By Richard Devine, Social Worker for Bath and North East Somerset Council
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This case is an exception and therefore doesn’t resemble the vast majority of children and families that social workers come into contact with. In the 10 + years of working in child protection, I have yet to meet parents who were as callous and abusive as Thomas Hughes and Emma Tustin.
In my opinion it is crucial that any discussion about this tragic case should acknowledge that ‘While it is understandable that strong emotional views are expressed in the immediate impact of a tragic death of a child, it is important that politicians and senior managers make it clear that the child protection service can only aim to reduce child maltreatment, not eliminate it’ (Munro, 2019: 106).
In response to this tragedy, I have heard many commentators (Academics, Social Work Leaders, Charity Leaders) discuss the training of social workers, austerity measures, cuts to early help, workloads, and supervision as potential contributing factors to be considered – all of which are important issues. However, this might mislead the public and even social workers into thinking that if we have the ‘right’ training resources, funding, support, early help, etc that we can investigate child abuse allegations and make infallibly correct predictions. It is simply, unfortunately, an unattainable ideal and creates the false impression that we could be capable of faultless and accurate prediction of outcomes in families where maltreatment occurs. As pointed out by Munro, ‘it is surprisingly hard to develop a high accuracy rate in predicting a relatively rare event’ (2019, 114).
In addition to the fact that some child deaths are unpredictable, there are issues with organizing a service around serious incidents. Fox Harding (1997) previously identified three issues with a child protection system unduly influenced, designed, and predicated on lessons from individual cases of extreme abuse and neglect. Firstly, such deaths, whilst influential in policy and practice are rare. Secondly, because human behaviour is unpredictable, it is misguided to presuppose that any system could be designed to eliminate severe child abuse and death. Thirdly, excessive vigilance to child abuse increases the likelihood of over-and-misidentifying risk, thus leading to unnecessary (and harmful) state intrusion into family life and the traumatic removal of children from their families (e.g. Baby P effect).
‘Hindsight bias’ heavily distorts any review of past decisions and response to risk, especially when the outcome is undesirable. Once you know the outcome, it looks inevitable – in fact, ‘the worse the outcome, the greater the hindsight bias’ (Munro 2019, p.50). In other words, now we know the outcome, it seems obvious looking back retrospectively. I suspect that this will be especially pronounced in this case because unlike previous serious case reviews we (and the public) have access to the devastatingly sad audio and video footage of Arthur crying for help. This wasn’t the case with Baby P or Victoria Climbie for example. Availability bias suggests that we give disproportionate weighting to information that is most readily available, especially emotionally affecting and sensory information (Kahneman 2011). It is not surprising therefore that this case will evoke extremely strong reactions, not least because the case involves horrific abuse of a young and innocent little boy, but also because we have video and audio footage of the abuse.
In characteristically thoughtful and insightful fashion, Harry Ferguson in his Guardian article outlined some of the contextual factors that may have contributed to the decision making in this case. He notes that ‘it is clear that they were frighteningly strategic in their abuse of Arthur and no doubt in concealing it’ and that often inquires conclude that social workers lack curiosity and are ‘too’ optimistic in the face of concerning child abuse. He adds, however:
‘My years of practice and research into child protection social work suggests that far from being optimistic, when faced with such aggressive and manipulative parents, social workers’ states of mind are often closer to helplessness. They are outmanoeuvred and overcome by the suffering and sadness in the atmosphere of such homes and in the children’s lives.
It’s a very painful truth that when faced with the helplessness of children, social workers and other professionals can become helpless because they find the children’s suffering unbearable and the organisational support is not available to help them recognise the impact of fear and anxiety and their distorted thinking’.
I would also add that the reverse could be plausible. In one report I read, it was noted that when the social worker visited Arthur, he presented ‘happy, playful and boisterous’. The social workers might have also witnessed positive and warm interactions between Arthur, his father, and his stepmother. In addition, Emma and Thomas may have been perfectly pleasant, welcoming, and seemingly cooperative with the social workers visiting providing a convincing, plausible, albeit false account of the bruising he sustained. If Arthur was asked about the bruising, he might have provided an account consistent with his father and stepmother. He might have been coercively coached into giving the answer Emma and Thomas told him to provide. Or he may have been so fearful of the repercussions should he disclose his experiences that he would have been compelled to stay quiet.
Not only will any review need to analyse the decision making in the context of which the social workers made the decision, but also take into consideration the information that was available at the time, and how the social workers interpreted that information. In other words, we need to understand the personal-professional context the social worker was situated in when attempting to handle the case. This will reveal the challenges they faced and provide a richer understanding of the decision-making that is currently missing.
I suspect it will also highlight the ethical and moral dilemmas that social workers grappled with, and the considerable emotional/intellectual challenge of making the ‘correct’ decision when dealing with conflicting information, contradictory accounts, and competing rights.
Any attempt to improve the system through learning from past mistakes must recognise however that such an endeavour will always be limited. Social workers will have a different range of experience, knowledge, and competence – and importantly, are always in a process of learning and evolving – that will influence the way a case is dealt with at any given point in time. Of course, this doesn’t mean that we abandon or restrain our ambition of providing a high-quality, child-centred service to children and their families, nor that reviews should shy away from highlighting areas of improvement.
Substantial increases in investigations have not led to increased identification of abuse or overall child safety (See Case for Change Interim Report by Josh McCallister 2020, p.30). In the past, Serious Case Reviews (SCR) have been used to intensify and strengthen the child protection system, typically with more referrals, assessments, investigations, and interventions. However, this has not increased the identification of and reduction of child abuse (Devine, 2015). We should therefore be cautious about any attempt to increase investigations of children and their families as a solution to reducing child maltreatment or child deaths.
As pointed out by Lauren Devine (2016, p.22) ‘Child abuse is rightly considered a problem, but the solution is considered to be as simple as detecting ‘signs’ that indicate risk and referring them early. This is undoubtedly a logical if simplistic response, but it does not take account of the complexity of the issue of child abuse, the unreliability of risk prediction and the important protections that families need from state interventions’.
In addition, there is accumulating and powerful qualitative evidence illustrating the harmful effects of social work involvement on the lives of children and families. There is also increasing evidence that social work involvement disproportionately effects poor, female, and ethnic minorities, and thus reinforces structural inequalities (Featherstone 2018, Bywaters et al 2016, 2019, 2020).
In the absence of a bio-psycho-social and developmental perspective, the behaviour of Thomas and Emma will remain unfathomable and incomprehensible. Our ability to derive learning from the types of experiences in life that lead people to abuse children seriously, sadistically, and fatally is crucial in identifying and supporting others who may have had similar experiences and/or developed similar ways of functioning/parenting.
Currently, there is extreme anger, condemnation, and a desire for retribution for these parents. This is unsurprising given the heinous acts they committed on a young and beautiful little boy. However, it strips away the complexity and prevents us from being able to understand the interpersonal and psychological functioning that underpinned their behaviour.
On this issue, Crittenden (2016, p.215) writes ‘Many people react to child death with outrage, but once we know the whole story, including the parent’s backstories, is known, anger seems insufficient for the tragedy. The more deeply one looks, the clearer it becomes that the parents were not able to protect either themselves or their children and that their own childhood experience was one of intense lack of safety and comfort’.
There will be lessons to learn from this case and a full review will no doubt identify those with the advantage of having access to all the information. I can think of several themes already based on the limited, partial information. It might also be the case that his death was entirely predictable, and professionals demonstrated gross negligence in the face of overwhelming, irrefutable evidence that Arthur was subject to serious harm. However, that is currently manifestly unclear. Therefore, I think we should be extremely cautious of the media’s instant, ungrounded and speculative vilification and demonisation of social workers (and the host of recommendations that immediately follow). There is a presumption of guilt and incompetence without any regard for the facts or the complexity of our work.
The social workers I know are extremely busy, working excessively long hours, trying their best to support the most vulnerable children and adults in our society, often placing themselves at risk (emotionally, and during COVID, physically) and making life-changing, inordinately complex decisions. When a tragedy occurs, I don’t think the default position should be to blame, castigate and pillory us. It doesn’t help social workers or the children and families we serve. That doesn’t mean that social workers shouldn’t be held accountable, or that we can’t improve or learn from these horrendously sad cases. Donald Forrester puts it succinctly:
I will conclude with Munro (2019) who details the complexity and challenge of child protection:
Child protection work inevitably involves uncertainty, ambiguity, and fallibility. The knowledge base is limited, predictions about the child’s future welfare are imperfect, and there is no definitive way of balancing the conflicting rights of parents and children. The public rightly expect high standards from child protection workers in safeguarding children but achieving them is proving problematic (p.1).
The image of a vulnerable child suffering pain and fear at the hands of their carers stirs up deep feelings of horror and outrage. Equally, the idea of powerful officials invading the privacy of the family and interrogating us on the intensely personal issue of our competence as parents provokes anger and resistance. It is hard to imagine circumstances that pose a greater challenge to reasoning skills: limited knowledge, uncertainty, high emotions, time pressures and conflicting values (p.2).
Recommended reading: Over the next few weeks we will no doubt hear lots of debates about whether we intervene too little or too much. I would highly recommend Lorraine Fox-Hardings book, Perspectives in Child Care Policy (1997). I have summarised the book here
Final note: It will be important for social workers to be provided opportunities to discuss this case with their manager and colleagues, and examine the effect of it on their well being, practice, and decision making. I have no doubt that my judgement will be influenced by this case – it would be inhuman for it to be other wise. I can’t change this, but I can bring some awareness to it, aided by supportive colleagues, and unpick the effects it might be having on my judgement. It is a deeply upsetting case, and the level of publicity means it will impact on all professionals that have involvement with children. Social Work managers and leaders have a responsibility to offer support and containment to their staff during this period. Importantly, we have a duty of care to one another. A failure to acknowledge the impact of Arthur’s tragic death may result in our judgement being skewed in favour of self protection and risk aversion, impair creative and reflexive practice, and thus, unfairly impact on the children and families we seek to help.
By Richard Devine (06.12.21)
32 thoughts on “5 points about the tragic death of Arthur Labinjo-Hughes (we are unlikely to hear in the media)”
Extremely interesting thought provoking read. Thank you
As ever a really thoughtful and helpful article
Richard a very balanced view of this very sad case with great insight into the knee jerk reactions that the media portray the social work profession after these very rare child protection tragedies
Thank you Declan.
A highly thoughtful balanced read
I’m looking forward to reading more from you
Have sent this piece about Arthur to my team – whom have all been affected by this death, as it brings many issues into perspective that we can explore both personally and professionally.
Thank you Sukbinder for your feedback and thank you for sharing with your team, much appreciated.
A very good response and in my professional capacity I can see your point of view. I would however have to say that the system that puts social workers under such pressure has played a huge part in this poor child’s death. Over worked and lacking in real support and supervision means that in the cases I know around the UK there is very often superficial and short term work with many families.
Thank you Matt, yes I would very much agreed. CP social work is intensely stressful with unbearably high pressures that make high quality practice exceedingly difficult to achieve.
I am the founder and CEO of CatchU and the author of “Daughter of a murderer” that’s my experience of what it’s like, living with DV, then being bereaved of a mother and left with no support, Arthur was handed over to people who couldn’t cater to his needs, kids like Arthur need specialist support, if you want to do a blog about this, let me know I am happy to chat, my book is raising money for the charity
excellent blog Rich!!
Thank you Andrew, much appreciated. Hope your well.
Hi Richard Thankyou for this excellent blog
A few news programmes ive watched on this have been far too simplistic and keen to hunt down ‘bad social workers’. So it has been refreshing and reassuring to see a more balanced and nuanced look at this tragedy and what it means for the future of social work.
I first started practising during the Baby P news storm and I saw numerous knee jerk reactions and it was hard myself not to get caught up in the hysteria and panic.
I agree with you; yes its understandable that there is revulsion and horror at what has happened and a desire to prevent it; but lets not just start blindly shooting randomly at everything that moves.
p.s. The only thing I’d add is its curious that in all of the government speeches on solutions there has not been one single peep on NAAS accreditation, and yet for years they have pushed and promoted this spending over £24 million and numerous amounts of time energy and effort on this. Its almost like the acknowledge that NAAS is not all that its built up to be. We don’t know whether Arthur’s social workers were accredited but they work in an LA that has put workers through NAAS.
Tom Taylor Social Worker and Practice Educator Children, Young People and Families Plymouth City Council Midland House Plymouth PL1 2EJ T +441752398348 E firstname.lastname@example.org http://www.plymouth.gov.uk
A massive thank you Richard for providing an extremely balanced & succinct overview in such sad circumstances.
Thank you Richard, a very balanced , thought provoking, grounding view of the challenges that frontline workers are presented with.
Thank you for a very well reasoned analysis of a catastrophe.
I work in health governance and have a major interest in ‘Human Factors’ and System Engineering. Your points map directly to a concept we use of ‘Safety 2’, see anything written by Erik Holgnagel (https://erikhollnagel.com/). This tells us that we spend disproportionate effort examining examples of unwanted or untoward outcomes of the system and redeveloping systems to ‘stop it happening again’ as there almost certainly will be in the response to Arthur’s death. Safety 2 states that far more benefit will be derived by trying to learn from and replicate good outcomes.
Weeding out ‘bad apples’, individual professionals who have been involved in unwanted outcomes of complex systems will only serve to increase anxiety, decrease functioning and affect recruitment, retention further damaging the system, not to mention the human cost of scapegoating individuals for systems that are under-resourced and not fit for purpose. See https://hbr.org/2019/03/the-feedback-fallacy for some further exploration of this concept.
All we can do is compassionately examine the actions and decisions of the individuals in the system from an inquisitive standpoint asking ‘why did that decision make sense at the time given the information available at the time?’.
Also excellent to point out the importance of understanding how did these adults become people who could carry out such abuse. As a named doctor for safeguarding I have been involved in many child protection case conferences and read many serious case reviews that almost invariably uncovers a history of neglect, abuse and being failed by the same system that 20-30 years on has failed a child and are as such also victims as well as perpetrators of abuse.
There are children who are being abused today that if identified will be seen as innocent victims but if they are missed and not helped will abuse children they have care of and be vilified by the same public.
Thank you for your detailed and thoughtful response Richard. You’ve raised and made some excellent points. I will be certain to check out the links that you sent me, thanks again – much appreciated!
Rich, well written and excellent points made, I hope you are well, all the best, Joe
Thank you Joe, really hope your well too.
Really excellent overview Richard.
Really appreciate that Katrina, thank you.
Well written Richard. It’s tragic news and we need to highlight learning but we have a tendency to knee jerk as a profession with such negative media – it’s a balancing act. I hope you are well.
Thank you Jo, nice to hear from you. Hope you are well too.
Thank you. Very interesting and insightful. My thoughts are with the family. Sad incidents like these unfortunately continue to happen within our valuable and much needed service It prompted me to review a couple of prior Serious Case Reviews. Let’s hope in the journey to rightfully investigate; to learn any lessons that those practitioners and managers are the forefront of this case are given professional support and not unfairly critiqued and judged.
Thank you Amelda.
It was an extremely balanced read which in my view, gave an objective appraisal of baby Author’s death and lessons to be learned
I genuinely enjoyed reading this article Richard, thank you for sharing. You offer a critical analysis of the reality of being a social worker in such a balanced way. I would like to reflect on this blog as part of my SWE CPD log, as I want to unpick my own feelings about Arthur’s tragic death as preparation for group supervision for colleagues I supervise. I work with 18 – 25 year olds who have learning disabilities and lifelong conditions/disabilities and while Arthur was obviously only a child, I think any social worker working with any age group will feel terribly sad about his premature death. It just highlights to me how the media always want someone to blame and your points are so valid I only wish they were published more widely – you need a column in a newspaper!
Thank you again, this has been such a valuable read.
Excellent article Richard. Good to read such a wide perspective and good to read the view of others including Munro in respect of the reality of CP work.
Point 4 reminded me if the WHO and OECD perspective outlined in Child Abuse Review 2008. C Prichard, A Sharples. Worth a read if you haven’t already.
Thank you Mike, I really appreciate it. I haven’t read that article but have now downloaded it and will give it a read, thanks very much. Hope your well.
I was forwarded your blog to read quite recently- really quite thought provoking and a must read!
I guess it further highlights the extremely difficult job we do – all social workers I know are extremely committed hard working and work hard on building relationships with families regardless of challenges.
Let’s wait for the SCR…