The murder of 13-month-old Preston Davey, who was sexually abused and killed by his adoptive father Jamie Varley, has shocked and saddened people across the country.
As horrific details emerged during the trial, many people were left asking the same question: how can so many agencies know about a child and still not see what was happening?
Reports suggest that multiple organisations had contact with Preston during his short life. Within approximately two months of being placed with his adoptive parents, Preston attended hospital for the first time. Over the following nine weeks, there were at least ten contacts with multiple agencies and professionals before his death.
Like many previous incidents, concerns were raised, injuries were observed, explanations were given, referrals and decisions were made across different parts of the system. Surely, if enough professionals know about a child, someone should be able to see the danger?
The unfortunate reality is that many children who experience these tragic outcomes are known to services. Recent analysis by the independent child safeguarding review panel found that 84% of families in reviewed cases were already known to children’s social care. Similar findings emerged from reviews we conducted in Wales, where the overwhelming majority of children had previous involvement with agencies before the incident occurred.
No single professional or agency usually holds the complete picture. A teacher may notice a change in behaviour. A health professional may see an injury. A social worker may become concerned about family circumstances. Police may respond to an incident. But each piece of information can appear relatively minor when viewed in isolation. It is often only when those pieces are connected that a fuller picture of risk emerges.
This is one reason why safeguarding reviews repeatedly identify challenges around information-sharing and multi-agency working. The issue is rarely that nobody cared. More often, it is that different professionals hold different parts of a child’s story.
Preston’s age (13 months) makes this case particularly challenging. Modern safeguarding practice rightly emphasises listening to children, hearing their voices and understanding their lived experiences. But babies and very young children cannot articulate what is happening to them.
Professionals must build a picture through observation, behaviour, development, injuries and interactions with carers, and collate pockets of information held across multiple agencies. Research examining non-accidental injuries in infants has repeatedly highlighted the importance of recognising patterns, rather than viewing incidents in isolation.
Lessons (not) learned
Past safeguarding reviews have identified these challenges for decades. So why are they still happening?
Numerous reviews, including our research in Wales, suggest that many of the issues identified following child deaths are remarkably consistent.
National reviews following the deaths of Arthur Labinjo-Hughes and Star Hobson highlighted challenges around information sharing and recognising cumulative harm.
Similar themes emerged in our recent review of child safeguarding incidents in Wales, and in multiple reviews for adult safeguarding.
Across cases, children and families were often known to several agencies, sometimes over many years. Yet awareness did not always translate into action or effective intervention. Experts and academic research have questioned whether safeguarding systems rely too heavily on professionals “joining the dots” between fragmented pieces of information, rather than creating systems that make risk easier to identify collectively.
Safeguarding is a complex system involving hundreds of organisations, thousands of professionals and constantly-changing pressures, policies and priorities. Learning a lesson is one thing. Embedding it consistently across an entire system is another.
Our research has highlighted the gap that can exist between identifying lessons and translating them into meaningful change. Training does not automatically change culture. New procedures do not automatically change decision-making. And publishing a review does not automatically make children safer.
Following Preston Davey’s death, there will, rightly, be a safeguarding review. Its purpose will be to understand what happened and identify lessons that could help protect children in the future. The challenge will be to make sure that what is learned in Preston’s review results in real change for other children at risk.
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There are signs that those responsible for safeguarding systems are beginning to think differently about how to apply the lessons from these many reviews. In Wales, a new safeguarding review process has brought different systems together within a single national framework. Alongside this, a publicly accessible dashboard has been introduced, allowing recommendations, actions and themes to be tracked nationally.
Rather than treating each review as an isolated exercise, the aim of Wales’ new review process is to identify recurring themes, strengthen accountability and build a clearer picture of the challenges that safeguarding systems repeatedly encounter.
It is too early to know whether these changes will reduce repeated recommendations or improve outcomes for children. But they reflect an important shift in thinking.
In England, wider reforms are underway. This includes the creation of a child protection authority to strengthen national oversight and accountability, and a unique identifying number assigned to every child to help bring together information held from different agencies.
Additionally, guidance is being developed to support professionals to build a more complete picture of children’s experiences across services.
The review into Preston’s death will rightly seek answers about what happened to him. Every child deserves that commitment. But it should also help us find the solution to a broader challenge: making sure that what is learned in one tragedy helps prevent another.
Michelle McManus receives funding from various government organisations including Department for Education, Home Office and across Welsh Government.
Emma Ball receives funding from various government organisations including Department for Education, Home Office and across Welsh Government.