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​​Changes in child protection practice

Lessons from the past

It is estimated that 1 to 2 children in the UK die each week from abuse or neglect. Some cases receive high profile national news coverage; many do not, but are no less shocking. Whenever a child dies in such circumstances, the case is reviewed to see what lessons can be learned.

    • Case study 1.  Victoria Climbié
    • Case study 2.  Holly and Jessica
    • Case study 3.  A neglected family
    • Case study 4.  Baby P


Case study 1

When she died at the age of 9, Victoria Climbié had no fewer than 128 separate injuries. She had spent much of her last days in an unheated bathroom bound hand and foot inside a bin bag, lying in her own urine and faeces. In the space of just a few months, Victoria had been transformed from a healthy, lively, and happy little girl, into a wretched and broken wreck of a human being. The inquiry into her death was highly critical of health professionals who, despite numerous contacts, failed to protect Victoria and prevent her death at the hands of her carers.4

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Case study 2

On a summer evening in 2002, 10-year-old friends Holly Wells and Jessica Chapman disappeared close to home. After an eleven day search their bodies were found, brutally murdered and dumped in a ditch. The man convicted of their murders was someone they knew, the school caretaker with a history of alleged sexual offences against children, who had managed to gain employment in a setting where he would have contact with children. The Bichard Inquiry that followed identified shortcomings in information sharing and errors in recruitment and vetting procedure​s.​6


Case study 3

In 2004 an ambulance was called to a house to attend a lifeless 18-month-old twin boy. Paramedics found five starving children under the age of eight living in squalor, with urine soaked mattresses and dog excrement in their bedrooms. Meanwhile the living room and bedroom used by their parents were clean and stocked with high-tech entertainment equipment. The family were not known to social services and had apparently ‘slipped through the net’.


Case study 4

When Baby Peter died aged 17 months a post-mortem revealed a broken back, eight broken ribs and a missing tooth, which he had swallowed. During his short life he had been repeatedly seen by children’s services and NHS professionals but efforts to protect him from cruel and repeated maltreatment were inadequate and ineffective. It was shocking that this could happen despite all the changes introduced since the death of Victoria Climbie. The case prompted a nationwide review of child protection services published in 2011.59 Peter’s mother, her boyfriend and the boyfriend’s brother were later convicted of causing or allowing the death of a child.

Improvements for the future

Health care professionals need to keep up-to-date with changes in child protection policy, procedures and practice to ensure that lessons learned from past tragedies benefit the generation of children that follow.


Government guidelines and legislation​7,8 now place emphasis on:

    • preventing abuse and neglect
    • improving multi-agency working
    • encouraging early intervention when problems are identified
    • supporting all children, whatever their background or circumstances, to achieve five key outcomes: being healthy, staying safe, enjoying and achieving, making a positive contribution, economic well-being9

Examples of developments in the last decade include:

    • appointment of a Minister for Children and Families
    • publication of the ‘National Service Framework for Children, Young People and Maternity Service​s’​​​ 10
    • appointment of a Children’s Commissioner for England, a ‘champion’ for children
    • pilot schemes for improved record keeping and information sharing in children's services. ​​​​​


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