Child protection report reveals nature of serious harms in care

Article 39 has obtained a report from the Department for Education containing devastating information about children dying and suffering serious harm in care in England.

The Department for Education had refused to release the report for nearly two years, and was ordered to do so after Article 39 won an information rights tribunal case last month (judgment here).

The report was commissioned by the Child Safeguarding Practice Review Panel – the statutory body charged with improving child protection in England. The author was asked to review serious incident notifications received by the Panel from local authorities concerning looked after children. The Panel would, in response, consider the guidance it gives to local authorities, and any future reviews.

The Child Safeguarding Practice Review Panel was notified of 89 cases where looked after children died or suffered serious harm across a two-year period (June 2018 to June 2020). Local authorities sent copies of their ‘rapid reviews’ for each of the 89 cases.

The nine-page report obtained by Article 39 gives the age breakdown of 88 of the 89 looked after children, showing that 84% were of secondary school age and the largest cohort was aged 16-18:

  • 48% were aged 16-18 (43 children);
  • 36% were aged 11-15 (32 children);
  • 12% were aged 0-5 (11 children);
  • 2% were aged 6-10 (2 children).

No information about the ethnicity of children is provided in the short report. The reviewer states this is because there was inconsistency in the information provided by local authorities.

20 of the 89 notifications related to deaths of children in care, and 69 to serious harm suffered while the child was in care. Of these: 

  • 2 of the 20 children who died in care had health needs/disabilities;
  • 7 looked after children had died after taking their own life;
  • In 5 instances, the mother or child was looked after and the baby had died suddenly and unexpectedly;
  • In 3 cases, a baby suffered non-accidental injury;
  • 11 looked after children were alleged victims of rape/sexual assault;
  • 13 looked after children were victims of stabbing/assaults;
  • 13 looked after children suffered serious harm following abuse by an adult while in care;
  • 4 looked after children had attempted to take their own life;
  • 4 concerned looked after children who were alleged to have been the perpetrator of rape/sexual assault;
  • 6 concerned looked after children who assaulted other looked after children.

The 89 notifications came from all regions of England, with the South East and North West having the highest rates of serious incident notifications.

Of the 89 incidents overall under review, there were 48 children who had died or suffered serious harm as a result of the abuse or neglect which led to them first entering care. In other words, the care system failed to protect them from continuing serious harm. Of these 48 children in care: 

  • 11 children (all girls) were the victims of alleged rape/sexual assault while in care;
  • 7 children took their own lives while in care;
  • 6 children (all boys) were the victims of stabbing/assault while in care;
  • 4 children had tried to take their own lives while in care;
  • 4 children (all boys) were alleged perpetrators of rape/sexual assault while in care;
  • 3 children suffered drug-related overdoses while in care;
  • 3 children (all boys) were alleged perpetrators of stabbing/assault while in care;
  • 2 children in care were reported as “accidental death due to road/train”.

The reviewer makes four main findings: 

  1. There are not enough suitable, regulated homes available for children in care: “clear evidence that for many of these children due to their high level of complex and challenging needs mainly as a result of childhood trauma…placements are at times impossible to commission”; “many examples of secure welfare criteria [in the Children Act 1989 being] met but there was no placement availability of secure welfare beds”; “Many of the children who are 16+ are placed in semi-independent unregulated provision as this is the only available placement which however do not have residential staff and struggle to meet their needs and do not reduce risk taking behaviour”.
  2. Children’s mental health needs are not being addressed in care: “Children frequently have historically had no therapeutic work to help them with their childhood trauma/behaviour”.
  3. Children are suffering serious crimes and exploitation in care: “A high number of vulnerable females [in care] appear to be victims of rape/sexual assault/child sexual exploitation”; boys in care “are victims or perpetrators of stabbing/assault…even when children are [sent] to other LA areas to minimise risk”.
  4. Children abusing other children: 7 (15%) of the 48 cases were identified as involving ‘peer on peer abuse’. Of these 7 cases, 4 “involved the stabbings/assault and sexual assault of children” in the same residential unit or foster family.

The information rights tribunal set out a number of factors pointing to a “strong public interest” in disclosure of the report, including:

“a need for transparency in child safeguarding, due to its protective function”

“a need to promote and protect the human rights of children, especially children in care who are said to be among the most vulnerable in society”

“a need for openness and transparency regarding the role of the DfE [Department for Education] relating to child protection and relating to the safety and well-being of children in care”

“the number of people in society (including children and their families) who are likely to have an interest in, or may benefit from, the information” 


Article 39 first sought this report during judicial review proceedings where we were challenging secondary legislation introduced by the Department for Education which banned the use of unregulated homes for children in care aged 15 and under, but not for those aged 16 and 17. (We lost that case, in March 2022).

We had been alerted to the report through a short summary of it in the Child Safeguarding Practice Review Panel’s annual report for 2019/20, published in May 2021.

The Department for Education said the Child Safeguarding Practice Review Panel had shared the report with the Secretary of State (then Gavin Williamson) only after the judicial review proceedings started, so it was not relevant to the judicial review (that is, the report had no influence on the secondary legislation we were challenging). Having failed to obtain the document through the judicial review disclosure process, we made a freedom of information request in December 2021.

Had the Department for Education not breached section 10 of the Freedom of Information Act 2000, Article 39 would have received its response ahead of the High Court hearing on 8/9 February 2022.

The report is dated August 2020: this was the period when ministers in the Department for Education were deciding changes to law and policy in respect of older children in care.

Comment from Article 39’s Director, Carolyne Willow:

“This short document gives the public a small window into the devastating state of the children’s care system. Sitting behind the statistics are the worst nightmares of loving parents and families – children taking their own lives, children being raped and sexually assaulted, children being stabbed and beaten up, and children found dead on roads and rail track. These were all children for whom the state was responsible – being in care was meant to protect them and to help them recover from past abuse and trauma. Yet they suffered in the most appalling ways. 

“Almost half of the 89 children in care who died or suffered serious harm were aged 16 to 18. The report found that many children this age were housed in unregulated accommodation by local authorities because there was nowhere else for them. It highlights the absence of residential staff in these properties, and the failure to reduce the risks faced by older children. 

“It is sickening that the Department for Education fought for nearly two years to keep this report out of the public domain, and refused to let our charity have sight of it when we were in court trying to secure equal protection for older children in care. It is inexplicable that the national statutory body for child protection, which is meant to be independent of government, also chose to sit on this information.

“The report is dated August 2020, which was when the then Education Secretary, Gavin Williamson, was making critical decisions about protecting children in care. The minister should have been given all available information on children’s experiences, and the known risks from leaving children in places where they are unsupervised and without any day-to-day care. His decision to change the law to ensure that children in care always receive care and proper supervision where they live, but only to the age of 15, has cast a long shadow on the children’s care system. It is now government policy that Ofsted can, in exceptional circumstances, register caravans, boats and even tents as official homes for children in care aged 16 and 17. Bedsits, properties shared with adult strangers and hostels are now deemed to be suitable homes for this age group, and still there is no requirement to provide them with care in these settings.“Government must urgently revisit its decision-making around the care and protection of older children, this time fully acknowledging and understanding the scale and enormity of harms suffered by teenagers before and after they enter care.”