Written by Lauren Alexis
Globally, an estimated 400 million children under 5 experience psychological or physical abuse at home (UNICEF, 2024). Over the past 5 years in England alone, there have been almost 3000 serious incidents of harm and deaths to children, with many more going unreported. Most children were known to primary health services, yet only 1 in 11 were on a child protection plan at the time (Department for Education [DfE], 2024). With organisations’ efforts to improve early recognition of children at risk in health settings, are we actually sacrificing personalised, equitable care for standardised processes that overlook the complexities of families’ lives?
Boundaries
As part of my PhD research, I have spent a lot of time speaking with parents about their experiences with midwives and health visitors. One of the most striking findings is that participants felt there were very few types of personal question they would be uncomfortable being asked – whether about finances, relationships, or other sensitive topics. As a midwife, the reality I experienced was different. In a busy clinic, with just 20 minutes to address the standard physical care while also exploring a family’s wider wellbeing, suddenly asking a personal question off the back of an assessment tool felt jarring – for me and for families. These questions, posed out of context, were frequently met with one-word answers, leaving the interaction feeling awkward and disconnected. But research participants highlighted one vital caveat: these questions must be asked in the right way.
For professionals, knowing where the line is can be challenging. Families appreciate when midwives and health visitors show genuine care and curiosity, but rigid or insensitive questioning risks eroding trust or denotes a lack of choice over sharing information. This challenge is compounded for families who are underprivileged, marginalised, or facing difficult circumstances. In these cases, tools – designed to standardise assessments – can feel mechanical, intrusive, or even accusatory, making it harder for families to open up.
The Problem with Rigid Tools
In recent years, the Western world has increasingly adopted standardised decision-making tools, in an attempt to provide consistent frameworks to identify families’ support needs and children at risk. However, the efficacy of these tools remains a subject of debate (Barlow et al., 2020). Recent studies evaluating their effectiveness are limited, and their ability to predict risk of harm and inform interventions is not conclusively supported (McNellan et al., 2022). Although my own review, ‘A systematic review on the effectiveness and impact of decision-making tools in safeguarding children and young people (CYP),’ is still in progress, the dearth of quality, real-world evidence supporting the use of tools is strikingly evident.
Despite the continued use of tools, “extreme inequalities” exist in services and experiences when it comes to child safeguarding (Nuffield Foundation, 2018). Certain groups, for example Black children, continue to be disproportionately referred to social care and are more often placed out of home on closure of an investigation (DfE, 2023). It’s crucial to balance the use of these tools with personalised assessments that consider each family’s uniqueness; a set of prescribed questions doesn’t account for the nuances of cultural contexts, past traumas, or unique circumstances. The rigidity of tools can inadvertently perpetuate the alienation, oppression, and marginalisation of the very families and children they aim to support.
Cases like the tragic death of Sara Sharif in England highlight how rigid assessments may allow vulnerable children to fall through the cracks. It raises critical questions about tool limitations, particularly in situations where professional judgment and deeper insight into family circumstances are required, rather than the mechanical application of a set framework. While tools offer structure, they cannot replace the nuanced understanding that comes from human interaction.
The Importance of Human Connection
With tools becoming so integrated into Western healthcare, I don’t see them going anywhere. However, something needs to change for these tools to truly support families, spark open conversations, and prevent discomfort for both professionals and those they serve. Could co-designed tools bridge the gap between standardisation and personal connection? If families were involved in creating these tools, could they help ensure they are not only effective, but also inclusive and empathetic – fostering a sense of collaboration rather than compliance? Could tools include features that encourage family input and dialogue instead of dictating a rigid script? While relatively unexplored in this specific context, co-design shows potential in wider health service re-design and other sectors (Silvola et al., 2023).
I also wonder if there is room for a preliminary step to tools – something that focuses on building trust and setting expectations. Professionals could explain why certain questions are asked, how the information will be used, and, most importantly, encourage families to share their boundaries. Midwives and health visitors are not infallible. Letting families know they can voice discomfort without judgment is a simple yet powerful way to preserve trust, shifting the dynamic from authority and compliance to collaboration and respect.
Ultimately, safeguarding is about more than risk assessment; it’s about relationships. Families are more likely to share personal or difficult information when they feel safe and understood. Building human connection into the very foundation of safeguarding – not as an afterthought – could transform the way we support families.
By listening to families, reflecting on our tools, and embracing flexibility, we can create systems that do not just identify risks but foster trust and equity in the process. Safeguarding should feel like something done with families, not to them.
About the Author
Lauren Alexis is a midwife, researcher, and health inequalities advocate with experience across clinical practice, project management, and digital health. Currently pursuing a PhD at Keele University, her research explores equitable care and decision-making in midwifery and health visiting services, aiming to improve support and safeguarding outcomes for families with children aged 0-5. Lauren draws on her own experiences to champion inclusive approaches that recognise and embrace diversity. Utilising her experience as a midwife, public health project manager, and electronic health record analyst, Lauren is committed to bridging clinical practice with solutions that facilitate equitable care, shaped by families and professionals in tandem. She is also a Shuri Digital Fellowship alumna and Iolanthe Midwives Award winner.
References:
Barlow, J., Barret, H., Pössel, P., & Higgins, J. (2020). Effectiveness of child protection practice models: A systematic review. ResearchGate. https://www.researchgate.net/publication/343721424_Effectiveness_of_child_protection_practice_models_a_systematic_review
Department for Education [DfE]. (2023). Adopted and looked-after children. Ethnicity facts and figures. https://www.ethnicity-facts-figures.service.gov.uk/health/social-care/adopted-and-looked-after-children/latest/
Department for Education [DfE]. (2024). Serious incident notifications in England, 2023-2024. Government publication. https://www.gov.uk/government/publications/serious-incident-notifications
McNellan, C. R., O’Leary, P., Smith, A., & Harvey, A. (2022). The evidence base for risk assessment tools used in U.S. child protection investigations: A systematic scoping review. Journal of Child Protection Research, 19(3), 131-145. https://pubmed.ncbi.nlm.nih.gov/36152529/
Nuffield Foundation. (2018). Inequalities in child welfare and social care. Research report. https://www.nuffieldfoundation.org/inequalities-in-child-welfare
Silvola, S., Restelli, U., Bonfanti, M., & Croce, D. (2023). Co-design as enabling factor for patient-centred healthcare: A bibliometric literature review. Journal of Health Services Research & Policy, 28(1), 33-40. https://doi.org/10.1177/13558196221105254
UNICEF. (2024). Nearly 400 million young children worldwide regularly experience violent discipline at home. UNICEF. https://www.unicef.org/press-releases/nearly-400-million-young-children-worldwide-regularly-experience-violent-discipline