Chris Barnes represented the journalists, Louise Tickle and Hannah Summers, in proceedings before the High Court and Court of Appeal arising from applications for the disclosure of papers from the family proceedings concerning Sara and her family.
On 13 November 2025, the Child Safeguarding Practice Review following the death of Sara Sharif has been published. It makes devastating reading, and has already generated reporting in the national and local media.
Child Safeguarding Practice Reviews (CSPRs) replaced Serious Case Reviews in England in 2018 as the mechanism by which systems are reviewed following child deaths, or serious abuse, especially in the context of cases which may be especially complex, or might have wider significance in informing good practice in organisations working together.
CSPRs are an enormously significant tool in the broader safeguarding systems, and are a powerful resource in permitting analyses of patterns of systemic weakness. The CSPR concerning the circumstances of Sara Sharif’s life, and death, is an impressive, comprehensive, and analytical piece of work – carried out by two Independent Reviewers, Jane Wonnacott, and Dr Russell Wate – the result of a broad review of material and engagement with a wide range of professionals and agencies who had involvement with Sara and her family (§2.6), and detailed interviews with family members (§2.7) including her mother, two siblings, and her father, who was convicted of her murder.
Some initial observations
The CSPR covers a very lengthy period, detailing the family’s involvement with Surrey Children’s Services which predated Sara’s birth in 2013. Similarly, the family’s involvement with the Family Court took place over the course of three sets of proceedings: the first set of care proceedings between December 2012 and September 2013, the second set of care proceedings between November 2014 and November 2015, and private law proceedings (within which there was no dispute between the parents that Sara should continue to live with her father, and step-mother) involving two hearings in July 2019 and ending with a final hearing on 8 October 2019.
This gap in time is important to note. There are some issues identified (the robustness of supervision orders, the content of section 7 reports, the mechanism for reporting back from Domestic Abuse Perpetrator programmes, and others) where processes have, in the intervening period, been changed or updated.
It is also notable that Surrey Children’s Services have reported that changes to some of their own processes and procedures are now different, or have changed. Some are likely to have changed following the initial ‘rapid review’ (a swift process whereby an initial review happens to seek to identify ‘initial learning’ urgently). The press statement made by Surrey County Council emphasises the changes made in recent years but properly notes that “Surrey County Council will be working to implement all local recommendations relating to the organisation in full”.
Some of the wider, national, lessons to be learned from this CSPR may also be reflected in amendments to national practice which have already been put in place. One of the significant issues identified was what happened when a local authority, and a children’s guardian (a person – an experienced social worker, almost always employed by Cafcass – appointed to represent the interests of children in public law proceedings, and some more complex private law proceedings) disagree about the outcome of a case. The CSPR reveals strong cultural issues within the Family Court of the relative weight given (or, perhaps sometimes, felt to be given) to local authority social workers, and guardians respectively.
On this issue, recent guidance sets out a new protocol for what should happen when such a professional disagreement arises. That is predicated on trying to understand, through an open process with a noted meeting, the basis of that disagreement. Though it will be important to see what the product of this new protocol is, it has the potential to be a substantial improvement on more informal discussions, which might lead to important points of disagreement being glossed over, or not pursued because of a perception (or reality) that one party’s view might be held in higher esteem. As this case emphasises, a particular risk arises where, perhaps only on a fine margin, all parties ultimately support a care plan to rehabilitate children, notwithstanding potentially significant inherent issues of risk. The CSPR highlights the adversarial nature of the Family Court process (§5.66), and it is unquestionably the case that the depth of a judge’s understanding of a case is likely to be enhanced in circumstances where they hear full evidence, fully challenged through questioning, on contested issues. That is not to say that agreement is inappropriate – parties should obviously seek to agree matters if they are not disputed, but there are some cases where agreement (especially where one party might come to that agreement whilst retaining significant concerns, and reservations) has the potential to inhibit the court’s safeguarding, and risk assessment function. Whilst the Family Court process is often said to be “quasi-inquisitorial”, and a judge can ultimately refuse to endorse even an agreed position, it is difficult, in practice, for a judge to undertake a full forensic process when faced with agreement between all of the parties.
It is also worth recognising that for anyone whose Sara’s life touched – from her neighbours and community, classmates and teachers, social workers, guardians, and safeguarding professionals, lawyers and judges, and above all her family members, her siblings and her mother – the appalling circumstances of her death will have taken an emotional toll. It can be enormously challenging, against that backdrop, to engage openly with a process that seeks to analyse what went wrong. Part of that was achieved in the Family Court by orders made permitting the disclosure of, and reporting on, papers from the three sets of proceedings which took place (Tickle & Ors v Surrey County Council & Ors [2024] EWHC 3330 (Fam) – This Review provides even more depth and detail; it is an enormously significant report, and an acknowledgment should be made to all of those who took part – including over 40 practitioners, two sets of neighbours, and family members – to help to inform its findings and conclusions.
The findings made
Whilst the report contains an enormous amount of detail, and many specific findings and observations, the Review makes eight central findings:
1.In March 2023, the “front door” of Surrey Children’s services, where referrals are received, did not identify that Sara was at risk of being abused by her father, stepmother and uncle. Expected robust safeguarding processes were not followed. Information gathering and assessment at this stage did not adequately triangulate information and respond to the presence of bruising alongside inconsistent explanations. Sara’s “voice” expressed through her change in demeanour was not heard.
2. When Sara was withdrawn from school to be educated at home, national legislation and guidance provided a context where there was no requirement for a formal discussion between parents and professionals, even though she had a history of extensive involvement with statutory services. This context also meant that her birth mother was not consulted and there was confusion about the process for recording that she had been withdrawn from the school roll. Lack of effective management oversight also meant that the good practice in Surrey of offering home visits within 10 days was not followed.
3. Work with the father as a domestic abuse perpetrator was not integrated to childcare assessment and plans. The seriousness and serial nature of his abusive behaviour to his family was not recognised beyond the second set of care proceedings. There was an assumption that attendance at a group programme for domestic abuse perpetrators was sufficient and his account of completion of this programme was all that was needed. There was no clear statement of what needed to change to mitigate his future risk to women and children and how change in his behaviour would be evaluated.
4. The overall process of the private law proceedings (when it was agreed that Sara should live with her father and stepmother) did not maintain sufficient focus on the needs of the children, their cultural heritage and the ability of Father and Stepmother to provide safe care.
5. Within the two sets of care proceedings, the local authority changed their care plan to a supervision order and Sara remained living with her family. Supervision orders did not provide adequate safeguards; problems associated with the effectiveness of supervision orders in keeping children safe have been identified as a national issue.
6. The Review has found a notable lack of consideration given to Sara’s race and culture and how her dual Polish/ Pakistani heritage may have impacted at various stages of her life. The use of an interpreter for Sara’s mother was almost non-existent and in private law proceedings this had a negative impact on her ability to be heard and contribute.
7. Work with the family in health, social care and education lacked a consistent whole family approach which gathered all relevant information including past involvement and knowledge of the wider family. This was influenced by staffing capacity alongside a lack of confidence and knowledge about what information could be sought or shared and the roles and responsibilities of other safeguarding professionals.
8. There were instances where individual practice did not conform with practice expected by the agency, and management and supervision systems did not provide the necessary oversight, challenge and support.
Many of these themes are familiar from those considered in other LSPRs and SCRs. The broad range of findings emphasises the sad reality that in cases of abusive child deaths there are frequently multiple systemic and individual failings, and a failure to share information, and properly implement processes all of which contribute to the missed opportunities to intervene to protect children at risk.
For those working in child protection, and in the Family Court, the Review reiterates the importance of ensuring that supervision order planning is robust, that a focus on safeguarding is placed at the heart of both public and private law proceedings, and that all professionals ensure that they have far greater awareness of domestic abuse, and the manner in which perpetrators operate to manipulate and control victims and professionals.
The recommendations made
The main areas for learning identified by the Review’s authors are helpfully summarised in an Executive Summary which is available on the website of the Surrey Safeguarding Children Partnership (the organisation responsible for commissioning the CSPR):
- The importance of robust safeguarding processes within a system that supports parents to care for their children
- Working with perpetrators of domestic abuse.
- The role of Family Justice – safeguarding children in Care Proceedings and Private Law.
- Hearings.
- Race, Culture, Religion and Ethnicity.
- Seeking, analysing and sharing of information.
Within those areas, the Review makes 15 recommendations, some of which are specific to local agencies, and some of which are directed at changes to national policy:
- Safeguarding Partners should ensure that robust multi-agency safeguarding processes are in place, understood, adhered to by all agencies and quality assurance processes ensure that they are adhered to. These processes must include the requirement to hold a strategy discussion when a child comes to the attention of professionals with bruising which is suggestive of physical abuse.
2. The Department for Education should build on the 2025 evaluation of MASH LINK and provide clear practice guidance to ensure that “front doors” into children’s social care routinely include an evaluation of whether a child is at risk of abuse. Safeguarding processes must be in place at the “front door” to ensure that any bruising to a child is properly assessed and strategy meetings held where there is significant harm or the likelihood of significant harm to a child.
The National Child Safeguarding Review Panel should be asked to promote good practice at the “front door” of children’s services. This should highlight what a good “front door” looks like including (but not restricted to) resourcing and capacity, qualifications and experience of staff, (including specialist domestic abuse practitioners), management and supervision and practice audit. In order to develop this good practice guidance as well as making use of the learning from the 2025 MASH (Multi-agency safeguarding hubs) evaluation, Consideration should be taken from the findings of ‘The MASH guiding principles document’ published in April 2025 by the National Police Chiefs Councils, Vulnerability, Knowledge and Practice Programme.
3. The Department for Education should:
Review contradictions between pupil registration requirements and legislation and guidance underpinning Elective Home Education;
Update statutory guidance to:
• Require a formal meeting with parents and professionals to assess support needs in all cases where a child has been previously known to children’s social care, is currently known to children’s social care or the school has recorded concerns about the wellbeing of the child before receiving notification.
• Ensure that all parents with parental responsibility are consulted when a decision has been made to educate a child at home and there is a clear pathway to follow if one parent objects.
• Include a requirement that a home visit should always take place and children seen within two weeks of notification of withdrawal from school to home educate.
Work with the National Child Safeguarding Review Panel to consider the findings of the review in relation to Elective Home Education.
4. Surrey County Council should work with Surrey Police to incorporate police checks into the process for responding to elective home education notifications. This should include ensuring that the elective home education service always shares such notifications with the C-SPA EXPLAIN for prompt triage to identify any child open to Surrey children’s social care or for whom a previous safeguarding concern has been raised, and that via the C-SPA police checks are carried out for children found to be in either of these categories.
5. All managers and practitioners involved in safeguarding children need to have a good knowledge of the ‘modus operandi’ of domestic abuse perpetrators. This includes how they manipulate through coercive and controlling behaviour and groom professionals by their disguised non-compliance. Management and supervision sessions must ensure that a focus is maintained on any current risks to women and children through domestic abuse.
Multi-agency domestic abuse training should take place both locally and nationally for practitioners and managers. This should include both knowledge of all aspects of domestic abuse, including perpetrator behaviours and beliefs and attitudes underpinning responses. The outcome should be that tackling of domestic abuse is seen holistically and a whole system issue.
At both a local and national level, services to attempt to change behaviours of domestic abuse perpetrators should be reviewed to ensure there is the right range of programmes available. Where children are involved this needs to ensure that there is always a feedback loop from commissioned services to child safeguarding practitioners who are working with the children and families.
6. Practice guidance underpinning Section 7 reports and other reports for private law family justice should be updated to include a requirement that the safeguarding letter filed by Cafcass should also be sent to the organisation completing the section 7 report and always be reviewed as part of the process. Section 7 reports should be subject to the same level of scrutiny within the local authority as documents provided for care proceedings.
When the local authority and/or Cafcass are involved in private law proceedings they should, if they believe that it may be appropriate for a care or supervision order to be made, request that the court considers whether an order is made for the local authority to complete a section 37 investigation instead of a Section 7 report.
7. The potential for safeguarding risks not being recognised or addressed in private law proceedings must be eradicated. This should be approached through the work of both Local and National Family Justice Boards to specifically focus on changing culture, policy and procedure that private law is not just about family dispute resolution in relation to the children involved but to recognise the risks in particular during separation to not just the adult but also the children.
8. Where a parent’s first language is not English, the appropriate process should always be that an interpreter is available to ensure that there is a full understanding of the complex court proceedings. Where this is not possible due to capacity and there is a risk of delay to the proceedings the court should on all occasions ensure that the parents understand what is happening at each stage of the proceedings.
9. When the independent advice of the children’s guardian and the assessment of the local authority differ, this should be recorded in line with guidance (July 2025) CROSS REF to enable the lead judge in the case to read in summary form, the points of difference before the judge in respect of the care plan. This will save the court time and will enable parties to consider these points in detail as decisions are made. An audit is recommended for local and national family justice boards to complete in twelve months’ time which could help to indicate how successful this guidance has been.
10. In order to ensure that children subject of supervision orders are adequately protected from significant harm:
The principles set out by the Public Law Working Group for the implementation of supervision orders should become expected practice in all local areas and further evaluation carried out to ensure that these adequately protect children from significant harm.
The principles should be reviewed and include a requirement that the implementation of supervision orders is based on consideration of equality, diversity and inclusion, and advice has been taken from those with relevant knowledge, expertise and lived experience.
11. Surrey Safeguarding Children Partnership should require all agencies to develop a pathway for practitioners to consult with experts where they need additional knowledge about context and practice across diverse family cultures. This should include consultation with local organisations from minoritised communities who are already providing services in the field of domestic abuse and safeguarding.
Safeguarding audit activity (multi-agency and single agency) should always include a review of the level to which a child’s culture and heritage is highlighted and explored within day-to-day practice. This includes the opportunity to reflect on the impact of assumptions and biases on decision making and whether there is a need to improve practitioners’ cultural competency.
Surrey Safeguarding Children Partnership must highlight to all practitioners from early help through to those that work in the family court that a person’s ability to communicate conversationally in English does not negate the need for all official meetings to employ the services of an interpreter. Where this is not possible due to capacity and there is a risk of delay to child protection or child in need processes, professionals should on all occasions ensure that children and their parents understand what is happening at each stage.
Surrey Safeguarding Children Partnership should benchmark their local strategy policy, procedure and practice against the recommendations and reflective questions set out in the National Child Safeguarding Practice Review Panels report on racism and safeguarding children.
12. Any real or perceived barriers to information gathering and sharing must be explored at both a local and national level. This can be achieved by providing clear, role specific, practice guidance developed for staff working at the front door, and all those responsible for safeguarding children. As well as developing and embedding as good practice the provision of closing summaries, the exploration in digital and AI solutions may assist with information assessment to prevent risk.
13. The importance of health professionals, and in particular the health visitor role or allied health professionals, in safeguarding children should be strengthened. This can be achieved in health visiting by ensuring that the commissioning arrangements within local authorities for health visitor teams are sufficiently funded to enable capacity and flexibility to use evidence-based interventions to respond to complex family circumstances.
14. Surrey Safeguarding Children Partnership should work with partner agencies to review learning and development opportunities including the multi-agency training offer. This should ensure there is opportunity for increased understanding of roles and responsibilities as well as developing effective multi-agency relationships embedded within the learning and development opportunities and that individual organisations support their staff to attend and participate so that there are no barriers to specific professional groups attending
15. Surrey Surrey County Council should review and strengthen the existing culture, systems and processes designed to support good practice in working with children and families. This should ensure that:
- Practice standards and expectations are clear and understood.
- Quality Assurance activity within each service identifies where practice is not meeting expectations. This activity should include relevant specialist services.
- Staff development and training expectations are clearly set out, and professional development is prioritised at all levels.
- Supervision provides an opportunity to reflect on any barriers to achieving and maintaining good practice, assists practitioners in thinking clearly in complex cases and identifies learning and support needs.
Reflections
The Review makes a significant number of important recommendations. Given the circumstances of Sara’s death, the outcome of this Review is likely to gain a significant amount of attention. It will be important though that, as media reporting fades, the imperative continues to use the Review to drive improvements.
Whilst the reality is that no system of safeguarding can ever be perfect, and that some parents will, sadly, cause serious harm to their children, the involvement of the Sharif family with children’s services, the Family Court, and other agencies means there is much to be learnt from what went so seriously wrong in this case.
The new national protocol for managing – openly – disagreements between local authorities and guardians is welcomed. The courts have long emphasised that social workers should enjoy parity of esteem – as social work professionals – within the court process with those who work as guardians at Cafcass, and that must be reflected in a sincere openness to engaging with, and analysing a range of opinions where they might arrive at different conclusions.
The Public Law Working Group recommendations, allied with Court of Appeal approval in Re JW (Child at Home Under Care Order) [2023] EWCA Civ 944, have done much to strengthen the requirements of Supervision Order planning, but that must be followed through during the course of those plans being implemented.
For safeguarding professionals, and those working in the Family Court, there is also a further need to reflect on the sufficiency of professional and judicial understanding of domestic abuse so that safeguarding is prioritised in private law proceedings, as well as those public law proceedings where local authorities are more fully involved. In all those areas transparency of response, and transparency in future practice is key to ensuring that lessons are learnt, and recommendations properly and fully implemented.
The authors of the Review outlined at the outset an important series of observations about the absence of a simple solution, and the fundamental responsibility, which of course lies at the door of those responsible for her murder:
‘There is no single solution that will address all the factors that affected Sara, and this review has resisted simplistic responses to the complex set of circumstances of Sara’s life and death. There are clearly several points in Sara’s life, in particular during the last few months, where different actions could and should have been taken and the system failed to keep her safe. But it should not be forgotten that at the heart of Sara’s life and death is a violent woman, and a violent man who was capable of grooming and manipulating those around him. His capacity to groom others included his family and any professionals whom he encountered. Sara’s stepmother also had a troubled history. She was not open with professionals about her past and was capable of inflicting serious harm to a child in her care. Sara’s father and stepmother proved to be a lethal combination, and with hindsight it is clear that they should never have been trusted with the care of Sara.’
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