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Seeing the Whole Child: Learning from practice

The CSCP has drawn critical learning from a series of Case of Concern reviews, an innovative process developed to examine complex cases that fall below the statutory review threshold but still offer significant opportunities for system-wide improvement.

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The cases of Cassie, Carlos, and Camille reveal key learning about the importance of centering the child’s voice, applying professional curiosity, and strengthening multi-agency coordination. This thematic study highlights cross-cutting issues and promotes reflective supervision, encouraging practitioners to embed these insights into everyday safeguarding practice. Each case offers a distinct lens into the risks and responsibilities of multi-agency work. Together, they form a critical thematic learning opportunity.

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Cross-Cutting Reflections: Strengthening Systems by Centring the Child

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A review of the Cassie, Carlos, and Camille cases identifies consistent patterns that expose systemic vulnerabilities. These are not isolated failings but indicators of broader practice challenges requiring collective ownership and deliberate change.

 

1. Centring the Child’s Voice Is Not Optional

 

Across all cases, the child's perspective was either diminished, misinterpreted, or deprioritised in favour of procedural, legal, or operational constraints. A child-centred approach must go beyond statutory compliance, it requires:

  • Actively seeking the child's voice, especially during transitions or crisis points

  • Understanding behaviour as communication, particularly where verbal expression is limited or trust is fractured

  • Embedding mechanisms for children to participate in planning decisions, and not just be recipients of them

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2. Professional Curiosity Requires Depth, Not Just Compliance

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Curiosity is not simply asking more questions, it is about asking the right questions and being open to answers that challenge professional assumptions. These cases demonstrate that:

  • Risk is often hidden behind procedural conformity; a plan being in place does not mean it is effective

  • Biases—such as adultification and criminalisation, undermine safeguarding by reframing vulnerability as culpability

  • Curiosity must extend to peers and other professionals, checking assumptions across the network, not just within individual assessments

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3. Escalation and Decision-Making Must Be Process-Led, Not Person-Dependent
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Inconsistent escalation routes, reliance on informal relationships, and lack of clarity in roles contributed to drift and risk exposure in each case. Improvements are needed in:

  • Clarifying escalation protocols and thresholds across agencies, particularly for non-statutory but high-risk cases

  • Ensuring decision-making processes are transparent, auditable, and collaborative

  • Using formal structures (e.g. case of concern process, strategy meetings) to generate system-wide solutions, not just single-agency actions

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4. Placement Sufficiency and Suitability Must Be Understood as a Safeguarding Issue
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The shortage of regulated placements and delays in mental health access are not logistical issues alone, they are safeguarding concerns that have direct consequences for children's safety and wellbeing. Professionals must:

  • Continue to escalate placement barriers through appropriate strategic channels

  • Advocate persistently for placements that meet therapeutic and relational needs, not just beds that are available

  • Monitor the impact of unsuitable arrangements as active risk, not just as temporary compromises

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Cassie: System Drift, Missed Protocols and Emotional Safety

Cassie, a vulnerable child with mental health needs, remained in A&E for over two weeks due to the absence of a coordinated discharge and placement plan. Despite the existence of inter-agency protocols, their inconsistent application delayed care and led to further harm when Cassie later self-harmed and required secure accommodation.

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Learning Themes:

  • Child’s voice was secondary to systems-focused discussions around process, placement, and risk ownership

  • Failure to escalate proportionately, with decisions relying on relationships rather than structured processes

  • Mental health interventions were not prioritised early enough, delaying access to essential care

 

Why Read the Full Briefing: Cassie’s case underscores the importance of professional vigilance in managing escalation, monitoring care pathways, and ensuring the child’s emotional safety is never sidelined by procedural complexity.

Carlos: Discharge Failures and Dual Victimhood

Carlos sustained injuries after being attacked by a group of young people, but was discharged from hospital into police custody shortly after surgery. His mother was not informed, and he was interviewed under general anaesthetic recovery, with a scheme-allocated adult instead of a family member.

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Learning Themes:

  • Unconscious bias: Carlos’s identity as a child was overshadowed by his perceived criminality

  • Lack of joined-up communication meant agreed safety plans were not followed

  • Insufficient safeguarding lens during critical transition points such as discharge and police procedures

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Why Read the Full Briefing: Carlos’s case demonstrates how safeguarding can fail when children are viewed through a deficit lens, and how professional curiosity is needed to challenge assumptions and see the whole child.

Camille: Placement Breakdown, Crisis Response and Unseen Harm

Camille was placed in emergency accommodation due to an urgent lack of suitable placements. The environment failed to meet her complex needs, resulting in multiple police callouts and hospital admissions. The case prompted questions about national placement sufficiency and local agency coordination.

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Learning Themes:

  • Her voice became lost amidst urgency and structural limitations

  • Systemic strain on placements left professionals to make difficult compromises

  • Reactive rather than trauma-informed response, escalating Camille’s vulnerabilities

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Camille’s case illustrates the importance of building resilient systems that prevent short-term placement decisions from compounding trauma. It also highlights the importance of listening to the child, even under crisis conditions.

Further Resources and Tools


Practitioners are encouraged to revisit:

Reflective Supervision Prompts: Embedding Learning into Practice

These prompts are designed to support reflective dialogue during supervision, team debriefs, and case audits. They move beyond task completion to explore the quality, intent, and impact of professional interventions

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