Learning from serious safeguarding incidents and responding effectively to child mental health

What can we learn from serious safeguarding incidents about responding effectively to child mental health?

The role of the Child Safeguarding Practice Review Panel is to learn from serious incidents where a child has died or been seriously harmed, and abuse or neglect is known or suspected. We published our fifth annual report on 12 December 2024, which examines data from incidents which occurred between 1 April 2023 to the 31 March 2024. The report provides an oversight of the child safeguarding system during this time, highlighting necessary trends, evidence and learning for practitioners and policymakers alike.  

Over a fifth of children featuring in reviews were recorded as having a mental health condition, either diagnosed or undiagnosed. Therefore, one of the key themes that we chose to examine in close detail within this report were the critical issues facing children with mental health needs, their families and the practitioners involved in their care. 

Responding appropriately to children’s mental health needs can be a challenge within the safeguarding system. The cases we analysed highlighted how children’s education was frequently disrupted, which for some meant isolation not only from their peers but also from the protection and support that schools can offer. Children and their families can face long waiting lists for assessment and treatment, without sufficient support in the interim.

There is also a critical absence of early interventions for children with emerging emotional, behavioural and mental health needs, alongside a national shortage of placements and beds. There has been a significant increase in the use of deprivation of liberty (DOL) orders; even when appropriately used, the increase in the use of DOL orders underscores the need for more effective therapeutic responses to children with complex mental health needs, and in commissioning at a national and local level. 

We found that some practitioners can lack necessary knowledge and understanding of mental health, including the remit of Child and Adolescent Mental Health Services, and the differing interpretations of legislative frameworks for mental capacity and deprivation of liberty orders. In some cases, a holistic assessment of a child and family’s needs, involving all relevant agencies, was absent.  

There is yet to be sufficient recognition of the interrelationship between neglect and abuse on children’s mental health. Reviews revealed that practitioners frequently focused on the presenting issue or attempted to manage a child’s behaviour, rather than questioning underlying causes. Instead, there was a tendency to attribute behaviour to a child’s mental health condition, neurodivergence or disability, rather than any potential abuse or neglect they may be suffering. Additionally, assumptions were sometimes made about a child’s condition and recorded erroneously in agency records. There were also missed opportunities to recognise when a child’s condition deteriorated, or their behaviour escalated.  

While reviews focus on identifying learning to improve practice, it was positive to see many cases in our analysis, which demonstrated tenacious multi-agency work on behalf of practitioners, with examples including effective regular oversight of management and planning, well-attended meetings and professional challenge concerning decision-making. It is certainly acknowledged that many of the challenges facing children with mental health needs and their families are also obstacles for safeguarding practitioners. At a national level, we believe it is vital for the Department for Health and Social Care, NHS England and other relevant bodies, including local commissioners, to continue to work with the Department for Education and other relevant government departments to improve the support available for vulnerable children with poor mental health.  

The Panel hopes that the focus on child mental health within our annual report will help enhance practitioner understanding and improve outcomes for children, families and services alike. We have included reflective questions for leaders and practitioners in the report to encourage consideration of current policies, practices and challenges to enhance their work concerning children with mental health needs.