The Reported Findings from the Sara Sharif Safeguarding Review
The independent review identified eight key findings
Finding One: “Front door” practice Professional Curiosity and Triangulation
In March 2023. the “front door” of Surrey Children’s services, where referrals are received, did not identify that Sara was at risk of being abused by her father, stepmother and uncle. Expected robust safeguarding processes were not followed. Information gathering and assessment at this stage did not adequately triangulate information and respond to the presence of bruising alongside inconsistent explanations. Sara’s “voice” expressed through her change in demeanour was not heard.
Finding Two: Invisibility of Children in Elective Home Education (EHE)
When Sara was withdrawn from school to be educated at home, national legislation and guidance provided a context where there was no requirement for a formal discussion between parents and professionals even though she had a history of extensive involvement with statutory services. This context also meant that her Birthmother was not consulted and there was confusion about the process for recording that she had been withdrawn from the school roll. Lack of effective management oversight also meant that the good practice within Surrey of offering home visits within 10 days was not followed.
Finding Three: Domestic Abuse and Lack of Perpetrator Focus
Work with Father as a domestic abuse perpetrator was not integrated to childcare assessment and plans. The seriousness and serial nature of Father’s abusive behaviour to his family was not recognised beyond the second set of care proceedings. There was an assumption that attendance at a group programme for domestic abuse perpetrators was sufficient and Father’s account of completion of this programme was all that was needed. There was no clear statement of what needed to change to mitigate his future risk to women and children and how change in his behaviour would be evaluated.
Finding Four: Poor information flow into private law proceedings
The overall process of the private law proceedings (when it was agreed that Sara should live with her father and stepmother) did not maintain sufficient focus on the needs of the children, their cultural heritage and the ability of Father and Stepmother to provide safe care.
Finding Five: Fragmented multi-agency responses
Within the two sets of care proceedings, the local authorities changed their care plan to a supervision order and Sara remained living with her family. Supervision orders did not provide adequate safeguards and problems associated with the effectiveness of supervision orders in keeping children safe have been identified as a national issue.
Finding Six: Race, Culture, Religion and Ethnicity
Within the two sets of care proceedings, the local authority changed their care plan to a supervision order and Sara remained living The review has found that there was a notable lack of consideration given to Sara’s race and culture and how her dual Polish/ Pakistani heritage may have impacted at various stages of her life. The use of an interpreter for Birthmother was almost non-existent and in private law proceedings this had a negative impact on her ability to be heard and contribute. g with her family. Supervision orders did not provide adequate safeguards and problems associated with the effectiveness of supervision orders in keeping children safe have been identified as a national issue.
Finding Seven: Seeking, Analysing and Sharing of Information
Work with the family in health, social care and education lacked a consistent whole family approach which gathered all relevant information including past involvement and knowledge of the wider family. This was influenced by staffing capacity alongside a lack of confidence and knowledge about what information could be sought or shared and the roles and responsibilities of other safeguarding professionals.
Finding Eight: Oversight, Challenge and Support
There were instances where individual practice did not conform with practice expected by the agency, and management and supervision systems did not provide the necessary oversight, challenge and support.