2004) and Protecting Children and Young People: Child Protection Committees (2005) were particularly important in improving roles, effectiveness, significance and influence (Daniel, et al., 2007). These steps have supported the ethos and value-base for the national approach to improving outcomes for children, Getting it Right for Every Child ( GIRFEC). There is widespread recognition that a whole system approach is needed, professionals cannot work in silos and they must have a shared aspiration to improve outcomes for all children and young people at the earliest opportunities.
1.6.Inspection reports focused on child protection across Scotland have demonstrated the excellent frontline work of professionals and strategic partners who are 'continuing to make significant strides in improving the quality of services' (Care Inspectorate, 2014a:9). Scotland has a child protection system which works; the purpose of this review is to further support the improvement of delivery of child protection work locally, regionally and nationally to ensure that Scotland's child protection system can meet the needs of our most vulnerable children and young people now and in the future.
1.7. Ministers at a national level, elected members at a local level and professionals working with children and young people need to ensure that legislation, policy and practice are working effectively to protect children. It is not processes and procedures that protect children; people protect children. However, it is important to regularly consider the structures and processes which need to be in place to support those working together to identify and protect children at risk of significant harm.
1.8. On 25 th February 2016, the then Cabinet Secretary for Education and Lifelong Learning, Angela Constance MSP, announced a National Child Protection Improvement Programme for Scotland ( CPIP). This programme includes existing commitments on child sexual exploitation, child trafficking and internet safety, along with a number of new areas of work. These include: a review of practice in the Children's Hearings System; agreeing steps to promote and support leadership; refreshing the role of inspection agencies; improving data and evidence; and agreeing further action to address the impact of neglect on children and young people; as well as this review which has been looking at how the child protection system currently works and what could be improved across Scotland, drawing on research evidence and practice experience.
1.9. As part of the CPIP, this Review was commissioned by Mark McDonald MSP, Minister for Childcare and Early Years, to examine the role and function of Child Protection Committees; the use of Child Protection Registers and Child Protection Case Conferences; and the efficacy of Significant and Initial Case Reviews and to recommend what changes or improvements may be needed to these underpinning processes and structures in order to protect children more effectively.
1.10. The Scottish Government established a National Review Group independently chaired by Catherine Dyer CBE (Former Crown Agent and Chief Executive of the Crown Office and Procurator Fiscal Service) which involved representation from a wide range of professionals with child protection expertise at a national and local level. This included professionals from local authorities, health boards, Police Scotland, Care Inspectorate, Scottish Children's Reporter Administration, Social Work Scotland, Child Protection Committees Scotland, Royal College of Paediatrics and Child Health Scotland, Scottish Association of Social Workers, Convention Of Scottish Local Authorities, Children and Young People's Commissioner in Scotland, Coalition of Care and Support Providers in Scotland, as well as other professional membership organisations and academia (see Appendix A for Review Group Membership and Terms of Reference). Logistical support and background information was provided by Dr Louise Hill, based at the Centre for Excellence for Looked after Children in Scotland ( CELCIS), University of Strathclyde.
1.11. The Review Group has considered how child protection systems currently work, or don't work, across Scotland with the aim of recommending what can be done to strengthen the steps that are taken by professionals working in child protection when children have experienced, or are at risk from, harm. The tight timescales and remit for this Review inevitably meant that it could not be as wide-ranging as to cover in detail the system which supports children who are not the subject of child protection measures. The Review Group acknowledged that much work is already underway - including improving the identification of, and support for, children who may require protection - and that there will always be a need for ongoing learning and improvement for how well partners across the whole system are working together.
1.12. The Group met six times between August and December 2016. Background papers summarising legislation, policy, practice developments and research evidence on different aspects of child protection in Scotland were written for the Review Group and circulated in advance of each meeting. All papers were also peer-reviewed by experts in the field who were not members of the Review Group. Each paper concluded with a series of questions that were used to focus the Review Group's discussions and for subsequent consultation. At each stage of the process, Review Group members consulted via their organisations and networks and provided written and/or oral feedback. Over forty written consultation responses have been analysed as part of the review process; alongside information from attendance at meetings of professional bodies and visits to services supporting children and families. Analysis of all publically available Fatal Accident Inquiries ( FAIs) and Significant Case Reviews ( SCRs) has been undertaken. Recommendations included in this report were developed with the Review Group and this Report was submitted to the Minister for Childcare and Early Years, Mark McDonald MSP at the end of December 2016.
1.13. The Report of this Review is divided into three sections. The first section provides an overview of the existing child protection structures in Scotland, how they originated and how they are currently used. The second section reflects the Review Group's findings and discusses three thematic areas that the Group considered to be critical to improving the protection of children: Leadership, Governance and Accountability; Developing a Learning Culture; and Shared Values. Recommendations for future approaches are presented throughout this section. The final section provides a conclusion and appendices, including a glossary and list of acronyms, for those readers requiring additional information.
Email: Judith Ainsley