Sara Sharif: A child the system failed, what went wrong?

The murder of 10-year-old Sara Sharif in August 2023 is one of the most disturbing and consequential safeguarding failures in recent history. In the months leading up to her death, Sara suffered extreme, escalating abuse, including beatings, burns and torture, inflicted by her father and stepmother. Yet, what makes this tragedy even more devastating is the overwhelming evidence that Sara’s death was preventable.

The Child Safeguarding Practice Review, commissioned by the Surrey Safeguarding Children Partnership, running to more than 60 pages, paints a stark picture of systemic failings across multiple agencies. It concludes unequivocally that:

“There were 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.”

  — Review Conclusion (p.3)

In this blog, Dr Richard Dune synthesises the review’s findings and wider contextual insights to explore what went wrong, why these failures continue to recur across England, and what systemic change is now urgently required.

Sara’s life: Born into risk, surrounded by danger

As early as page 3 of the review, the panel describes Sara’s background with heartbreaking clarity: she was born into a family already marked by domestic abuse, coercive control, poverty and instability. Her father had a documented pattern of abusing women and manipulating professionals, while her mother had a history of trauma and domestic abuse in previous relationships.

Sara spent her first years on a child protection plan, and the courts considered removing her from her parents more than once. Nevertheless, following a sequence of flawed assessments, incomplete information-sharing and inconsistent decision-making, Sara remained within her family.

By 2019, aged six, she and her sibling were placed permanently with her father and stepmother, a decision the review now acknowledges placed her directly in harm’s way. The review states:

“With hindsight, it is clear that they should never have been trusted with the care of Sara.”

  (Preface, p.3)

This conclusion is strengthened by extensive evidence of coercive control, serial domestic abuse, and violence towards other children in the household; all of which were known to agencies, yet never triangulated into a coherent risk assessment.

Key systemic failings: Five critical themes

The review identified five key failings:

Failing 1: Lack of trust in social workers and professional marginalisation

Social workers repeatedly raised concerns and advocated for Sara’s protection, particularly during the early care proceedings. Yet they reported feeling undermined in court settings, where the children’s guardians' views were perceived to carry greater weight. The review notes:

• Social workers’ views “were not heard”

• Critical disagreements were not clearly summarised for the judge

• Court decisions reflected incomplete information and flawed assumptions.

This dynamic, where frontline safeguarding professionals feel disempowered or overshadowed, is a recurring theme in national child protection failures over the decades.

Failing 2: Missing critical information in court proceedings

When Sara’s father applied for custody after remarrying, a newly qualified social worker was assigned to complete the Section 7 report. The review finds that:

• The report lacked vital information

• Key historical concerns were not reviewed

• The GP returned blank medical information, omitting the stepmother’s serious mental health history

• The judge was not reminded of crucial details from earlier care proceedings.

This resulted in Sara being placed with adults who were, as the review puts it, “a lethal combination”.

Failing 3: Misdirected response to bruising - A rushed, superficial assessment

In March 2023, Sara returned to school with a golf-ball-sized bruise on her cheek and other facial marks. Her demeanour had drastically changed,  from bubbly and affectionate to withdrawn and subdued. The school acted correctly and notified Surrey Children’s Services.

Yet the review found:

• The referral was coded “amber”, requiring a response within 24 hours

• No police checks were undertaken

• No strategy meeting was held

• The social worker did not speak to the school

• The explanation from Sara’s father, that the marks were from premature birth machinery, was accepted uncritically.

This was, according to the review, a fundamental failure of professional curiosity, risk recognition, and multi-agency communication (pp. 21–25).

Failing 4: No effective monitoring when she left school - The disappearing child

A month after the bruising incident, Sara’s father withdrew her from school to home-educate her. The review reveals a cascade of administrative and systemic errors:

• The elective home education team went to the wrong house

• The correct address was known to the school but not updated on the council’s IT system

• The home visit, expected within 10 days, was neither completed nor escalated

• The birthmother, who still had parental responsibility, was never informed. 

Home education became the mechanism through which Sara was removed from professional oversight and subjected to the most severe abuse.

The BBC reporting confirms:

“Staff attempted to visit Sara the day before she was murdered, but attended the wrong address, due to outdated records.”

  — BBC News, 21 November 2025

This was the last chance to save her.

Failing 5: Racism and cultural assumptions acting as barriers to safeguarding

The review documents multiple points at which race, culture, religion and identity were misunderstood, ignored or avoided, including:

• Sara began wearing a hijab at age eight, though neither parent did.
  The school sought clarification but accepted the explanation without deeper exploration

• Neighbours heard worrying noises but hesitated to report concerns for fear of being labelled racist

• Assumptions were made about cultural norms around caregiving responsibilities, family hierarchy and domestic dynamics.

The review emphasises that a lack of cultural competence and the absence of robust frameworks for navigating identity-based sensitivities created dangerous blind spots (pp. 39–42).

Failures across the system: A timeline of missed opportunities

The review identifies eight major practice failures and over 40 specific missed opportunities. The most critical systemic issues are summarised below.

Weaknesses at the front door of safeguarding (C-SPA)

On multiple occasions, including March 2023, C-SPA staff:

• Misinterpreted thresholds for strategy discussions

• Relied too heavily on parental self-report

• Did not check police records

• Prioritised throughput over analysis due to workload pressures. 

The review explicitly states that the “front door” lacked “robust safeguarding processes” (Finding One, p. 43 onwards).

Failures in domestic abuse assessment and management

Despite a known history of false imprisonment, coercive control, and allegations of violence against multiple partners, the father’s risk was repeatedly underestimated.

The domestic abuse perpetrator programme he was ordered to attend was:

• Inappropriately selected

• Poorly monitored

• Inadequate for someone with such entrenched behaviour. 

The programme provider’s own report (only partially reviewed by professionals) described ongoing high-risk behaviours, yet these were not acted upon.

Poor information-sharing and professional isolation

Across schools, health visiting teams, occupational therapy, social care, police and voluntary organisations:

• Critical information was siloed

• Records were incomplete or inaccessible

• Professionals assumed others held the necessary details

• The family court was not updated with key background evidence. 

This fragmentation directly contributed to Sara being left in harm’s way.

Elective home education as a safeguarding gap

The review devotes significant attention to the structural weaknesses of elective home education (pp. 30–32). Its findings mirror a growing body of national evidence suggesting that:

• Home education is increasingly used by high-risk families to avoid scrutiny

• Local authority powers to enforce visits are insufficient

• Systems for tracking home-educated children are inconsistent and vulnerable to administrative error. 

The BBC’s coverage echoes this, highlighting that “Sara effectively disappeared from view”.

Sara’s final weeks: Abuse escalating in silence

The criminal trial revealed a pattern of severe abuse that escalated rapidly in the months leading to Sara’s death. Doorbell footage confirmed she had not left the house for at least three weeks prior to her murder (review p. 30).

Texts recovered during the investigation showed:

• Regular beatings

• Night-time punishments

• Physical restraint

• Burns and scalding

• Malnutrition. 

Sara was deliberately silenced, isolated and deprived of opportunities to disclose abuse.

The review concludes:

“Had a home visit taken place within the expected 10 days, it is likely the abuse would have been identified.”

  (Review, p. 25)

Why these failings keep happening: A pattern repeated over decades

The BBC analysis notes the striking parallels between Sara’s case and earlier child protection tragedies, including:

• Maria Colwell (1973)

• Victoria Climbié (2000)

• Peter Connelly (2007)

• Daniel Pelka (2012)

• Arthur Labinjo-Hughes (2020)

• Star Hobson (2020). 

The BBC transcript includes an expert who observes:

“You can go back 50 years… and see the same failings.”

  — BBC World at One transcript (expert commentary)

The Surrey review identifies eight systemic areas of learning, including:

• Failures at the front door

• Weaknesses in elective home education oversight

• Poor domestic abuse practice

• Failures in judicial and Section 7 processes

• Insufficient recognition of race and culture

• Inadequate information-sharing

• Weak multi-agency collaboration

• Gaps in management oversight and organisational culture. 

These are not new problems. They reflect long-standing structural limitations that reform efforts have repeatedly failed to resolve.

Implications for children’s services, safeguarding partnerships, education and leadership

The review’s recommendations, which span pages 43–57, offer a blueprint for change. Key priorities include:

Reforming front-door safeguarding processes

• Mandatory strategy discussions for unexplained bruising

• Clear national guidance on MASH expectations

• Multidisciplinary panels, including specialist domestic abuse practitioners

• Better supervision and leadership oversight.

Strengthening home education safeguarding measures

• Mandatory home visits within two weeks

• Consultation with all parents holding parental responsibility

• Police checks for home education notifications

• Multi-agency discussions when previously known children are withdrawn from school.

Ensuring domestic abuse is centrally addressed

• Recognition of serial perpetrators

• Strengthened training across all agencies

• Programmes designed for high-risk offenders

• Mandatory feedback loops from perpetrator services.

Reforming private law family court processes

• Better use of Section 37 investigations

• Clear escalation pathways when professional views differ

• Interpreter provision as standard

• Improved scrutiny of Section 7 reports.

Embedding race, culture and identity competence

• Access to cultural experts

• Reflective supervision

• Ensuring decisions are culturally informed, not culturally inhibited. 

Improving whole-system information sharing

• Clear closing summaries in case records

• GP information reforms

• Shared professional training across agencies

• Consideration of digital and AI tools to support history analysis. 

Conclusion: Moving from learning to systemic change

The death of Sara Sharif exposes, once again, the profound vulnerabilities in our safeguarding system. The failures were not isolated, nor rooted in the actions of a single practitioner. They were systemic:

• Weak thresholds

• Poor professional curiosity

• Fragmented information

• Administrative errors

• Overreliance on parental explanations

• Misplaced confidence in court orders

• Cultural hesitancy

• Leadership and supervision gaps. 

The BBC’s reporting reflects public sentiment: that this was a “catalogue of missed opportunities”. The Surrey review confirms that these failures were foreseeable, preventable, and deeply embedded in the structure of safeguarding practice.

But the most important truth is this:

Sara’s death was preventable. And because it was preventable, it demands more than reflection. It demands reform.

True systemic change must:

• Strengthen the front door

• Modernise information systems

• Enhance cultural competence

• Prioritise domestic abuse understanding

• Reform private law processes

• Address weaknesses in home education regulation

• Embed multi-agency accountability

• Shift from procedural compliance to compassionate curiosity. 

These reforms are not optional. They are essential to prevent the next child, already in the system today, from suffering the same fate.

Sara’s story must become the line in the sand. Not another case study. Not another review. A catalyst for real, measurable system change.

Anything less would be an injustice not only to her memory, but to every child we are duty-bound to protect.

References

• Surrey Safeguarding Children Partnership (2025). Child Safeguarding Practice Review: Sara Sharif 

• BBC World at One (2025). Safeguarding Review Coverage

• BBC News (2025). Lack of trust and racism concerns: Five key failings in Sara Sharif's review

• HM Government (2023). Working Together to Safeguard Children 2018/2023; Education Act 1996; Children Act 1989.