The murder of 10-year-old Sara Sharif in 2023 exposed devastating and preventable failures across England’s safeguarding system. In this blog, Dr Richard Dune examines the findings of the official Child Safeguarding Practice Review, which revealed serious breakdowns in information sharing, court processes, domestic abuse risk management, and professional oversight. He explores how flawed decisions, cultural hesitancy, and weak accountability allowed known risks to go unchallenged, ultimately costing Sara her life. The article calls for urgent systemic reform - stronger leadership, clearer thresholds, and integrated multi-agency working - to ensure no child is ever failed in the same way again.