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New child safeguarding measures implemented following academic case reviews

To strengthen child protection measures, Bradford Safeguarding Children Board (BSCB) invited Professor Kim Holt at Northumbria University to review three child death and injury cases. The review and Professor Holt’s subsequent recommendations have had a major impact on the BSCB’s local policies and procedures around child protection.

Newborns and children under a year old are particularly susceptible to abuse and neglect, due to their total dependence on adults and limited physical reserves. Consequently, safeguarding measures can be implemented in cases where child protection agencies or other individuals believe that an expected baby could be at risk of significant harm.

Professionals dealing with mothers of unborn babies have a responsibility to promote their welfare and to raise concerns as early as possible to allow appropriate and timely protocols to be arranged. Unfortunately, even with measures in place, abuse and neglect may still occur.

The Bradford Safeguarding Children Board (BSCB) commissioned independent case reviews following the death of or serious injury to three children. The investigations were conducted by Professor of Family Law at Northumbria University, Professor Kim Holt, who over the past 34 years (1987–2021) has carried out more than 200 serious case reviews.


All three of Professor Holt’s reports called for a change to the procedure for pre-birth assessments. She identified that the pre-proceedings protocol (which can divert a case from going to court) was overshadowing the pre-birth conference (child protection conference concerning an unborn child). Consequently, this meant it was impossible to effectively challenge the local authority perspective. Professor Holt’s recommendations were acknowledged by the BSCB, prompting it to develop a new procedure to address decision-making in pre-birth assessments.


The new procedure was introduced by Professor Holt and BSCB Head of Service for Children’s Social Care, Abu Siddique, at two learning lessons events held in Bradford in 2017. The first event was for professionals directly involved in one of the serious case reviews and the second for a range of professionals responsible for safeguarding children within their own agency. Professor Holt and Professor Nancy Kelly (Professor in Northumbria University’s Department of Social Work, Education and Community Wellbeing), evaluated the impact of the learning lessons event in 2018 through interviews with participants who had attended either one of the learning lessons events.


The evaluation revealed that the procedure change had improved decision-making practice for pre-birth cases. Practitioners also reported that it had raised awareness of the visibility of the child within the child protection process, as well as the importance of maintaining their prominence within a system that is process driven. In addition, it highlighted the importance of the role of professionals in providing effective challenge where it is appropriate to do so and to escalate concerns.


Building on her expertise of serious case reviews, Professor Holt is currently investigating the impact of public inquiries into the care and protection of children. In collaboration with colleagues, Professor Kelly and Dr Sharon Vincent (Northumbria University researcher in Social Work and Social Care), the work focuses on developing a new methodology for undertaking public inquiries.

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