A damning safeguarding review has found that authorities missed repeated opportunities to protect 10-year-old Sara Sharif, who was murdered by her father and stepmother.

The Local Child Safeguarding Practice Review, published on Thursday, concluded that professionals overlooked the seriousness of her father’s long history of domestic abuse and failed to follow basic safeguarding procedures.

The review, carried out by the Surrey Safeguarding Children Partnership, sets out in stark terms how agencies dealt with Sara and her family.

It said: “There were numerous times before Sara was born and throughout her life, that the seriousness and significance of father as a serial perpetrator of domestic abuse was overlooked, not acted on and underestimated by almost all professionals who became involved with Sara and her family.”

Sara was found dead in the family home in Woking in August 2023, having suffered more than 70 external injuries including burns, fractures and bruising, and been bound and hooded.

Sara’s father, Urfan Sharif, stepmother, Beinash Batool, and uncle, Faisal Malik, were convicted in December 2024 for their roles in her abuse and death. Sharif and Batool were found guilty of murder on 11 December 2024 and later sentenced to life imprisonment. Malik was convicted of causing or allowing the death of a child and jailed for 16 years.

The report sets out a series of missed opportunities in the months leading up to her death.

Concerns about bruising on Sara were first noted in June 2022. In March 2023, staff at St Mary’s Primary School in West Byfleet raised the alarm after she arrived with three facial bruises, one described as being the size of a golf ball. She had been absent for two days, with her family reporting she was unwell.

A referral was made to Surrey Children’s Services and assessed as amber, requiring a decision on action within 24 hours.

According to the review, no checks were carried out with Surrey Police, despite the force holding information about Sharif’s history of domestic abuse. Nor did the service follow up with the school, which had noticed Sara had become increasingly withdrawn and was pulling her hijab down over her face.

When approached by a social worker, Sharif claimed the marks on his daughter were related to medical equipment used when Sara was a newborn. No further social work action was taken. Soon afterwards, he withdrew her from school to home educate her, and the review said that from this point Sara “effectively disappeared” from professional view.

The report said that Sara’s father, stepmother and uncle were able to exploit weaknesses in the home-education system to avoid scrutiny: “There can now be no doubt that Sara’s father and stepmother used home education to keep Sara hidden from view in the last weeks of her life.”

It also said that even in the year of Sara’s death, Surrey County Council (SCC) Children’s Services failed to identify the risks she faced.

According to the review: “In March 2023, SCC Children’s Services, where referrals are received, did not identify that Sara was at risk of being abused by her father, stepmother and uncle. Expected robust safeguarding processes were not followed.”

Woking MP Will Forster, who first called for the review a year ago, said the findings were damnng.

“All the warning signs were there, yet they were not acted upon,” he said. “The authorities were fully aware that Sara was at risk. She was placed on a child protection plan before she was even born and was a victim of domestic abuse from that day onwards.”

Mr Forster said the loophole around home education must be closed urgently. “It is now painfully clear that Sara’s killers used weaknesses in the home education system to conceal what was happening. Legislation is urgently needed to ensure this can never happen again.”

He has called for SCC’s Children’s Services to be placed into special measures and said senior officers must account for the failings outlined. He added that Executive Director for Children, Families and Lifelong Learning, Rachael Wardell, should explain why she accepted an £8,700 pay rise after Sara’s death despite the report’s findings.

Mr Forster added that both the Government and Surrey County Council must act immediately. “There must now be a fundamental cultural shift within Surrey County Council to ensure its own rules are enforced and that no other child slips through the cracks. It is vital that the 15 comprehensive recommendations set out in the report are urgently implemented in full.”

Surrey Police said the abuse and murder of Sara Sharif was “one of the most shocking and tragic cases we have ever investigated.”

Assistant Chief Constable Tanya Jones said: “No child should ever have to suffer what Sara did at the hands of those who should have shown her only love, and an extensive police investigation was carried out to ensure her father, stepmother and uncle were convicted for their crimes.

“The findings within the report are clear, and we will work with the partnership to help implement its recommendations and safeguard our children and young people as effectively as possible.”

In 2019 Surrey’s Children Services was given an ‘Inadequate’ rating from Ofsted. This was then upgraded to ‘Requires Improvement’ in 2022 and then ‘Good’ in 2025.

Surrey County Council has said it has already made “significant change” to how it handles child safeguarding. These include the creation of a multi-agency safeguarding hub to improve information sharing between social care, the police, and health services and mandatory domestic abuse training for all children’s social workers.

The council said it has also strengthened oversight of home education cases and requires additional checks and management reviews when a child is taken off the school roll.

However, the council has not clarified how it will acknowledge the importance of race and culture when considering child safeguarding, or how it will provide access to a translator if needed.

Tim Oliver, Leader of Surrey County Council said: “I am certain that everyone involved with this family will have reflected on what more could have been done to protect Sara, and my thoughts and condolences are with anyone affected.

“The independent and detailed review makes a number of recommendations both for national government and local partners and it is now essential that every single person in every organisation involved in child safeguarding reads this report and understands the lessons learnt.

“I am deeply sorry for the findings in the report that relate to us as a local authority. We will now act on those findings and continue to review and strengthen our culture, systems and processes designed to support good practice in working with children and families, as per the recommendations.

“I call on the government to review the findings and, where appropriate, legislate for the changes in the national system that it calls for.”

*Additional reporting by Emily Dalton, LDRS.