A recently published review into the tragic 2020 death of six-year-old Arthur Labinjo‑Hughes in Solihull, England, has concluded that there were three critical missed opportunities by public agencies which “could and should” have altered the course of events and potentially saved his life.

Arthur died after sustained abuse by his father, Thomas Hughes (convicted of manslaughter), and his father’s partner, Emma Tustin (convicted of murder). The independent review, commissioned by Solihull Council and carried out by INEQE Safeguarding Group in May 2024, examines local agency involvement between 16 and 24 April 2020.

The findings arrive against the backdrop of prior national analysis by the Child Safeguarding Practice Review Panel (CSPRP), which in its May 2022 report concluded that the cases of Arthur and the toddler Star Hobson exposed systemic weaknesses in multi-agency child protection in England.

Background: The Case of Arthur Labinjo-Hughes

Arthur died on 17 June 2020 in Solihull, a west-midlands town in England, after suffering a fatal head injury inflicted by Emma Tustin. His father Thomas Hughes was found guilty of manslaughter. (Safer Bradford) In the years prior to his death Arthur had lived under the care of his father, following his mother’s imprisonment for manslaughter.

In March 2020, the father and Arthur moved into the home of Tustin, at the outset of the initial UK COVID-19 lockdown. The national review and local practice review note that the coronavirus pandemic and associated lockdowns reduced visibility of vulnerable children like Arthur. (Norfolk Safeguarding Partnership)

Between April and June of 2020, Arthur experienced sustained physical abuse, neglect, isolation and deprivation. On the day of his death he had numerous bruises and significant head trauma. The local review notes that, by April, family members had raised concerns about bruising and scratches, and photographs of injuries were available to police and children’s services

The Independent Local Review: Key Findings

Three Missed Opportunities

The INEQE review identifies three distinct moments when statutory agencies had the chance to intervene but did not.

First: On 16 April 2020 the Solihull Emergency Duty Team of children’s social care requested a police welfare check, based on newly raised concerns by Arthur’s grandmother about bruising on his back and scratches on his face. The police response, however, relied on previous contact rather than treating the new information as a fresh safeguarding incident. The review judged this an “ill-informed over-reliance” on earlier interactions.

Second: On 18 April a photograph showing Arthur’s bruising was sent to the police. The review states that the picture depicted injuries “consistent with actual bodily harm”, which should have prompted immediate investigation. The police did not pursue further lines of enquiry, nor did they initiate a multi-agency child protection strategy discussion. The report states: “In my opinion … it is possible that Arthur may have been removed from the pathway to harm that he was ultimately on.”

Third: On 24 April further photographs were shared with children’s social care from the grandmother. At this point the review says practitioners “should have re-evaluated their position, demonstrated professional curiosity and revisited their approach.” Instead, following review of the materials, children’s services concluded the injuries were consistent with play fighting and closed the case. (solihullobserver.co.uk)

Conclusions on Agency Response

The local review concludes: “It is therefore not possible to rule out the likelihood that an appropriate intervention may have prevented Arthur’s murder.” (ITVX) It further states that “possession of photographs by statutory agencies could and should have changed the course of this case.” (safeguardingsolihull.org.uk)

The review also highlights systemic issues: limited visibility of children’s daily lives, inadequate critical thinking and challenge within and between agencies, a lack of specialist child-protection skills, and fragmented multi-agency working arrangements. Some of these mirror the national review’s findings. (Safer Bradford)