How many times can we say “Never again!” The Critical Role of Escalation: Lessons from the Sara Sharif Tragedy

On the surface, escalation might sound like a bureaucratic buzzword — but the horrifying death of 10-year-old Sara Sharif makes clear just how vital it is. Escalation in safeguarding means raising concerns, ensuring information is shared, and mobilising the right agencies when a child is at risk. In Sara’s case, failures to escalate — both in terms of agency communication and systemic urgency — proved catastrophic.

 A Summary of Sara Sharif’s Case

Sara was discovered dead in her family home in Woking, Surrey, in August 2023. Her body bore at least 71 external injuries, including bruises, burns, and bite marks; internally, there were multiple fractures. Her father, Urfan Sharif, and her stepmother, Beinash Batool, were later convicted of her murder. A postmortem revealed a “campaign of abuse” over weeks, not just an isolated incident.

Significantly, before her death Sara had been pulled out of school to be homeschooled. The judge in her case said that this removal was a “ruse … to cover up the abuse … and to continue with the abuse beyond the gaze of the authorities.” A recent safeguarding review found that multiple agencies “failed to grasp the full scale of danger she was in” and missed many opportunities to act.

Why Escalation Matters — and How It Failed in Sara’s Case

1. Early Warning Signs Were Missed or Under-valued

• According to reports, social services and other agencies had some information about risk in Sara’s family.
• The safeguarding review noted that “a great deal of information … was available but opportunities were lost to join up all the dots.”
• This points to a lack of escalation in thinking: even when individual pieces of concern were there, no one raised the alarm loud enough, or linked them into a coherent, serious risk picture.

2. Homes schooling Reduced Formal Oversight

• Once Sara was removed from school, she was less visible to teachers and other professionals who might notice bruising or behaviour changes.
• The judge explicitly noted that homeschooling allowed her abusers to act “beyond the gaze of the authorities.”
• The Children’s Commissioner has called for proper oversight of children who are homeschooled, especially when they are already known to social care.

3. Lack of Shared Information Between Agencies

• The safeguarding review highlighted systemic problems: agencies didn’t always communicate or escalate concerns appropriately.
• The Children’s Commissioner has argued for better data-sharing, including a unique ID for each child, so services can more easily “join up” their understanding of a child’s risk.
• Without escalation through communication, risk can become siloed, and no single agency sees the full picture.

4. Failure to “Think the Unthinkable”

• The safeguarding review explicitly recommended that professionals “maintain the capacity to ‘think the unthinkable’,” meaning: always be alert to worst-case scenarios, even when they seem unlikely.
• In high-risk or repeating cases, escalation isn’t just about reacting — it’s about anticipating and preventing.


The Broader Importance of Escalation in Safeguarding

• Protecting the Invisible Child: Not all abuse is obvious. Children like Sara, who are withdrawn from school, or who appear to behave “normally” in front of adults, may be invisible unless escalation mechanisms force agencies to look more deeply.
• Breaking Down Silos: Effective escalation means that separate professionals (teachers, social workers, health staff, police) don’t operate in isolation. Shared understanding of a child’s risk is essential so that no one misses the forest for the trees.
• Preventing Tragedies Through Proactive Risk Assessment: Escalation isn’t just about reporting what’s already happened — it’s about anticipating danger. When professionals adopt a mindset of escalation, they are more willing to challenge assumptions and press for help.
• Policy and Legal Reforms: As Sara’s case shows, escalation must happen not just at the frontline, but at the systemic level. When tragedies reveal gaps in law or procedure, public and political escalation can drive meaningful reform.
• Building Trust in the System: For families, children, and professionals alike, a strong escalation framework builds confidence that concerns will be taken seriously, and that the system can act before harm becomes irreversible.


Key Lessons and Calls to Action

1. For Social Workers and Safeguarding Professionals
• Regularly review “low-level” referrals with a risk lens. Don’t assume that closed cases are safe.
• Push for interdisciplinary meetings when risk is unclear. Make escalation part of case reviews.
• Train teams to “think the unthinkable” — worst-case thinking should be normal in high-risk work.
2. For Schools and Educators
• Maintain vigilance, even when children are homeschooled or have intermittent contact.
• Advocate for data-sharing protocols, so you can flag concerns to social services effectively.
• Support policy change that strengthens oversight for home education, especially when safeguarding concerns exist.
3. For Policymakers
• Enact and resource systems that encourage escalation: shared child IDs, data infrastructure, mandatory reporting pathways.
• Review and reform legal defences (e.g. reasonable chastisement) that may mask abuse.
• Provide funding and training to ensure local authorities and services have the capacity to escalate effectively.
4. For the Public and Civil Society
• Raise awareness: talk about the importance of escalation, not just reporting.
• Support charities and campaigns calling for reform in child protection.
• Hold systems to account: public demand can drive systemic escalation in policy.



Conclusion: Sara Sharif’s Legacy Must Be an Escalated Commitment

The death of Sara Sharif was a horrific failure — but it also has the potential to catalyse deep and lasting change. Her story underscores why escalation is not optional in child protection: it’s the backbone of a system that must prevent, not just respond.

If services, professionals, and society commit to escalation — to sharing information, raising concerns, and thinking ahead — then perhaps Sara’s legacy can be a safer future for other children. Escalation must become more than a process: it must be a principle.