Thoughts on the death of Sara Sharif

Reading both the Child Safeguarding Practice Review into the death of Sara Sharif and a week earlier the Child Practice Review: Our Bravery Brought Justice into the abuse carried out by the Welsh headteacher, Neil Foden, there is a strong sense of déjà vu and anger. How many times have we seen and heard this and yet it happens again? Why are we not making changes and learning?

In both cases, there are horrendous and numbing lists of systematic failures and missed opportunities to stop the abuse and change the narrative. There is no single person to blame for these failures, but a system where overstretched staff (and in Neil Foden’s case volunteer governors) lack the time, confidence and information to manage their role effectively and join the dots.

I am not going to go through all the findings, learning and recommendations from the Sara Sharif review here but pick up on what for me are some key themes.

Elective Home Education

There are going to be changes in the approach to Elective Home Education (EHE) for children under a Section 47 (Child Protection) assessment or subject to a Child Protection plan under the Children’s Wellbeing and Schools Bill. Although, Surrey’s practice in this area was beyond that expected or offered in most authorities at the time of Sara’s death. But neither is, nor was, enough to save her.

There were multiple policies on the Surrey website so practice and procedures were unclear. This was in part rooted in a confusion between the requirement for parents to express their wish to home educate and the requirements for schools about removing children from the school register. Then a staff absence and issues with management oversight meant the local authority home visit within 10 days of the notification of the intention to home educate did not happen in a timely manner. When the visit did happen, in the days before Sara’s death, an administrative error meant that the worker went to the wrong address.

We need a system that balances parental rights to educate their children outside of the school system and recognises that those not in school face a higher level of safeguarding risk. Approximately 20% of safeguarding referrals are made by schools, so simply not being visible to education services reduces the risk of abuse being identified. But we need to go further and consider the withdrawal of children from school as a possible safeguarding indicator. This needs to go beyond those already under Section 47 or being considered as at risk of significant harm. When Sara was removed from school, there had been social work involvement, including at Section 47 and care proceedings, throughout her life. The move to EHE was clearly planned to remove her from view and prevent scrutiny of her father and stepmother’s actions. The school raised concerns but these were not viewed through a safeguarding lens.

There is an additional element in that all those with parental responsibility have responsibility in relation to their children’s education, Sara’s birthmother was not informed or consulted about Sara’s removal from school to EHE. If she had been, the story might have been different.

Understanding of Domestic abuse

An underlying theme throughout the review into Sara’s death is about professionals’ understanding and consideration of domestic abuse and its impacts on victims, including children. Under the 2021 Domestic Abuse Act, children are recognised as victims of domestic abuse in their own right. Sara was undoubtedly a victim of domestic abuse. It was integral to her lived experience and the abuse she experienced. Yet this was not fully considered.

There was a consistent lack of understanding of coercive control and that abuse continues after a relationship ends leading to an undue focus on Sara’s birth-mother’s separation from Urfan Sharif as a protective factor. Yet that she could be, and almost certainly was, being abused at the point she agreed for Sara and her sibling to return to live with their father was ignored. This abuse was a clear factor in her exclusion from Sara and her sibling’s lives. Urfan Sharif’s narrative and counter allegations were allowed to prevail without full or detailed consideration of the known history of abuse or how it led to Sara’s birthmother being effectively silenced and isolated. She was not viewed as a victim, or even a possible protective factor. She was viewed as an abuser or simply disregarded.

It was widely known that Urfan Sharif had 2 allegations of false imprisonment made against him by 2 different women. This information was shared but did not appear to have been considered when assessing the risk he posed to other women or children. Sara’s stepmum had already experienced domestic abuse and possibly so-called honour based abuse in previous relationships. She had a history of mental health difficulties, including inpatient treatment and significant self-harm. She was immensely vulnerable to grooming, abuse and coercive control. The concern that she stated that she did not believe the previous allegations were true was not understood or seen as a risk factor. Her vulnerability and inability to act as a protective factor for Sara, even if she had wanted to, was not understood.

Following the care proceedings for Sara and her sibling in 2015, Urfan Sharif was required to attend a domestic violence perpetrator’s course. There are clear questions about the kind of course he was asked to complete. Given his history and lack of evidence of any motivation to recognise let alone change his behaviour, a group intervention of this kind was unlikely to be effective or appropriate. What is really shocking is that this course appears to have been regarded as a ‘tick box’ exercise that no one had enough faith in to feel it was worth monitoring. Monitoring his completion of the course was delegated to Sara’s half-sibling’s social worker without apparently sharing this information with them. This lack of monitoring meant that Urfan Sharif could self-report his completion of the course at a later point. This was taken at face value and not checked. He had, in fact, attended only 8 out of the 26 sessions. There was no consideration of the difference between attendance and engagement, even if he had completed the course.

Whenever there was a claim of child or domestic abuse, Urfan Sharif’s ‘go to’ was a counter claim. As soon as Sara’s mother made claims of her abuse at the hands of Urfan Sharif or raised concerns about the abuse of her children, he accused her of abuse in return. He then groomed and intimidated professionals and manipulating the social care and court system to ensure his view and voice were given precedence. There was no professional understanding or consideration of this as a strategy used in domestic abuse and coercive control.

Lack of professional curiosity

A constant theme in this case as in so many others is of overstretched staff with a lack of time, too many cases and too tight timelines. This was exacerbated by ongoing misunderstandings by professionals of both their role and that of other professionals, including in response to children with injuries. The review notes that more and more, particularly if there is not a clear allegation from the child against a particular person, these cases are not considered as a potential physical abuse concern. The case is pushed back to the school to talk to and advise the parents. This is what happened in this case with a tragic outcome. In this case it was compounded by a mismatch between senior social work staff’s expectation of how the system would work and what had become the practice followed by ‘front door’ staff. We must take allegations and evidence of physical abuse seriously; we cannot fall back to accidents and ‘reasonable chastisement’ as explanations for injuries. This requires both an understanding and consideration of children’s history and lived experience and professional curiosity. The word of a parent needs to be considered with ‘respectful uncertainty’ and not just taken at face value. All professionals need to be prepared to think and verbalise the unthinkable and if necessary, act upon it.

 There is also an issue for schools in relation to the weight that was given to the court judgment in the private law proceedings that granted Urfan Sharif a child arrangement order. Schools do not have legal expertise and it is all to easy to accept court orders without question. Schools need to be aware that these have their limitations and may be based on a false premise, as it was in this case, as much as any other document. We need to be willing and have the access to the legal support to ask questions about these documents and their appropriateness. Just because a document has been issued by a court, it does not mean that it is right.

Time and again the word of Sara’s father was taken without sufficient question or scrutiny, including the reasons for Sara to be removed from school. Urfan Sharif groomed and bullied professionals. For example when the school tried to investigate Stepmum’s language to the younger children outside the school, father’s response was to become ‘animated’ and then remove Sara from school. All professionals needed to be able to link these behaviours, not just with each other, but with the known history. Then ask questions.

Information sharing

Underlying the issues about professional curiosity and overstretch are concerns about information sharing. In 2019 when Sara moved back to live with her father, he exploited the confusions and poor information sharing between Hampshire and Surrey local authorities, core and emergency duty teams and other agencies, including home-start and the NHS walk in service to gain custody of Sara and her sibling. No-one had oversight of all these interactions and was able to identify where Urfan Sharif had lied and manipulated the truth, even when the case reached the court arena.

There were uncertainties around the need for consent for information sharing. Sara’s school was not confident to approach the schools attended by her siblings to share information. The GP completed health information for the children but not the adults in the family so that stepmother’s mental health issues were not seen and could not be considered. Sara’s half-sibling’s social worker was supposed to oversee that Dad completed his domestic abuse perpetrator course but was never told of this expectation. Stepmother did not disclose and falsified information about the presence of Sara and her sibling in the home at the time of the birth of Sara’s half-siblings. The lack of review of medical evidence meant that dad’s assertion that Sara had marks as a result of medical treatment after her premature birth went unchallenged.

The information sharing guidance for professionals (May 2024) is clear, as was the previous iteration of this guidance that: ‘Protecting a child from such harm takes priority over protecting their privacy, or the privacy rights of the person(s) failing to protect them.’ Safeguarding takes precedence over GDPR and Data protection. The updated guidance specifically states that: ‘Consent should not be seen as the default lawful basis for sharing personal information in a child safeguarding context, as it is unlikely to be appropriate in most cases.’ There is now a clear recognition that in cases of Child Protection schools and other agencies may be seeking consent from those who are in fact abusing the child and this is not appropriate.

Schools need to be confident to act without consent when they believe that they are in a child protection scenario. The welfare of the child must be paramount. But for this information sharing to be effective requires good professional relationships, trust and time. These are in short supply when services are overstretched and drowning in poorly organised or inconsistent information. The lack of a clear chronology which could give an overview of the experiences of Sara and her family would have been a key tool to support more effective safeguarding for them.

The impact of race and culture

Sara had dual Polish/ Pakistani heritage. While this was not really considered by services that Sara came into contact with, it was key in what happened to her. Fear of being seen as racist inhibited the actions of her neighbours and professionals. The school did enquire why Sara had started to wear a hijab but did not pursue the issue. There was a tacit acceptance of their overcrowded living arrangements. The experiences of Sara and her siblings were not investigated or understood.

Further, Sara’s birthmother was silenced by the lack of interpreters for her in court proceedings and other meetings. We need to be aware that even where someone presents as having good English, being able to access legal and technical language, understand nuance, follow and express themselves in court are a different matter.

The voice of the child

Sara was described in the review: ‘As a beautiful little girl with a lovely smile and a loud laugh. She was full of personality. It is clear that Sara stood up for herself and she could at times be feisty.’ But what is not evident in the review is her voice. What was Sara’s daily lived experience? What did she want and think?

The voice of the child was collected in 2019 as part of the private law proceedings, but the factors that might have influenced this were not examined and it over relied upon without further question. In 2023 when the school raised concerns about bruising, Sara’s voice expressed through her behaviour and demeanour was not heard. We need to remember that children are not always able to express their voice through verbal disclosure and value the other ways they communicate.

Conclusions

The experience of domestic abuse runs through this case, particularly the lack of recognition of its victims. Sara’s birth and stepmothers, her siblings and most of all Sara herself were all victims of domestic abuse. The lived experience of the women in daily contact with Urfan Sharif was not fully explored or recognised. Their voices were silenced in the case of her birthmother or not heard in Sara’s case.

In both this case and that of Neil Foden, these crimes were committed by, to quote Sara’s review, ‘adults who should have loved and cared for her, and they are ultimately responsible for her death. (7.2 p.54)’. There was a perpetrator, and in Sara’s case their associates who were responsible for their abuse and the steps they took to hide it. Both Urfan Sharif and Neil Foden were ‘powerful’ men who bullied and threatened to cover their tracks. Their actions were facilitated by multiple professional failings and missed opportunities, but they remain responsible for their actions and the abuse they inflicted on their victims.

Yet at the same time, we must not demonise and ‘other’ these men. We need to remember that branding them as ‘monsters’, ‘evil’ and ‘depraved’ sets them apart from others. It excuses us from trying to understand their behaviours. It makes it harder for us to see and for children and others to recognise, understand or share the abuse they are experiencing. We need a real culture of ‘it could happen here’ and to think the unthinkable supported by asking questions and professional curiosity. Only by embedding this as reality in our daily practice can we hope to make the changes needed for this not to happen yet again.