Summary in English

The Norwegian Board of Health Supervision has been given a new permanent assignment to compile and analyse findings and experiences from supervision of the Child Welfare Service.

The data used in the report consists of information the supervisory authorities obtain in connection with supervisory cases, complaints and scheduled supervision activities. As such, the information does not provide a fully representative picture or description of the situation within the Child Welfare System as a whole, but it does provide insight into prominent areas and topics for county governors carrying out supervisory activities.

The information in the report is limited to the years 2022 and 2023. The report is primarily based on quantitative data from the NESTOR registry system and qualitative data from a selection of supervisory cases and complaints that took place in 2022 and 2023, the county governors’ summarised annual reports on the supervision of child welfare institutions in 2022 and 2023 and interviews conducted with all county governors during the spring of 2023. A more detailed description of the materials and the method can be found in Chapter 2.

Chapter 3 of the report presents statistics on supervisory cases, complaints and institutional supervision obtained from NESTOR and the county governors’ annual reports on the supervision of child welfare institutions.

We have identified the following main findings relating to supervisory cases in the statistics:

• With the introduction of new processing methods, the number of registered supervisory cases has increased and the proportion of matters in which violations of law are considered has decreased.
• The most prominent topics registered in connection with supervisory cases relate to the Child Welfare Service’s cooperation with the child, parents, family and network and the Child Welfare Service’s case processing.
• When it comes to matters in which the county governors consider whether or not violations of law have taken place, the child’s participation and the requirement of justifiability are the most frequently considered legal provisions.

With regard to complaints, the statistics show:

• There are generally few complaints relating to decisions made by the Child Welfare Service.
• Most complaints relate to voluntary assistive measures followed by assistive measures for young people over the age of 18 (aftercare).
• The majority of the complaints are either affirmed or returned to the Child Welfare Service for full or partial reconsideration. A small proportion of the complaints are upheld and this proportion has decreased from 8 per cent in 2022 to 3 per cent in 2023.
• There is variation in which cases were upheld and which were not over the two-year period.

With regard to the supervision of child welfare institutions and complaints relating to the use of coercion and other interference, we can highlight the following from the statistics:

• Almost all children residing at a child welfare institution or care centre were offered meetings during inspections by the county governor, but fewer than half of these children wanted to talk to the supervisor.
• There has been a significant increase in the number of records of use of coercion and interference, from 7,652 in 2022 to 11,185 in 2023.
• The correlation between the number of records and the number of complaints about the use of coercion and other interference remained stable in 2022 and 2023.
• The use of coercion in situations of acute danger remains the most frequently considered legal provision in complaints.

Based on statistics, reviews of a selection of supervisory inspections and complaints, as well as information from interviews with county governors, we will highlight nine topics in Chapter 4 that we believe to demonstrate key findings or important findings:

• the child's participation
• voluntary assistive measures and aftercare
• the child welfare service’s administration competence
• cooperation with parents
• collaboration between services and lack of follow-up on children and families
• the Norwegian Office for Children, Youth and Family Affairs’ duty to assist with the placement of children outside the home
• child welfare institutions and use of coercion and other interference upheld complaints relating to the use of coercion in situations of acute danger
• abuse and inappropriate behaviour towards children in institutions

With regard to the first four points, these topics are clearly visible in the statistics. These are key topics known from earlier reports, including the Norwegian Board of Health Supervision’s review of 106 child welfare cases and summaries from nationwide supervision, as well as other reports and public investigations. We know that several measures have been implemented to improve the quality of the work of the child welfare service with regard to both the safeguarding of children’s  participation and cooperation with parents, as well as to strengthen administration competence in the services. New legislation imposes clearer requirements and the rights of children and parents have been clarified. We do not consider this to be sufficient and find that there is a need for additional training and skills development initiatives. We find that there is a clear need to strengthen the legal expertise within the child welfare service and ensure more equitable services for children and families. Improvements in this area will also help prevent the need for more intervention.

The last five points specifically address serious cases. There may not be a high number of such cases, but the cases are serious as they have major consequences for the children in question. We consider the cases involving violations of law associated with the Norwegian Office for Children, Youth and Family Affairs’ duty to assist to be particularly serious, especially with regard to the lack of placement measures when an emergency order is issued. There are children who have to live at home in unsustainable care situations, children living on the streets, actively taking drugs and getting involved in situations involving violence and crime. This means that more children remain in unsettled situations, and this affects the implementation of other necessary, comprehensive support. This raises concern that children are not receiving the help they need from a coordinated support system.

The challenges arising from the reports on supervision of child welfare institutions have previously been highlighted and remain applicable. The reports highlight the fact that children’s needs are not being met by the rules, regulation, competence and professional qualifications of the institutions, that inconsistent staffing results in an increased lack of security and predictability for children and that there are continued challenges associated with cooperation with other sectors. These challenges provide insight into a serious situation that could have negative consequences for some of the most vulnerable and exposed children. The institutions’ mission to safeguard and protect children from harmful situations must be viewed in the context of the alarming increase in the number of records of use of coercion and other interference, especially in situations of acute danger. Whether this increase is due to children having increasingly complex needs or due to a greater focus on the documentation of incidents is unclear.

We believe that it is absolutely essential to view the highlighted issues in context. It can be easy to lose a comprehensive perspective when each topic is considered separately. Issues associated with collaboration and fulfilling the duty to assist with placements must be understood in the context of the issues institutions encounter in providing adequate care to children. This should also be viewed in the context of the interventions initiated at earlier stages. In our opinion, the findings demonstrate the importance of early prevention.

Regardless of the causation that forms the basis for understanding or explaining the failure, we find that the topics covered in this report indicate overall system failure and that adequate comprehensive measures need to be put in place urgently. In future, it will be important for the supervisory authorities to investigate cases with a more holistic approach, across disciplines, but also the various services within each field of expertise. We believe that it is necessary to ensure supervisory development that will enable us to investigate a more complex pattern of issues.