The objective of this paper is to present some findings on professionals’ management of suspected child maltreatment cases in a Victorian child protection network, focusing in particular on the extent to which effective interprofessional coordination and communication has been achieved. The results of an in situ tracking of suspected child abuse and neglect cases will be used to form the basis for a discussion of professional case management and the implications for child protection practice.

Coordination in child protection networks has been generally adopted in the western world as a desirable work practice (Jones, Pickett, Oates & Barbor, 1987; Morrison, 1994). There is a belief that a coordinated response to the problem of child abuse results in more effective interventions. Specifically, good coordination can lead to greater efficiency in the use of resources, improved service delivery by the avoidance of duplication and overlap between existing services; the minimisation of gaps or discontinuities in services; clarification of agency or professional roles and responsibilities in ‘frontier problems’ and demarcation disputes; and the delivery of comprehensive services (Hallett & Birchall, 1992). Hallett and Birchall contended that the desire for a coordinated response to child protection was often ‘. . . asserted, rather than demonstrated, and was taken to be self-evident.’ (Hallett & Birchall, 1992:18).

While there would appear to be overall agreement that coordination in child protection is a necessary and valuable practice, it has been commonly reported as being difficult to achieve (Dale, Davies, Morrison & Waters, 1986; Jones et al., 1987; Goddard & Hiller, 1992). Hallett and Birchall (1992) provide a concise summary of some of the problems which may arise when agencies or professionals work together.

These include:

The overall project was designed as an evaluation of the decision making of the various professionals involved in the management of suspected and confirmed child abuse and neglect cases. The aim was to map a child protection system for a period of six months, to trace what happened to cases once they entered the professional network, to examine the role of the various professions who played a part in case management; and to determine which factors influenced the case management decisions taken by the professionals.

The study was carried out in the predominantly urban, Barwon region of the State of Victoria, with data collection being undertaken in 1992 and 1993. The region comprised the city of Geelong and surrounding local government areas and had a population of approximately 200,000 inhabitants. The region was selected for a number of reasons:

1. The population size meant that adequate numbers of suspected child maltreatment cases could be tracked.

2. The region was relatively ‘quiet’, in terms of child maltreatment cases. That is, the regional services were not, at the time of tracking, overloaded with suspected or confirmed child maltreatment cases as were other regions of the State. In addition, the region was not known for high numbers of serious physical abuse cases, or child deaths. Thus, it was more likely than other regions to provide a balanced picture of the case management of suspected or confirmed child maltreatment cases, rather than that of a ‘worst case’ system. In this way the researcher hoped to avoid any conclusions being perceived as ‘catastrophising’ the state of case management in the child protection system, and to increase the likelihood of the results generalising across regions and child protection systems.
3. The Barwon region operated as a ‘closed system’, with clearly defined boundaries which were breached relatively infrequently. That is, the region was sufficiently far from Melbourne (the state capital) that the vast majority of cases remained in the region during all phases of case management. This made it easier for both the professionals involved with child protection cases and the researcher to gather a comprehensive picture of the children and their families, to identify the professionals who became involved with each case and the case management decisions that were subsequently taken.
4. An additional benefit of using the Barwon region as the basis for the study, was that due to the relatively small size of the professional network, many informal links had been set up between workers and agencies. It was hypothesised that these would facilitate interagency and interprofessional communication and therefore enhance case management. Morrison (1994; 1998) has emphasised the importance of such informal professional links in the maintenance of an adequate level of functioning by the formal, structured child protection system.

The sample consisted of 110 professionals from the major health/counselling and investigative agencies in this region. These workers played a significant role in the reporting, assessment and/or alleviation of child abuse, and all agreed to participate in the study. The professions were: police officers (from the Community Policing Squad), child protection workers (from Community Services Victoria), paediatricians, social workers (from all major treatment agencies and the regional hospital), school medical and counselling personnel, and infant welfare nurses.

During the tracking study, suspected cases of physical, sexual, or emotional abuse, or neglect, identified by any of the participating professionals, were collected. The workers had the option of providing case information via a detailed questionnaire they themselves completed; or alternatively, the author could conduct a structured interview (using the tracking questionnaire).

Each worker was expected to report any cases with which s/he had had a role in the case management process, regardless of how brief the involvement, the type of involvement, and whether or not the case was deemed to be unsubstantiated, referred on, or subject to an ongoing case management plan.

Each questionnaire or interview identified the worker filling out the questionnaire, and provided the target child’s age, sex, date of birth, and postcode of normal residential address. This enabled the researcher to monitor the target child’s progress through the treatment network - in many cases more than one worker was involved with individual cases simultaneously and/or at different stages of case management.

The aim was to collect all suspected child maltreatment cases presenting at one or more of the participating agencies or professions; however, this was not achieved for a variety of reasons.

First, it should be noted that some of the missing cases may in fact have been ‘consultations’ where the worker involved was not actually participating in case management, rather, provided advice to other professions. The intention was to collect cases where the professional was involved in the case management; a ‘consultation’ would not meet this criteria. Thus, some of the missing cases may not have been suitable for collection, and would therefore inflate the estimated number of missing cases to some extent.

Second, for those cases which were suitable for inclusion in the study, it is hypothesised that the missing cases may have occurred because of some or all of the following: some workers may have mistakenly excluded some cases from the study; some obviously withheld cases, possibly because of a fear of criticism; most workers were very busy, and due to the demands of their job some may not have wanted to spend time doing an interview or completing a questionnaire; some workers (and one agency) restricted the author’s access to subjects, severely affecting the author’s ability to collect data; and finally, the author, who conducted all data collection himself, may have missed the collection of some cases while continually attempting to set up appointments for case interviews, and conducting follow-ups with the various agencies and professionals.

It was not feasible to employ random sampling in a case tracking study. While the intention had been to collect the regional population of suspected child abuse and neglect cases, the result was an accidental, purposive, non-probability sample (that is, as many cases were collected as possible). The issues identified in this study are likely to occur in other child protection systems in Australia and overseas and are thus, theoretically generalisable. However, because of the nature of the sampling method used it is acknowledged that the generalisability of the results is limited, and that no formal claims can be made regarding the total population of child protection cases (Goddard & Hiller, 1993).

Overall, 295 questionnaires or interviews outlining a case of suspected child abuse were collected from 37 professionals from the original sample — the vast majority of cases were collected from police and staff of Community Services Victoria. Table 1 provides a breakdown of the number of cases collected from each agency or profession. The high number of cases received from the police and child protection service were expected. These two groups performed the major child protection role and as statutory authorities were mandated to investigate suspected child abuse and neglect cases and to remove (where necessary) children at risk of maltreatment.

Why did fewer than 40% of the professionals who originally agreed to participate in the study supply cases for the tracking study?

Some professionals only had a limited role in child abuse case management, having contact with only a small number of cases in a year, particularly those groups with a role in the early detection of maltreatment, such as school medical and counselling staff. It was apparent that some of the professionals were not involved in managing child abuse cases during the six month tracking period. Some workers left their positions during the tracking study and were either not replaced, or their replacement was not able to participate in the study. Additional reasons for the lack of cases being supplied by some professionals were outlined in the Missing Cases section.

An estimation of the number of missing cases was calculated by using the annual child abuse statistics from each agency or profession participating in the study in conjunction with questionnaire responses that reported which other workers were involved in the management of individual cases. A conservative estimate was that there were approximately 70—80 missing cases. This would indicate that approximately 80% of the cases that were active in the child protection network during the study were collected for tracking.

In reality, the 295 questionnaires represented a sample of 260 individual cases where the physical, sexual, emotional abuse or neglect of a child was suspected. For 35 of the children, more than one professional had been involved in case management, and subsequently completed an interview or questionnaire on that case as part of this study.

This number does not adequately reflect the true number of professionals involved in managing the cases. Approximately 54% of cases had involved at least one other professional contact prior to the case reaching the worker who actually reported the case as part of this study. Almost 20% of the sample had had three or more professional contacts prior to the tracked presentation. Overall, 51% of the children had been previously suspected of being maltreated.

Throughout this paper the total number of cases will be quoted as 295 not 260, with cases for which information was received from two or more sources being considered as separate cases for the purpose of analysis. This was deemed appropriate given that the information reported about a case, such as the official label applied to the case and the abusive concerns identified, often differed markedly between workers. Additionally, because the decision making options open to workers varied quite significantly because of their different roles, philosophies of service and case protocols, it was not possible to combine the data.

There were two main case classification methods employed in this study: type of maltreatment and case outcome.

With regard to type of maltreatment, approximately 70% of the cases collected in this study (206 of 295) were officially labelled by the various professionals as either sexual, physical, emotional abuse or neglect. The remaining 89 cases were labelled as a combination of the four types of abuse, or given agency-specific labels such as ‘welfare check’ (used by the police). An analysis was conducted of the constituent elements of the suspected child maltreatment cases in comparison with the official labels applied by the workers. The 89 cases with a ‘combination’ or ‘agency specific’ label were re-coded to provide a label based on only one of the four main categories of abuse.

The re-coding was done on the basis of which label had been applied by the worker concerned, and also by the actual case content (as evidenced by the types of abusive actions reported by the workers). This classification system was used on the assumption that it approximated the weighting given to different types of child maltreatment by the various professionals involved in child protection case management. Thus a case involving sexual, physical and emotional abuse became a sexual abuse case; a case of physical abuse, neglect and ‘child at risk of abuse’ became physical abuse; and so on. Table 2 shows the breakdown of the case sample following re-coding into the four main child abuse categories of sexual, physical, emotional abuse and neglect.

The second classification, case outcome, was based upon the professionals’ decisions to substantiate a case, and if substantiated, what legal interventions they recommended be taken. The main outcomes were therefore: unsubstantiated, substantiated, protection application (CSV only), and charges laid (CPS only). Table 3 presents the case outcomes for the sample.

These statistics represent the reality of current child protection systems in Australia and overseas - the majority of substantiated cases do not require statutory protective intervention (that is, the issuing of a protection application), and are deemed suitable for a community-based caseplan.

In order to provide an introduction to the case data, Figure 1 (Appendix 1) provides a descriptive map of the direct referrals made by the various professions involved in cases of suspected child maltreatment. The mapping/path analysis provides an apt description of the complexity of child protection systems and exemplifies the ease with which cases may get lost in a system if overall case coordination and effective interagency communication are not maintained.

It should be noted that attempts were made to construct additional maps indicating: inter-professional consultations; prior histories of professional involvements, and an aggregate of professional involvements (referrals, consultations, prior contacts). However the links were so many and the maps so intricate that they were unusable.

It was evident from the cases collected in the study that the child protection network under investigation suffered from a number of interprofessional coordination and communication problems. Along with the aforementioned problem of missing cases, the problem of missing data within the collected cases had to be contended with. In extreme instances this meant that basic child demographics were not collected and/or the official designation applied by the worker to identify the type of maltreatment that was suspected for specific cases was omitted.

Additionally, in a number of cases workers had not collected (or been able to collect) data concerning familial stressors (for example, domestic violence, parent history of being maltreated) and significantly, were not informed of the involvement of other workers, or the actions those workers had taken. For some individual cases collected from more than one professional, there were major differences in: the maltreatment that was suspected to have occurred, the workers’ ratings of case severity and risk to the child of further maltreatment, and the level of intervention employed to alleviate the situation. It would therefore appear that in a sizeable proportion of cases provide some evidence of inter-group communication problems.

In Victoria at present, statutory protective intervention of all types of child maltreatment cases is managed by CSV under a ‘single track’ system (Fogarty, 1993). The Police however, are mandated to conduct criminal investigations of alleged physical and sexual abuse cases in order to assess their suitability for criminal prosecution of the perpetrator(s). Thus, many cases of sexual and physical abuse necessitated the involvement (at least initially) of both services. This is a recent development; until early 1992 the police had the authority to conduct protective as well criminal investigations under a ‘dual track’ system (Fogarty, 1993). This tracking study was conducted shortly after the reduction of the Police protective investigation role, in a period where CSV and the police were still adjusting to their new protocols.

Communication and information exchange between the statutory services was based around formal protocols, which in theory, should have meant that a high degree of coordination existed between the services. Most formal exchange of information was expected to occur via between-group referrals, consultations, and particularly during case conferences.

First, this study was conducted just prior to the introduction of mandatory reporting in Victoria, and it was obvious that some professionals were openly refusing to refer some of their cases to CSV or CPS for further investigation and/or intervention. This may have been due to: the worker making a judgement that some cases did not require more intrusive intervention; previous inter-agency conflicts with the protective services, and/or the worker’s negative perceptions of the role of CPS or CSV in child abuse case management.

It would be expected that mandatory reporting requirements would act to reduce the number of cases not referred to CSV protective services by mandated professionals.

Second, it was apparent that CPS and CSV were often not following their own agency protocols with regard to interagency referral and the demarcation of protective service roles in child abuse cases. Within the case tracking study, it became apparent that many cases of suspected physical or sexual abuse known to CSV were not being referred to CPS, and vice versa. Overall, approximately half of all physical and sexual abuse cases managed by CSV or CPS were not referred to the other statutory agency.

With regard to CSV and CPS cases where referrals were made, the reports of the number of referrals made versus the number of cases actually received were somewhat different for both samples. Table 4 provides an indication of the mismatched referrals, and the disparity between CSV and CPS reports. It should be noted that the cases referred and received were often not the same cases.

For example, it would appear that the referral system worked well in terms of sexual abuse cases sent by CSV (15) that were received by CPS (17), with a discrepancy of only two cases. In reality however, a sizeable proportion of the 15 cases referred between the agencies were not the same case (that is, the 15 sent were not the same as those that were received). The major interagency discrepancies were for the sexual abuse data where CPS workers reported making 17 referrals, yet CSV staff reported that they received only 6 referrals. With physical abuse cases, CPS sent 4, but CSV received 8 cases. In both emotional abuse and neglect cases CPS sent many more than were known to have been received by CSV.

With regard to the CPS role it was apparent that the reality was that CPS members were still playing a significant role in the investigation of emotional abuse and neglect cases - a role which should have ceased to exist. Some emotional abuse and neglect cases were never referred to CSV, but were dealt with entirely by CPS. Of particular interest therefore was the CSV referral of 8 neglect cases to CPS.

Given that CPS in theory, no longer had a role in emotional abuse or neglect cases, it is assumed that the cases contained sexual or physical abuse concerns that required CPS criminal investigation. Alternatively, the referrals may have been made in order to set up CSV/CPS joint investigations.

Overall, the apparent discrepancies in the referral process may, in part, be accounted for by the author having failed to collect all cases active in the child protection network. Alternatively, the receiving agency may have deemed some ‘referrals’ to be ‘consultations’, and thus excluded the cases. A more detailed discussion of missing cases was given in the Method section.

The case conference is also commonly identified in the literature as one of the formal mechanisms for case coordination (Jones et al., 1987; Hallett & Birchall, 1992). In many child protection services throughout the world (including CSV), holding case conferences is set down in worker protocols (CSV, 1988). They are deemed to serve a variety of purposes:

In this study only 84 case conferences were reported to have been held (28.5% of all cases). Workers participating in this study reported being in attendance at either one of the 43 internal conferences (intra-agency) or 41 external case conferences (inter-agency) (see Table 5).

There was an obvious discrepancy between the number of suspected child maltreatment cases investigated, and the number of case conferences held. The most frequently reported reasons given by workers for a failure to hold some form of case conference are listed in Table 6. It would be unlikely that workers would hold case conferences for unsubstantiated cases, or where few other agencies or professions were involved with the case.

Hallett and Birchall (1992) cite varying rates of the frequency and regularity of case conferences in the U.K., ranging from 25% to the ‘vast majority’. Packman and Randall (1989) found that in the absence of a case conference, workers usually indulged in intra- and inter-agency consultation and information-sharing. It was apparent from Table 6 that similar types of reasons were given by workers for the failure to hold a case conference in this study. The most common reasons being that a conference was ‘not required’, was ‘not applicable’, or was ‘unsubstantiated’.

At times interprofessional and interagency communication and coordination problems may result in interagency or interprofessional conflicts or disputes. In this study workers reported problems with what they perceived as other worker’s non-cooperation in 12.2% of cases; disputes with other workers were reported in 10.8% of cases. Of the external case conferences held (see Table 5 above), eight conferences (20% of the external conferences) were reported to involve significant disagreement between participants.

According to Shane (1982), some reasons for ineffective coordination and interprofessional conflict are: a lack of trust between agencies or professionals, professional ‘turfism’ that is, professional claims to particular aspects of case management), inter-agency (or interpersonal) power struggles, a lack of resources to support ongoing coordination, and finally, the potential for agencies to be trapped in a conflict of interest. Hallett and Birchall (1992) noted that conflicts (or breakdowns in coordination) may result from a lack of understanding by workers of other agencies’ (or professions’) standards of practice, conceptual bases or ethical standards.

The literature is full of studies and inquiry reports indicating the problems that may arise in case management when communication between workers breaks down. The problems of poor inter-professional communication in research studies differ appreciably to the problems which may arise for children when worker communication breaks down. Problems children may face have been identified for example, in Victorian death inquiries (CSV, 1991a, 1991b; Health & Community Services Victoria, 1993) which indicated that poor communication between police, welfare services and police physicians, led to children being left in ‘at risk’ situations, with sometimes tragic consequences. Similar findings have been reported in overseas death inquiries, and other descriptive studies (Department of Health and Social Security, 1982; Hill, 1990).

If services are not properly coordinated, workers are not aware of the roles of other agencies or professions involved with cases, or are simply not fully appraised of the ‘facts’ of a case, the probability of problems arising in case management appears to be far more likely . In extremes, this can potentially lead to the network’s failure to protect the child, and perhaps leave the child open to the risk of serious injury or death.

This study was completed in what could be described as a reasonably ‘harmonious’ network, where the inter-professional links between workers were good, and the system (based on the perceptions of a number of workers) was functioning well. It was evident however, that formal inter-agency or inter-professional methods of communication, such as case conferences and referral protocols, appeared to have been circumvented in a large proportion of cases.

The failure of workers to effectively utilise case conferences and referral protocols would appear to indicate that the main means of information dissemination in this study was by informal methods. It appeared that the informal contacts developed between workers in the region supplemented and/or supplanted the more formalised communication pathways.

Challis et al. (1988), noted the important role that informal professional relationships and communication paths can play in combination with formal child protection structures. Morrison (1994, 1998) also emphasised the benefits of informal contacts or relationships in strengthening the formal child protection system. It should be noted that in both cases it is acknowledged that informal linkages need to operate in conjunction with more formal communication structures.

Taken to extremes, the tendency to rely on informal communication methods may lead to the variety of interagency communication problems identified by the author and often by the workers themselves. That is, running a child protection network on an ad hoc basis may result in poor information sharing and at times, the loss of cases through inter-professional ‘gaps’ in the system. The probability of ‘losing’ cases is amplified in child protection networks, given the vast number of inter-professional links commonly occurring. The complexity of such networks is clearly shown in the descriptive map in Figure 1.

However, the problems caused by ineffective coordination or communication in this study were to some extent ameliorated by the relatively ‘mild’ nature of the maltreatment identified in the case tracking. There were no serious physical abuse or child death cases reported in the region during the case tracking, and few cases which seriously tested the communication and coordination strategies resulting in a clear negative outcome. The case of Jane and Mary in the Appendix provide one example of the effects of poor communication and coordination on case outcome.

Justice Fogarty (1993) indicated in his review of Victoria’s child protection system that the introduction of the ‘single track’ approach had progressed in a satisfactory manner, with both statutory services following the appropriate interagency protocols. It would seem that the findings from this case tracking study indicate that there are still significant inter-agency issues or case management practices which need to be further refined in order for the ‘single track’ system to function as was intended.

Challis, L. et al. (1988). Joint approaches to social policy - rationality and practice. Cambridge University Press, Cambridge.

Community Services Victoria (1988). Victorian Children at Risk Register Procedure Manual. CSV: Melbourne, Victoria.

Community Services Victoria. (1991a). Confidential Report of the Ministerial Panel of Inquiry into the Death of D.V. Melbourne: L.V. North Government Printer.

Community Services Victoria. (1991b). Summary of the Report of the Ministerial Panel of Inquiry into the Death of R.M. Melbourne: L.V. North Government Printer.

Dale, P., Davies, M., Morrison, T. & Waters, J. (1986). Dangerous Families: Assessment and treatment of child abuse. London: Tavistock.

Department of Health and Social Security. (1982). Child Abuse: A study of inquiry reports 1973-1981. London: HMSO.

Fogarty, J. (1993). Protective Services for Children in Victoria: A Report, Justice Fogarty for the Victorian Government, Melbourne.

Goddard, C.R. & Hiller, P.C. (1992). Tracking physical and sexual abuse cases from a hospital setting into Victoria’s criminal justice and child protection systems - A report for the Victorian Law Foundation (Vols 1-3). Melbourne: Departments of Social Work and Anthropology and Sociology, Monash University.

Goddard, C.R. & Hiller, P.C. (1993). Child sexual abuse: Assault in a violent context. Australian Journal of Social Issues, 28(1), February, 20-33.

Hallett, C. & Birchall, E. (1992). Coordination and Child Protection: A review of the literature. Edinburgh: HMSO.

Health & Community Services Victoria (1993). Ministerial inquiries into child deaths - Annual report 1992/93. Child Protection Victoria: Melbourne.

Health & Community Services Victoria (1994). Protective Services Statistical Report 1993-94 H&CS: Melbourne.

Hill, M. (1990). The manifest and latent lessons of child abuse inquiries. British Journal of Social Work, 20(3), 197-213.

Jones, D.N., Pickett, J., Oates, M.R. & Barbor, P.R.H. (1987). Understanding Child Abuse (2nd ed.). Basingstoke: Macmillan.

Morrison, T. (1994). Collaboration in a changing world: Developing an integrated response to child sexual abuse. Paper presented at the First National Conference on Child Sexual Abuse: ‘Developing an integrated response to the prevention and treatment of child sexual abuse’, Melbourne, March, 1994.

Morrison, T. (1998). Inter-agency collaboration and change: Effects of inter-agency behaviour on management of risk and prognosis for change in dangerous family situations. Paper presented at the Twelfth International ISPCAN Congress on Child Abuse and Neglect, ‘Protecting Children: Innovation and Inspiration’, Auckland, New Zealand, September 6-9, 1998.

Packman, J. & Randall, J. (1989). Decision-making at the gateway to care. In O. Stevenson (Ed.), Child abuse: Public policy and professional practice (pp.88-109). Harvester, Hemel, Hempstead.

Shane, P. (1982). Special analysis: Interagency coordination. G.H. White, San Francisco.

CPS -- Community Policing Squad (Victoria Police)

Other Police -- General Duties Police, criminal investigation and specialist squads

CSV -- Community Services Victoria

Other CSV -- Other CSV regional offices and specialist departments

FAMILY -- Family counselling agency

FOSTER -- Foster care agency

GP -- General Practitioner

MCHN -- Maternal and Child Health Nurse

MSW -- Medical Social Work department (Local hospital)

OTHER -- All other agencies/professions

NON-PROF -- Non-professional referrals into CSV and CPS (e.g. family, friends, neighbours)

PAED -- Paediatrician

PWC -- Pupil welfare coordinator (student counsellor)

PSYCHIA -- Mental health/Psychiatric services

SCHOOL -- School principal or teacher

S/MEDIC -- School medical personnel

S/SUPPT -- School Support Centre (Education counselling unit)

NB.1 Shaded boxes identified those agencies and professions from which the cases were collected.

NB.2 The numbers on the map beside each arrow refer to the number of cases referred by a particular agency/profession.

NB.3 Numbers followed by an 'R' (e.g. 3R), are cases that a worker reported as having been referred to CSV, but where the worker reported that CSV had refused to accept the referral.

Jane, aged 9 years, and Mary, aged 5 years disclosed to a friend that their 12 year old brother Michael, was sexually abusing them at night. They presented with immature speech patterns, a lack of confidence and were socially isolated. Mary also had frequent headaches and was still bedwetting. Michael was reported by school medical personnel as ‘emotionally damaged’. The abuse was reported to consist of at least 10 incidents of sexual penetration of both girls. Once abuse was disclosed, a teacher and the school principal became involved, referring the girls to the local educational counselling service for assessment. The principal interviewed Mary, Michael, and the children’s parents. Michael admitted assaulting his sisters.

The principal then referred the parents to be interviewed by an educational psychologist. School medical personnel were brought in to conduct further interviews of all of the children and the parents. At this stage no attempt had been made to involve CPS or CSV staff. The principal and educational psychologist wished to handle the case themselves, despite the severity of the assaults on the girls. They refused to refer the case to statutory services, and attempted to influence (and intimidated) the school medical staff member so no report would be made. However, this intimidation was unsuccessful and a report was finally made to CSV.

Rather than conducting an investigation, the CSV worker relied on the reports of the various professionals involved with the case. Given that the family appeared willing to accept counselling, a caseplan was arranged with the principal as the key worker coordinating the case.

The case was also eventually referred to CPS by CSV. When CPS investigated all of the professionals refused to make statements without being subpoenaed to give evidence. It was reported by CPS that the family had in fact been warned of the impending involvement of CPS by the principal. CPS were then unable to continue with the investigation and closed the case.

The caseplan that was devised had the school principal as the key worker coordinating case follow up, and a treatment plan that was reliant on regular, close supervision of Michael and the rest of the family. Unfortunately the school and the service designated to fulfil this role closed for a period of weeks over the Christmas period, leaving the family without supports and without monitoring or supervision.

• workers refusing to refer cases on, and inappropriately conducting criminal and protective investigations
• the professionals involved with the case intimidating other professionals to avoid a report being made
• a failure by CSV to adequately determine the ‘facts’ of the case, and instead relying on the reports of professionals obviously resentful of CSV involvement — raises issues regarding the quality of case data and interagency communication.
• were the children adequately protected, particularly given the severe nature of the assault?
• the failure to investigate why Michael was raping his sisters, was he himself the victim of sexual assault?
• the reliance by CSV on obstructive, untrained professionals to manage a serious child sexual abuse case, and to report any further developments to CSV
• the ‘late’ referral of the case by CSV to CPS, exacerbating difficulties in conducting a criminal investigation