Star Hobson report details missed opportunities to save her life

The national child safeguarding practice review, published today, also says 16-month-old Star’s wider family were “not listened to” and that warnings about the toddler’s wellbeing were too quickly dismissed as “malicious.”

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The review carried out by the national Child Safeguarding Practice Review Panel says that while many failings were Bradford specific, others “reflect wider problems in national child safeguarding practice.”

And an NSPCC spokesperson said it is “crucial we ensure Star’s memory and the outpouring of grief and anger act as a catalyst for the fundamental changes needed to child protection in Bradford and across the country".

The review was commissioned after the death of Star, who was living in Keighley at the time, and six-year-old Arthur Labinjo-Hughes, both of whom were killed by partners of one of their parents.

It finds that along with failings in Bradford and Solihull, where Arthur lived, there are major issues in children’s safeguarding across the country, and the report makes numerous recommendations to prevent such tragedies from happening again.

One recommendation of the report is that every Council in the country introduces multi-agency child protection units to “undertake investigation, planning and oversight of children at risk".

Star was murdered by Savannah Brockhill, the partner of her mother, Frankie Smith, on September 22, 2020, in Keighley.

Brockhill was jailed for life with a minimum term of 25 years for the murder. Smith, 20, who was found guilty of allowing Star’s murder to happen, was initially jailed for eight years, but that sentence was later extended to 12 years.

The trial of the pair last year heard that little Star had suffered from physical and mental abuse, and died from catastrophic internal injuries.

Social services, police and health services all had contact with Star in the months before her death, and the newly released report says a lack of communication between different bodies meant warning signs were missed.

It says concerns over Star’s safety raised by family had been dismissed as “malicious” – with Smith telling social workers that her family were making these reports because they were unhappy she was in a same-sex relationship.

Star Hobson

After the trial of Brockhill and Smith it was announced there would be a report looking into the various failings that led to Star’s death.

However, in January it was announced that this review would be combined with a review into the death of Arthur Labinjo-Hughes, and a wider study of the state of child safeguarding in the country.

The report found that the two deaths were “not isolated incidents and their deaths reflect wider problems in child safeguarding practice, including poor information sharing between professionals and weak decision-making".

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The safeguarding review panel is calling for Government to “strengthen the child protection system at a national and local level so there is a more effective joined-up response".

Coming in at 133 pages, the report goes into depth about the state of children’s protective services nationally as well as the interactions between the families of Star and Arthur and social services, police and health bodies.

A mural unveiled in memory of Star in Roberts Park, Saltaire

In the section on Star’s death, the panel detailed the numerous times concerns were raised with social services.

Opportunities to protect Star were being missed even before she was born, with the report saying: “A number of important missed opportunities when Frankie’s needs and vulnerabilities as a teenage first-time parent should have been identified.

“Had they been, then some of the risks in respects of her care of Star might have been better mediated and understood.”

It goes on to say no ante-natal health visit took place, adding: “An ante-natal visit would have been a moment to engage with Frankie and Star’s father, and to understand better the wider family context and how this might impact on Frankie’s care of her then unborn baby. It is of concern that this did not take place.

"The reason given by Bradford District Care Foundation Trust was human error in the context of a service under some strain with high caseloads and reduced funding under a new contract from the local authority.”

One referral to social services in January 2020 – a claim that Brockhill had smacked Star – was followed up by an assessment. However, the report says “case notes show a superficial and mechanistic approach to the assessment".

A referral in May 2020 by Star’s great Grandmother led to a further visit, where a social worker decided that further action was not needed.

The report says this decision “was not commensurate with the seriousness of the allegations” and that meetings should have been held between police and health services to further look at the allegations.

Smith had claimed that the referral had been malicious due to the couple being in a same sex relationship. The report adds says this claim “was too easily accepted".

It goes on to say: “The actions of Savannah and Frankie misled and manipulated professionals.

Frankie Smith and Savannah Brockhill

"As is often the case with child protection investigations, getting underneath the surface of what parents and carers may say to understand what is truly happening for children can be extremely challenging.

“Uncovering what was really happening to Star required greater challenge to the self-reported explanations of Savannah and Frankie. There needed to be more forensic follow-up.

“It is unrealistic to expect a single agency process undertaken by an inexperienced social worker to uncover and address these complicated issues.

“There would have been a better chance of uncovering what was happening to Star had statutory multi-agency child protection processes been initiated.”

A further referral led to a “virtual home visit” via Facetime, where the social worker did not raise any concerns.

After hearing the case had been closed, the relative that reported the abuse said “they ‘had a strong feeling something bad was happening to Star'”.

Star as a baby (Image: PA)

They contacted children’s social care to say the “would have another Baby P on their case as they are not listening to all the concerns".

Despite this concerns were noted to be unsubstantiated and the referral was regarded as malicious in intent.

Referring to this incident, the report says: “It is not clear why a virtual visit was undertaken rather than a face-to-face home visit.

“Too much weight was given to Frankie and Savannah’s self-reported information, and too little time was spent with Star.

“When the assessment was closed to children’s social care the ‘Signs of Safety’ scale recorded by the social worker on the assessment was eight. This meant that Star was considered reasonably, but not completely, safe.”

The report also says Star and Brockhill seemed to be engaging in “an emerging pattern of possible avoidant behaviour, seeking to keep professionals and family members at arm’s length".

Yet another visit was carried out by an agency social worker in early September, weeks before Star’s death.

Floral tributes outside the flats in Wesley Place, Keighley, where Star lived

The report says: “They recorded details of the visit in case notes, but left the local authority before the assessment was completed.

“Their intention to give notice was not apparent to local managers at the point when the case was allocated.

“The assessment was concluded and the case closed without due critical reflection and challenge.”

Referring to the state of Children’s Services at the time, the report says: “During the period in which key agencies were working with Star there were challenges of capacity across the system.

“In the local authority children’s services there was inexperienced leadership and management at all levels. Social worker vacancies and turnover, with high levels of agency staff, affected the capacity to improve practice.”

“In 2020, Bradford children’s social care service was a service in turmoil, where professionals were working in conditions that made high-quality decision making very difficult to achieve.

“There were undoubtedly multiple fault lines in multi and individual agency practice arrangements in Bradford in 2020, some of which are unique to that area. These contributed to the practice issues identified by this review. However, many of these fault lines have been identified in other situations and in other places.”

Recommendations include that Bradford:

•  Reviews, develops, commissions and resources a comprehensive, early help offer which can be accessed before/during and after the completion of any child and family assessment by children’s social care. This will include having a better understanding of “family risk factors” and extra support for teenage mothers over the age of 17.
•  Agrees clear expectations regarding risk assessment and decision making and these are understood by all agencies. This will include guidance that “no referral is deemed malicious without a full and thorough multi-agency assessment, including talking with the referrer, and agreement with the appropriate manager.”
• Jointly reviews and commissions domestic abuse services to guide the response of practitioners and ensure there is a robust understanding of what the domestic abuse support offer is in Bradford.

Helen Westerman, NSPCC Head of Local Campaigns, said: “Star was just 16 months old when she was tragically killed and it’s heart-breaking that professionals did not understand what was happening to her in her short life.

"It’s now crucial we ensure Star’s memory and the outpouring of grief and anger act as a catalyst for the fundamental changes needed to child protection in Bradford and across the country.

Star's murder shocked the nation

“The review highlights how services were in turmoil in Bradford with systemic problems in how agencies carry out their child protection duties.

"It paints a picture of information and family concerns not being shared and a system that is under-resourced, with a high turnover of staff due to ineffective leadership.

“It’s crucial all partners in Bradford act urgently to adopt the local recommendations and we stand ready to help build effective multi-agency working that has child protection front and centre. But the review tells an all too familiar story of a system struggling to cope. Political will and leadership from the very top of government are now needed to create a system that works to prevent harm and responds decisively to keep children safe in local areas.”

Panel Chair, Annie Hudson said: “Arthur and Star suffered horrific and ultimately fatal abuse. But sadly, whilst their individual stories are unique, many hundreds of children are seriously harmed each year.

“At the moment, each professional who comes into contact with a child holds one piece of the jigsaw of what is happening in a child’s life. Our proposed reforms would bring together experts from social work, police and health into one team so that they can have a better picture of what is happening to a child, listening carefully to relatives’ concerns and taking necessary actions to protect children.

“Professionals working to protect children have to deal with the most complex challenges and some perpetrators of abuse will evade even the most robust safeguards. However, in too many instances, there is inadequate join-up in how agencies respond to high-risk situations where children are being abused.”