Vulnerable babies | Leeds Safeguarding Children Partnership

Babies under one year old are at the greatest risk of serious harm, making early identification of vulnerability, effective pre-birth planning, and coordinated multi-agency support critical to keeping them safe. Key safeguarding concerns include non-accidental injury, unsafe sleeping arrangements, concealed pregnancy, parental adversity, domestic abuse, and other factors that can impact a baby's safety and wellbeing before and after birth.

Effective practice focuses on early intervention, strengthening family support networks, understanding risk and protective factors, and ensuring professionals work together to assess needs and plan appropriately for unborn babies and infants. Learning from safeguarding reviews continues to highlight the importance of trauma-informed approaches, robust pre-birth assessment, and clear safety planning.

The National Child Safeguarding Practice Review Panel sets the scene with four key statements aimed at helping you to recognise risk early and strengthen safeguarding responses

Babies under 1 face the highest risk of serious harm
36% of serious incident notifications relate to children under 1, and this age group has the highest fatality rate.
Unsafe co‑sleeping and non‑accidental injury are leading causes of harm
Reviews most commonly identify sudden unexpected infant death linked to unsafe co‑sleeping, and physical harm such as shaking.
Unborn babies require early safeguarding attention
More than 5,000 unborn babies and infants under 1 were subject to child protection plans last year, highlighting significant pre‑birth risk.
Greater support is needed for struggling families
Early, coordinated and trauma‑informed intervention can prevent harm and improve outcomes for babies and families.

This learning was brought together with the publication of Protecting all vulnerable babies better: The Child Safeguarding Practice Review Panel (2026) in February of 2026. The report, triggered by the death of baby Victoria Marten in 2023, provides the opportunity in all locality areas, for us to examine wider safeguarding failures for unborn babies and infants. It is based on extensive evidence (interviews, practitioner input, and multiple safeguarding reviews) to identify system-wide learning. Its purpose is to strengthen safeguarding systems so that vulnerable babies are better protected before and after birth, especially in high‑risk, complex family situations.

The report’s core message is that safeguarding vulnerable babies requires earlier action, stronger relationships with families, and fully integrated multi‑agency working, especially in complex cases involving trauma, domestic abuse, and repeated risk.

Key findings from the report

Safeguarding often comes too late: Opportunities to protect babies can be missed due to late identification of risk, especially during pregnancy. Concealed or late-revealed pregnancies significantly limits the opportunity to intervene.

Persistent parental non‑engagement increases risk: Families can avoid or disengage from services, meaning that risks remain hidden or misunderstood. This non‑engagement is frequently linked to trauma, mistrust, or previous child removals, rather than simple refusal.

Need for trauma‑informed practice: Safeguarding services can fail to understand how trauma affects behaviour and engagement. Systems need to actively build relationships and trust, not just assess compliance.

Fragmented multi‑agency working: Gaps in communication and coordination between children’s social care, adult services and criminal justice/offender management can increase risk.

Complex overlapping risks: Common high‑risk factors including domestic abuse, serious, offending, repeated care proceedings, frequent movement between areas are risks which can escalate across multiple pregnancies, without effective long-term intervention.

Weak continuity when families move: Frequent relocations can cause loss of information, unclear accountability and disrupted safeguarding responses.

Limited support for parents after child removal: Parents whose children are removed may receive insufficient support, increasing the likelihood of repeat harm in future pregnancies.

Recommendations:

Strengthen pre‑birth safeguarding:

Introduce earlier, more proactive intervention during pregnancy
Improve national guidance on:
- Unborn babies at risk
- Concealed pregnancies

Embed trauma‑informed practice:

Develop a shared national understanding of trauma
Ensure services:
- Recognise trauma responses
- Work to build trust, not just enforce compliance

Improve engagement with parents:

Do not treat non‑engagement as a reason to withdraw

Instead:

Persistently attempt engagement
Understand underlying reasons (e.g. fear, grief, trauma)

Provide better support after child removal:

Offer ongoing, tailored support to parents, post‑proceedings

Aim to:

Break cycles of harm
Reduce repeat safeguarding risks

Take a “Think Family” approach:

Integrate adult and children’s services
Assess risks across the whole family system, not in isolation

Strengthen work with serious offenders:

Improve links between:
- Children’s social care
- Offender management (e.g. MAPPA)
Ensure risks posed by offenders to children are fully understood and managed

Address domestic abuse more effectively:

Make domestic abuse central to safeguarding planning
Ensure practice reflects updated legislation and guidance

Improve systems for mobile families:

Introduce:
- Clear responsibility when families move
- Better information‑sharing systems
- Shared chronologies across areas

Strengthen multi‑agency coordination:

Require:
- Better joint working
- Clear accountability
- Integrated planning across services

National and inspectorate actions:

Update guidance such as “Working Together to Safeguard Children”
Ensure inspectorates assess how well systems:
- Protect babies
- Apply learning from serious case reviews

Supporting practitioners in this challenging area, the CSPR panel has created a learning space which provides a series of resources to inform your practice, including a WEBINAR: Protecting all vulnerable babies better .

What this means locally

This focus on the very early life of children has been reflected in work undertaken by the Children and Families Directorate in Leeds, with a review of pre-birth assessments, the social work evaluation carried out during pregnancy when there are concerns about an unborn baby's safety, welfare, or future care. It identifies family strengths, determines if extra support or early help is needed, and plans for the child's protection after birth.

These assessments follow the guidance included in the West Yorkshire Consortium Inter Agency Safeguarding and Child Protection Procedures most particularly those relating to

Pre-birth assessment and Concealed pregnancies

Alongside learning for social workers, this review exercise has also provided an opportunity to explore areas where practitioners across a wider partnership can support colleagues in the Children’s Social Work Service to prepare for and complete pre-birth assessments

When mothers are struggling with their mental health, in pregnancy and beyond

We all know that the mental wellbeing of mothers during pregnancy and in the first year after birth can directly affect the safety, health, and development of both the parent and the child. This was clearly outlined in the government’s First 1000 Days report, recently reviewed (2026). Poor perinatal mental health can increase vulnerability and may be both a safeguarding concern and a factor that contributes to wider safeguarding risk. The need to support infants, their mother’s and wider families, when they may be struggling at this time, is the whole focus of the Leeds and York Partnership NHS Foundation Trust - Perinatal Mental Health Service

Findings from reviews in Leeds have shown, however, that this is an area of practice which could be better supported, with the provision of focused practitioner guidance for the wider workforce. In collaboration with the Barnsley Safeguarding Children Partnership the Leeds Safeguarding Children Partnership has developed a series of briefings which do just that:

Learning points for practitioners

Safeguarding reviews of vulnerable babies consistently highlight the following areas where practice can be strengthened:

Act early in pregnancy. Identify concerns as soon as possible and undertake timely pre-birth assessments to understand risks, strengths and support needs before the baby is born
Prioritise multi-agency working. Share information effectively and ensure health, social care, police and other relevant professionals contribute to assessment, planning and decision-making
Involve fathers, partners and wider family networks. Assess the role of all significant adults and make use of family-led planning approaches to identify sources of support and protection
Recognise and respond to cumulative harm. Consider the combined impact of domestic abuse, parental mental health difficulties, substance misuse, offending behaviour, housing instability and social isolation on a baby's safety and wellbeing
Be professionally curious. Explore inconsistencies, non-engagement, frequent moves, concealed pregnancies and changing circumstances to gain a full picture of risk
Understand infant vulnerability. Babies are entirely dependent on their caregivers and can be seriously harmed by neglect, unsafe sleeping arrangements and non-accidental injury. Practitioners should maintain a strong focus on the baby's lived experience
Use trauma-informed approaches. Build respectful, honest relationships with parents while remaining focused on the baby's safety. Engagement should be supportive, transparent and strengths-based
Plan for birth early. Clear birth and discharge planning, with agreed roles and contingency arrangements, helps reduce uncertainty and improves safeguarding at a critical time for the baby
Provide support alongside assessment. Families should be offered practical and therapeutic support throughout pregnancy rather than waiting for assessments to conclude

Key practice message

Practitioners can improve outcomes for vulnerable babies by focusing on early intervention, effective pre-birth planning, robust multi-agency collaboration, meaningful family engagement, and maintaining a relentless focus on the baby's safety and lived experience.

Further resources

Below are a series of resources which you can draw on when you’re planning your interventions, all focused on enabling you and the families you’re working with to recognise risk early and strengthen your safeguarding responses, including:

Unsafe co‑sleeping and non‑accidental injury are leading causes of harm:

Safeguarding often comes too late: