Recognizing And Reporting Child Abuse Or Neglect: Your Legal And Ethical Duty Fatality File

Real Case: Child Safeguarding Practice Review – “Child W” (2025)

A five-year-old child, referred to as Child W, died following significant safeguarding failures that were later examined in a published Child Safeguarding Practice Review (May 2025). Prior to the child’s death, there had been multiple contacts with services and opportunities to identify escalating risk. However, concerns were not consistently recognized as indicators of significant harm, and critical information was not effectively shared between agencies. At one point, key partners — including the child’s early years setting — were not contacted during referral decision-making, limiting a full understanding of the child’s lived experience.

The review concluded that earlier escalation, stronger professional curiosity, and more decisive action based on reasonable concern could have altered the trajectory of harm. The case emphasized that safeguarding duties are triggered by suspicion or indicators of risk — not certainty — and that hesitation, fragmented communication, or assumptions can prolong a child’s exposure to danger. As a result, recommendations focused on improving multi-agency information sharing, reinforcing mandatory reporting responsibilities, and strengthening training to ensure early intervention when neglect or abuse indicators are observed.

Source: https://www.olscb.org