Think the unthinkable
Published by Professional Social Work magazine - 7 March 2019 (Updated 7 December, 2021)
John Fitzgerald’s career in child protection was forged in pain. Aged four, he was regularly strapped naked to a bed and beaten by a housekeeper while his father was at work and his mother in hospital being treated for TB.
It ended when his father came home early one day and walked in on the abuse. It was an aberration in a childhood that was otherwise characterised by loving parents, though not much money. And despite leaving school with no qualifications, he eventually qualified as a social worker and went on to become a leading figure in child protection during the 80s and 90s.
In a 40-year career, John led more than 50 investigations into child deaths or abuse, including the Fred and Rosemary West case. He helped shape policy – at times working with government, at others a thorn in its side – was made an OBE and regularly appeared in the media to explain the complexity of social work.
Now aged 79, his newly published memoir Lessons Learned? Reflections on 40 years in child care is the result of former colleagues urging him to share his wisdom. The late Joyce Brand, a social worker and mother of comedian Jo, describes it as “required course reading”.
There are indeed many lessons to be learned – for students, for practitioners and for policymakers.
A key one, informed by years investigating cases of serious child neglect, abuse and deaths is the importance of seeing and listening to the child.
“People would say you can’t always accept what children are saying,” he says. “But you have to listen to them carefully. And listen to not just the words they are saying but sit and watch their body language. If you don’t understand what they are saying, get out some creative materials that will help them.”
John knows there is nothing new in this. But somehow the lessons aren’t learned. Some of it is to do with cuts and the lack of time professionals have to spend with children and families. Some of it is an entrenched view – seen more recently in child sexual exploitation cases in Rotherham – that children can’t be trusted.
“In one inquiry I was involved in there was a 14-year-old boy chained to the banister who was sexually assaulted,” says John. “When it came to court the judge said to the jury, ‘you have to remember that children lie’.
“Actually so do adults, but he didn’t say that. In fact, I would say adults are more likely to lie than children who sometimes are too honest.”
John understands that poverty impacts on the wellbeing of children. The abuse he suffered as a child was able to happen because his father worked all the hours to pay for his mother’s treatment in pre-NHS Britain.
But deliberate abuse is something else.
“There was a case involving a child called Paul who died of neglect,” he recalls. “Everyone saw the family as living in poverty but happy. In fact the children were living in poverty, the parents weren’t.
“They had so many scams going. The amount of money going into the house was phenomenal, but the circumstances in which the children were living were appalling.”
The opposite of this is a story recounted in his book of a Nigerian woman who trekked 100 miles to an aid station feeding her child what little food she had on the way. Barely alive when they arrived, she insisted her child was fed first.
However, John knows things are never so simple in social work and often those who perpetuate abuse were themselves victims of it.
“If you take just about every case we ever dealt with as an inquiry where there had been a tragedy, the parents themselves had the most appalling lives. They had been abused, tortured.”
This, says John, is why it’s important that professionals have the time, training and skills to really understand families.
“It is about looking at every case and thinking ‘I must think the unthinkable even if I dismiss it on the basis of evidence’. At least think about it.”
In the 1990s, John and a colleague developed a practice guide called Dangerous Care: Working to protect children. It outlined a cluster of indicators showing when a state of potential “dangerousness” existed in families. This included evidence of violence and neglect experienced by carers, evidence of injuries, hunger, domestic violence and mental illness. But identifying this, he says, requires information sharing between agencies, something reviews into child deaths consistently highlight as not happening. In his memoirs, John also talks about the danger of “group think” infecting decision-making where professionals set out on a particular course and stick to it, dismissing new evidence as irrelevant. The phenomenon was highlighted by Professor Eileen Munro in 1996 in Avoidable and unavoidable mistakes in child protection work.
Criticisms of child protection are usually made with the advantage of hindsight and John stresses there is “no way all child deaths caused by abuse or neglect can be prevented”.
In Lessons Learned he outlines a 12-point guide to minimising the risk (see below). However, he stresses success can only be achieved if the whole system is functioning and that includes a supply of good preventative and therapeutic services.
Eradication of poverty is “long overdue” says John. But if there’s one thing his long career has shown him it’s that “children are not murdered or sexually abused because of poverty”.
His call is for compassion and understanding of the hardships families face but still being able to “think the unthinkable”. This, he says, will help distinguish the families that are a danger to children from the “95 per cent who are not, where parents do care but are struggling with the difficulties life throws at them”.
John’s three key lessons for social work
RESOURCES: "We need more but it needs to be spent on preventative and safeguarding services. Over my 40 years it has always been a pendulum swing from preventative to child protection. What you really need is both. And what we have never had is both.
"There are children removed who shouldn’t be taken into care if the right services were there. Some of the young parents we are dealing with are struggling.
"What they need is good solid help and support and they will make it eventually. But what happens is the support isn’t there, they don’t make it and it all falls apart and the kids get received into care."
CULTURE: "There needs to be a change of culture to enable people working in social work to have really good support from managers so there is a possibility of reflecting on their cases and making better judgements. I’m not in the field anymore but talk to people who are. What I hear is that people would like to spend more time with children and hear what they say but don’t have it.
"In some cases senior managers don’t understand the need for it and see it as a waste of time.
"It is also about how we teach people to communicate. We are never going to have all the resources we need so we have to find a way to develop our communication skills.
"I don’t think training is doing that. I know a couple of young people going through social work training and it horrifies me what they are telling me.
"They don’t have proper supervision, there is no support for them, they are taking on quite a large number of cases, particularly on these fast-track schemes, and expected to somehow behave like a qualified person."
LISTEN: "I know it is a cliché, but I go back to the Wests. For me it was the most graphic demonstration I have ever had to show we must listen to the children. If Gloucestershire police and social services had not listened to one of the seven West children received into care when she said, ‘I’ve got a sister and she’s under the patio’ we still would not know about the murders.
"They were a bit cynical at one stage, but they went and checked with the education department to see if a sister existed. Then they found two sisters, and two sisters who had disappeared from schools, with Fred West saying they’d gone to live with relatives.
"At that point social services and police said we are going to dig up the patio."
John’s 12-point guide for minimising risk
If risks to children and young people are to be reduced we must systematically ensure:
1) Politicians and senior managers stop paying lip service to learning lessons and support professionals by making sure they have the right resources.
2) Professionals understand there are children in need who require support and children in danger who need to be made safe. It is not about promoting one above the other.
3) The right training is available and mandatory across disciplines for all professionals.
4) The right integrated systems are in place to share information swiftly and effectively, so social workers and others are not bogged down by administration.
5) We put an end to a blame culture directed at professionals who are struggling with very difficult people. The people who cause the deaths of these children are those with the day to day care, not the professionals who are trying to solve the problems.
6) All professionals understand the significance of children and family histories in decision-making.
7) All professionals understand the part substance and alcohol abuse can play in creating risk for children and young people.
8) All professionals understand the part severe and specific mental illness among a small number of patients, who have a history of violent behaviour and non-compliance with medication programmes, can play in creating risks for children and young people.
9) Policymakers, politicians, professionals start to recognise there is a world of dangerousness inhabited by some children and cease denying its existence for ideological reasons.
10) There is ongoing high-quality research that is geared to increasing our knowledge over time and avoids the superficiality of the past. David Cameron asked Professor Eileen Munro to take a long hard look at child protection and to produce a report with significant recommendations. Professor Munro produced what is arguably the most significant report on the subject we have had for decades but how much has been implemented is another matter. The government might consider asking researchers such as Professor Munro and Ann Hagel who has specialised in criminology and dangerousness research, to develop a ten-year research strategy focusing on the needs of children in danger of significant harm, with the funding to implement it.
11) Constant organisational reorganisation, which costs monumental amounts of money for little return other than demonstrating “someone is doing something”, ceases. Reorganisations also place children at risk, as those who are being reorganised are coping with unnecessary change when they should be coping with the needs of children at risk.
12) All children and young people in touch with safeguarding services are always seen, their views obtained and listened to.
John's reflections on the Arthur Labinjo-Hughes tragedy
Over the last year or two there had been some improvement with the media beginning to recognise that 'safeguarding' was a collaborative exercise between services and not just the role of social work.
Now, however, we have gone backwards. On the night of the guilty verdict the ITV national news carried an interview with a police officer representing the force involved. The police spokesperson said: "It is correct that police officers did visit the family home following a complaint and when they found no evidence of a crime having been committed it was over to social services."
How they knew no crime had been committed I do not know as they did not see the child. From that moment on, journalists followed the pointed finger and the issue was all about the failures of social workers. I confess that was a moment I felt like throwing a brick at the TV.
The government has jumped on the ‘let’s blame social worker band wagon’ by setting up a national review (whatever that means) into the failures in social services before the serious case review has reported, thereby breaching its own procedures and guidance, "so that nothing like this happens again"!
No professional appeared to see the child. I was reflecting on this in the context of the first modern day child death inquiry, which became known as the Curtis Report in 1946, following the death of a Second World War evacuee called Dennis O’Neil. The report on this contributed to the introduction of the 1948 Children's Act.
In addition to commenting on the failure of organisations at that time to work together or communicate with each other, it was also scathing that visits to the farm did not include seeing the child. No one, therefore, could see the signs of starvation and brutalisation or discover Dennis was working 12 hours a day in the field or hear his pain.
In the 76-years since, and after hundreds of serious case reviews and inquiry reports that have similarly commented, no professional saw or talked to Arthur or heard his pain. The question I would pose is seven decades since the Curtis Report, why arewe are still not seeing or talking to children at risk? It really is not rocket science.
I have been very disappointed by the response of directors of social services in this latest case who have focused on highlighting cuts to preventive services. I share their concerns about the savagery of these cuts over years – BUT carers who murder children are not the people those services should be focusing on.
When a carer prevents professionals from seeing or talking to children by making excuses like "the child is asleep" or "they are with a friend or relative", all these things are checkable and should ringing very loud alarm bells.
If a professional raises fears for the safety of a child then that should be the moment managers act decisively. But it does require managers who understand that dangerous carers are not the same as those who need support to improve their quality of life.
Lessons Learned? is available at www.glasburyarts.co.uk