Was systemic gaslighting a factor in the Preston Davey tragedy?

I've spent a lot of time reflecting on the tragic case of baby Preston Davey. Like many others, I followed the trial updates and found myself transfixed by the horror of what was unfolding. 

Since then, I've repeatedly found myself returning to one question: how did this go so wrong, and what might have been done differently?

The reality is that none of us know every detail, particularly the facts that never emerged during the trial. It would therefore be irresponsible to make assumptions about specific individuals or decisions. 

Context and resources

What I can reflect on, however, is the wider context of social work practice, and one particular question that I believe deserves consideration:

Was anyone within the professional network truly in a position to pull the plug on this placement?

I've found myself thinking about Preston's social worker. Did she have concerns? If she did, was she working in an environment that would support her professional judgement, even if it meant challenging the prevailing view? 

Something I have observed throughout my career, not just in social work but across a range of professions working with children, is what I term "systematic gaslighting": a collective pattern of responses that gradually undermines professionals' confidence in their own safeguarding concerns.

It's layered and complex, and I'm not sure there is a single cause.

Part of the problem is undoubtedly resource pressure. When services are stretched, thresholds inevitably become influenced by capacity. Decisions that should be based purely on risk can become shaped, at least in part, by what resources are available.

Working cultures and normalised practices

Another layer involves organisational culture and poor practice becoming normalised. I've seen situations where flawed approaches are passed down from experienced practitioners to newly qualified workers. 

Over time, these practices become embedded within teams and services. At some point, people stop realising it’s poor practice because it’s so normalised.

As uncomfortable as it may be to acknowledge, I have also witnessed practice that sometimes seems more focused on justifying inaction than exploring risk. This is not because social workers don't care. Quite the opposite. Most are trying to do the best they can within systems that are under immense strain. 

But when workloads become overwhelming, there can be a reluctance to take actions that will further increase already unmanageable demands. 

And if this is the attitude of a leadership team, then a working culture is developed.

Specialisms and social work training

I also think we need to have a more honest conversation about training within social work. Many roles are described as "specialist", but the reality is that practitioners are often given little time to develop genuine expertise. 

Terms such as trauma-informed practice can become commonplace, even when there is limited evidence of that knowledge being consistently applied in day-to-day work. I have seen this first hand. 

I think it’s important at this point to say this is not the fault of frontline workers. Social workers often ‘hit the ground running’ in a new job, and their experiences vary significantly because so much learning is placement-based.

 When you're managing a demanding caseload, finding meaningful opportunities for professional development can feel impossible. 

Mandatory training becomes another task to complete, and before long it can feel unacceptable to admit that you don't feel confident in a particular area.

I think this is a problem that transcends social work: public sector jobs lack the time resource for staff development. Across my career, I have seen safeguarding concerns minimised because the professionals involved simply did not fully appreciate the significance of what they were seeing. 

Worryingly, I have sometimes observed this within decision-making processes at senior levels as well.

Unconscious incompetence and power imbalances

When I studied social work, we learnt about ‘unconscious incompetence’: when you’re unaware of your own deficit in knowledge. I thought it was an interesting concept.

How can we challenge the things we don’t realise we don’t know? Especially if the people around us don’t know either. Maybe we’re all here, validating each other, without realising the impact a gap in knowledge is having on our decision making. 

We’re accessing supervision with people who have the same gap in their knowledge. Our competencies are being signed off, or our training is being led by other people who don’t realise their deficits therefore they don’t realise ours either. 

There’s a power imbalance to be acknowledged, too. If we recognise a gap in our knowledge, do we feel able to call it out? And how do you challenge someone else’s unconscious incompetence when they’re in a position of power? 

Imagine being newly qualified and your whole team thinks differently to you. Maybe it’s easier to shove your head back down and accept it.

System sets practitioners up to fail

I need to point out, I love my job as a social worker. I feel passionately about the profession and the difference it can make. I believe it’s an extremely important area of work but because of that I believe it’s extremely important to critique it. 

Every day, social workers are helping people, supporting families, and making life-changing interventions under extraordinarily difficult circumstances. Many are carrying responsibilities that would be overwhelming to most people.

My concern is not with individual practitioners. My concern is with a system that often sets those practitioners up to fail. It is that same system, I would argue, that can inadvertently gaslight entire professional networks through repeated minimisation of safeguarding concerns.

When I think about Preston's case, I find myself imagining a scenario.

Imagine his social worker returning to the office after a visit where she had observed a baby who seemed withdrawn, unhappy, and wanted to be held constantly. This is something brought up at the trial. The explanation given was that he was under the weather.

On its own, that explanation is entirely plausible. Babies can be clingy, unsettled, tired, teething, hungry, overstimulated, or unwell. As a parent of three children myself, I've experienced all of those things. I wouldn’t consider that out of the ordinary.

If a social worker presented those concerns in isolation, I can easily imagine others offering reasonable explanations and reassurance. In that situation, she may have been left feeling that she was overreacting.

What if she then added the broken arm into the discussion?

That changes the picture. Yet if the hospital was understood to have no safeguarding concerns, perhaps she once again found herself questioning her instincts. Medical professionals were apparently unconcerned. There was no clear evidence of abuse. There may not have been sufficient grounds to justify removing a child. 

I find myself wondering what level of support would have been in place had she wanted to challenge the prevailing narrative. 

The same question applies to the hospital.

Why were there apparently no concerns regarding a non-mobile baby presenting with a broken arm? Perhaps concerns were raised and discussed. Perhaps professionals sought advice and were reassured. Perhaps competing explanations seemed more plausible at the time. 

Hospitals are busy environments, and not every clinician will have specialist expertise in recognising subtle indicators of abuse in very young children. Did they feel reassured that these people had been ‘assessed’ as suitable parents? 

What concerns me is the possibility that, somewhere along the line, reassurance became contagious. One person's confidence influenced another person's judgement. Reasonable doubt became collective underreaction. Gradually, concern was diluted across the entire network. 

That, to me, is what systematic gaslighting looks like.

Not everyone feels able to challenge decisions. Doing so often requires confidence, experience, supportive leadership, and a workplace culture that welcomes professional curiosity rather than discourages it. Did the professionals around Preston feel able to stick their heads above the parapet? Or were they, consciously or unconsciously, operating within a system that made them feel foolish for raising concerns? I’d be interested to see what comes out of the case review.

I believe we need to create more opportunities for practitioners to develop specialist knowledge. We need safe spaces where professionals can openly acknowledge gaps in their confidence without fear of judgement. We need stronger supervision, including access to clinical expertise rather than supervision focused solely on caseload management. We need professional opinions shared in more multidisciplinary settings so it’s shared decision making.

Most importantly, we need cultures that support people to challenge and questioning.

Workload pressures and resource limitations are real, but they should never become the factors that determine our safeguarding thresholds. Children's safety depends on professionals feeling confident enough to trust their instincts, speak up when something doesn't feel right, and know they will be supported when they do.

Caroline Storey has been a social worker for nearly eight years in a range of settings. She is currently senior clinician in an adolescent mental health service.