Death of a 16-year-old girl, in January 2013, from multiple stab wounds. Adult 1 contacted Child R via social media and convinced her to go to a commercial premises on the pre-text of being offered a job. Adult 1 was convicted of murder and received a 35-year prison sentence. Child R experienced multiple traumas during her childhood, including witnessing the death of a friend, physical assault, cyberbullying and rape. Identifies risk factors affecting Child R, including: going missing from home, sexual relationships with peers her own age, sexually exploitative relationships with adult males, preoccupation with fire, drug and alcohol misuse and self-harm. Adult 1 had a history of: physically and sexually abusive behaviour as an adult and child; cruelty to animals; and diagnosed child conduct disorder. Uses an adaptation of the Social Care Institute for Excellence (SCIE) systems model to present key themes for learning, including: recognition of abuse and risk to adolescents from outside the home; possible systemic bias in using safeguarding frameworks to assess risk to older children; compliance with missing from home (MFH) and child sexual exploitation (CSE) protocols in regard to young people resistant to help and intervention; and effective diagnosis and response to conduct disorder in childhood including the provision of evidence-based parenting programmes.
      
 Title:  A serious case review: ‘Child R’: the overview report. LSCB: Lancashire Safeguarding Children Board Author: Peter Maddocks Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Page 1 of 60        Lancashire  Safeguarding Children Board        A Serious Case Review  ‘Child R’  The Overview Report     September 2014    Page 2 of 60 Index  1 Introduction and context for the serious case review ................................... 3 1.1 Rationale for conducting a serious case review..................................... 4 1.2 The methodology of the serious case review ....................................... 4 1.3 Reasons for the review and terms of reference .................................... 5 1.4 The scope of the serious case review .................................................. 6 1.5 Particular themes identified by the review group for detailed analysis and examination ............................................................................................ 7 1.6 Membership of the case review group and access to expert advice .......... 8 1.7 Independent author of the overview report and independent chair of the serious case review panel ........................................................................... 9 1.8 Parental and family contribution to the serious case review ................... 9 1.9 Timescale for completing the serious case review ............................... 10 1.10 Status and ownership of the overview report ..................................... 10 1.11 Previous serious case reviews ......................................................... 11 1.12 Inspections of services for children in Lancashire ................................ 11 1.13 Summary conclusion of the review panel .......................................... 11 1.14 Child R ........................................................................................ 18 1.15 Adult 1 ....................................................................................... 21 1.16 Cultural, ethnic, linguistic and religious identity .................................. 24 2 Synopsis of agency involvement ............................................................. 26 3 Analysis of key themes for learning from the case and recommendations ...... 38 3.1 Cognitive influence and human bias ................................................. 39 3.2 Responses to incidents or information .............................................. 41 3.3 Tools for informing professional judgment and decision making ............ 43 3.4 Management and agency to agency systems ..................................... 51 4 APPENDICES .......................................... Error! Bookmark not defined. Appendix 1 - Procedures and guidance relevant to this serious case review ....... 55 Legislation ............................................................................................. 55 The Children Act 1989 .......................................................................... 55 The Children Act 2004 .......................................................................... 55 Safeguarding Procedures ......................................................................... 56 The local safeguarding children procedures .............................................. 56 4.1 Other local procedures relevant to this serious case review .................. 56 National guidance ................................................................................... 56 Working Together to Safeguard Children (2013) ........................................ 56 Common Assessment Framework (CAF)................................................... 57 A step by step guide for front line practitioners (child sexual exploitation) 2012 ........................................................................................................ 57 Guidelines on Prosecuting Cases of Child Sexual Abuse (2013) ..................... 57 Statutory Guidance on children who run away or go missing from home or care (2013) ............................................................................................... 58 4.2 Appendix 2 Specific questions addressed by the expert ....................... 59 1  Page 3 of 60 Introduction and context for the serious case review  1. In January 2013 the body of sixteen year old Child R was found in Blackpool. Child R had suffered multiple stab wounds. Child R had been lured to local commercial premises by Adult 1 on the pre-text of being offered employment.   2. The police arrested 23 year old Adult 1 the same night that Child R’s body was discovered. Despite his denials of involvement he was subsequently charged with murder and was convicted on forensic evidence and given a prison sentence of 35 years.   3. Adult 1 had previously lured another young adult to the same premises and had attempted to assault them but that young person had managed to make an escape. They had not made any complaint or allegation to any service including the police.   4. Child R was a student on a child care course and was living with both parents. Child R had been known to more than a dozen different services over several years that had been trying to help and support Child R. Child R was vulnerable to risks that arose from emotional and psychological difficulties that reflected traumatic experiences and were manifested in aspects of behaviour and lifestyle.   5. The review describes and explores those difficulties and how the various services responded. In exploring these issues the review panel make clear that the only person who is responsible for the dreadful murder of Child R is the convicted perpetrator.    6. Adult 1 had a troubled and isolated childhood. There had been concerns about his lack of social skills and his potential for aggressive behaviour as a child and an adolescent although he had not been assessed or identified as representing a significant and serious level of risk to the public.   7. Adult 1 had a ten year history of having no insight into other people’s feelings, had committed opportunistic assaults, had caused injuries to animals and had admitted a sexual assault of a fellow student. Although these behaviours and history are evidence of previous significant harm to other people they do not provide a definitive prediction about his capacity to inflict the level of violence perpetrated against Child R.   8. Neither the expert psychiatric report commissioned for the review nor the other evidence collated by the review has indicated that it would have been reasonable for an individual professional to have predicted that Adult 1 would kill. Some individual professionals had been concerned about examples of Adult 1’s cruel and aggressive behaviour in adolescence, such as  Page 4 of 60 an air gun attack on horses, that in isolation were not enough to have raised significant concerns and invoke multi agency public protection measures.   1.1 Rationale for conducting a serious case review  9. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 4 of Working Together to Safeguard Children (2013)1.   10. The LSCB is required to undertake a serious case review when a child dies and there is cause for concern as to the way in which the local services have worked together.   1.2 The methodology of the serious case review  11. A serious case review group was convened of senior and specialist agency representatives responsible for the methodology and to oversee the scope, collation and analysis of information and to identify the findings and learning from the review. The review was co-ordinated by an independent lead reviewer with appropriate experience and training who wrote this report. Further information is provided in section 1.7.  12. Following the publication of the revised national guidance for the conduct of serious case reviews in England in March 2013, the LSCB had participated in regional work in the north west of England to develop a learning and improvement framework (LIF) to guide the methodology for such reviews.   13. The review group that oversaw the SCR decided to build on the learning that had been developed from four previous SCRs in the county; one of those had been wholly conducted using the SCIE framework and other SCRs that had included a combined domestic homicide review (DHR) had used the framework to present the findings from the review.  14. In consultation with the review group, the professional advisor and the chair of the LSCB, the lead reviewer developed a methodology statement to guide the work of this specific SCR.   15. Work began on compiling a chronology in August 2013. From the collated chronology the review group identified themes for detailed analysis that also took account of information provided by Child R’s parents. In order to ensure that there was sufficient understanding about how and why particular events                                         1 Working Together to Safeguard Children. A guide to interagency working to safeguard and promote the welfare of children March 2013; also incorporates the revised arrangements for assessment of children that will be based on locally determined single assessment.  Page 5 of 60 or episodes developed the review group ensured there was a sufficient level of practitioner and family involvement in the compilation of information and in the development of analysis.   16. An expert forensic psychiatrist was commissioned to provide additional analysis and opinion particularly in regard to Adult 1’s childhood and adolescence.  The purpose of that was to establish if there were opportunities to have identified and responded to any evidence of risk in order to inform future practice with children and young people presenting with enhanced levels of complex need. The terms of reference for the expert report are included as an appendix to this report.   17. A practitioner session that involved professionals from the services who had direct contact with and knowledge of Child R was held in November 2013 and was facilitated by an experienced multi agency trainer who developed a framework for collating information during the day. This session was used to outline some of the contributory factors influencing key events and decision making.   18. A further session with practitioners in February 2014 provided an opportunity to discuss the key findings from the review.   19. At the second meeting of the review group there was discussion about how best to examine information in regard to Adult 1. An expert psychiatrist was commissioned with relevant expertise to review information and to provide advice and analysis. Further information is provided in an appendix to this report.   20. The analysis in the final chapter of this report uses an adaptation of the framework developed by SCIE (Social Care Institute of Excellence) to present the key learning within the context of the local systems. This takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children2. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions.   1.3 Reasons for the review and terms of reference                                          2 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans  Page 6 of 60 21. The reason for undertaking this review is that Child R died as a result of non-accidental and multiple injuries inflicted by Adult 1.   22. The case was discussed by the SCR group in March 2013, as to whether or not to undertake a SCR. This being a 'stranger murder', the LSCB would not usually review under those circumstances. At that meeting there was further information required before an informed decision could be made regarding the level and nature of different agencies contact and involvement and whether there were issues to be examined in regard to inter-agency working.    23. When further information had been provided the SCR group made the decision to recommend that the LSCB should undertake a SCR on 7th May 2013; this recommendation was agreed by the vice chair of the LSCB on the 14th June 2013 who was deputising for the independent chair person of the LSCB who was away at the time.  24. The reason for a SCR was to look at any vulnerability around Child R and the type and appropriateness of any help that was provided.   25. The SCR was also required to give consideration as to whether there was anything in Adult 1’s history that could have indicated significant risk to a child or young person and any learning to be identified for professional practice and multi agency working.   26. The review group first met on the 8th August 2013 to agree the scope of the review and a timeline for completion.  The scope and methodology of the review was routinely discussed and updated at subsequent review group meetings to take account of any new or emerging information and reflection.   27. The purpose of the review is to establish what lessons can be learned to improve inter-agency working and better safeguard and promote the welfare of children and young people in Lancashire.  1.4 The scope of the serious case review  28. The period under review in respect of Child R is from the beginning of 2009 until the end of January 2013.  29. The following services provided information via a chronology and also participated in collating further information and analysis  a) Health services in Blackpool and Lancashire that included:  o GP services; o Blackpool Teaching Hospitals NHS Foundation Trust (BTHFT) (provide Hospital services, CAMHS, adult mental health services,  Page 7 of 60 Connect Counselling services, Connect sexual health services and  School Nursing Services); o Lancashire Care NHS Foundation Trust (LCFT) (provide CAMHS in Lancashire); o Lancashire SAFE Centre (Sexual Assault Forensic Examination service that offers medical examination, advice and support to women, men and children who have experienced sexual assault or rape).  b) Young Addaction (young people’s substance misuse services) involved February 2012 until September 2013; c) Awaken Project (run jointly by children's services, health and the police in Blackpool its aim is to safeguard vulnerable children and young people under the age of 18 who are sexually exploited. It also aims to identify, target and prosecute associated offenders); d) Blackpool Education Service e) LCC CAPSS (child and parent support service)(involved briefly through the CIN plan in 2012 and made the referral to Addaction); f) Lancashire County Council (LCC) children’s social care (CSC); g) LCC children missing education service; h) LCC substance misuse service (involvement with Child R); i) Lancashire Constabulary (in relation to criminal investigation of the rape, responding to Child R missing from home and the investigation following Child R’s murder); j) LCC Young People’s Services; k) The HUB based in Blackpool (substance misuse service for young people aged 24 and under, their families, friends and professionals working with them);  30. Lancashire Probation Trust (undertaking a post sentence assessment on Adult 1 that had not been completed when the SCR had been concluded). Information was also sought from members of the families and is described in section 1.8.   1.5 Particular themes identified by the review group for detailed analysis and examination 31. These were:  a) Identification and response by services to older children who are at risk of significant emotional, psychological or physical harm and the cognitive, professional and legislative frameworks that are deployed;  b) Supporting young people who have been subjected to sexual exploitation or sexual abuse and violence and reconciling the young person’s needs for appropriate counselling and  Page 8 of 60 therapeutic support especially when parallel processes such as criminal proceedings are not completed;  c) Assessment and making enquiries including history taking on a single and multi agency basis; developing an overarching overview of need and risk;  d) Identification of risk to young people from internet and social media;  e) Escalation and de-escalation of help in terms of intensity and use of alternative frameworks that include the CAF (common assessment framework), CIN (child in need) and safeguarding arrangement and processes;  f) Transition and coordination of help across geographical boundaries and between children and adult services.  32. The review group collated information about the perpetrator to assist in identifying any indicators that he presented recognisable risk of significant harm either to himself or to others.  1.6 Membership of the case review group and access to expert advice  33. The case review group that oversaw this review comprised the following people and organisations;   Position Organisation Chair Independent lead reviewer Operations manager Young Addaction School improvement advisor Blackpool Education Service Designated nurse Blackpool Clinical Commissioning Group  Acting principal social worker Children’s Social Care Services (LCC) Review officer Lancashire Constabulary Designated doctor  Blackpool Teaching Hospitals NHS Foundation Trust  Assistant director of nursing – safeguarding children   Lancashire Care Foundation NHS Trust Named nurse for children looked after Blackpool Teaching Hospitals NHS Foundation Trust Named nurse for safeguarding children Blackpool Teaching Hospitals NHS Foundation Trust Assistant head of young people’s services Lancashire Young People’s Service (LCC) Clinical director Lancashire SAFE Centre Panel Observers/Support Business manager Lancashire Safeguarding Children Board (LSCB)  Page 9 of 60 Support officer Lancashire Safeguarding Children Board (LSCB)   34. The independent author of the overview report attended every meeting of the panel.  35. The panel had access to legal advice from a solicitor in the council’s legal service.  36. Written minutes of the review group discussions and decisions were recorded by a member of the LSCB staff team in Lancashire.  1.7 Independent author of the overview report and independent chair of the serious case review panel  37. Peter Maddocks was commissioned in August 2013 as the independent lead reviewer. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on three previous serious case reviews in Lancashire. Apart from this, he has not worked for any of the services contributing to this serious case review. He has participated in training and professional development as a reviewer; this has included specific training in the use of systems learning applied to serious case reviews.  1.8 Parental and family contribution to the serious case review  38. The parents of Child R were made aware of this serious case review when it was commissioned and were very helpful at a time of immense emotional trauma.  39. Child R’s parents felt that the rape that she was subjected to in 2010 aged 14 had an increasingly detrimental impact on her emotional well being and was a cause for the disruption to Child R’s schooling as well as contributing to the risk taking behaviours that she had, such as frequently missing from home and meeting strangers.   Page 10 of 60 40. Although Child R had been offered counselling this did not allow Child R to discuss the rape and the impact it had on her and her relationships. Counsellors working with Child R were concerned not to compromise the criminal investigation and prosecution. This is analysed in later sections of the report.  41. Child R’s parents had been worried about Child R’s pattern of going missing from home. They had resorted to trying to secure the house and to control Child R’s movements although this had little or no effect.   42. Child R’s attendance and relationships at school became particularly problematic after the rape in 2010 which had become public knowledge amongst other students. This led to behavioural problems and confrontations and Child R was eventually moved to another school which was followed by further transfers. From Child R’s parents perspective this was a watershed in that it marked a transition out of mainstream education after the second school placement broke down. Child R’s parents’ felt that Child R was increasingly in contact with other people including adults as well as young people who had various problems and challenges.   43. Child R’s parents felt they had to fight hard to get an education placement for Child R. They felt that in spite of the difficulties that Chid R experienced they were able to still talk with their child.   1.9 Timescale for completing the serious case review  44. The case review group met on five occasions between August 2013 and February 2014. The initial chronology of services involvement was completed by September 2013.  This overview report was presented to an extraordinary meeting of the LSCB in March 2014. After that meeting the lead reviewer met with Child R’s parents to discuss the findings of the review prior to publication.  1.10 Status and ownership of the overview report 45. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning board for the SCR.  46. Since June 2010, all overview reports provided to LSCBs in England have to be published in full3. This overview report provides the detailed account of the                                         3 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. This arrangement has been confirmed in the revised national guidance issued in April 2013 and referred to in earlier paragraphs. The coalition government had ended the formal evaluation of SCRs from the 5th July 2012.  Page 11 of 60 key events and the analysis of professional involvement and decision making in relation to Child R and her family.   47. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department for Education.    1.11 Previous serious case reviews  48. The LSCB in Lancashire have undertaken ten serious case reviews since 2008.   49. Some of the themes such as sharing of information, coordination and having a single lead professional and the limited focus of assessment have been revealed in some of the earlier SCRs.   1.12 Inspections of services for children in Lancashire  50. All children’s statutory services in England are subject to inspections.  In early 2012 there was a statutory inspection of safeguarding and looked after arrangements in Lancashire. This evaluated safeguarding arrangements as being good in Lancashire with a well managed child protection service; Child R was never subject of any child protection plan. The inspectors commented that the local authority contact, referral and assessment arrangements had been comprehensively redesigned and had already had a positive impact. The quality of referrals made by partner agencies seen by the inspectors was good.   1.13 Summary conclusion of the review panel  51. Adult 1’s attempted assault on another young adult shortly before Child R was murdered was not reported to the police or to any other service and therefore there was no opportunity to review any risk associated with Adult 1.   52. The review has provided the opportunity to collate information about a wide range of agency contact with Child R although until the practitioner event in November 2013 the extent of that contact was not fully known about, including by any of the individual people in direct contact with Child R. Serious case reviews have discussed how services can operate within silos and a feature of contact with Child R is the extent to which there was little joint or interagency work. None of the professionals were in charge or leading.    Page 12 of 60 53. The review panel have not identified a single event or incident that could have provided an opportunity to respond differently to Child R (or to Adult 1) that would have prevented Child R’s murder.   54. Child R was a child at risk of sexually exploitative relationships. She was sexually assaulted and had been raped. Child R had complex emotional and psychological needs that contributed to Child R engaging in high risk behaviour such as going missing from home (MFH) and using substances. Although Child R was advised and counselled about risk and vulnerability Child R had difficulties in accepting guidance.   55. In assessing whether a child or young person is a victim of sexual exploitation, or at risk of becoming a victim, national guidance4 requires careful consideration should be given to the issue of consent. It is important to bear in mind that:    a) a child under the age of 13 is not legally capable of consenting to sex (it is statutory rape) or to any other type of sexual touching;   b) sexual activity with a child under 16 is also an offence;   c) it is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority in relation to them;   d) where sexual activity with a 16 or 17 year old does not result in an offence being committed, it may still result in harm, or the likelihood of harm being suffered;   e) non consensual sex is rape whatever the age of the victim; and   f) if the victim is incapacitated through drink or drugs, or the victim or his or her family has been subject to violence or the threat of it, they cannot be considered to have given true consent and therefore offences may have been committed.   56. Child sexual exploitation is therefore a child protection issue for all children under the age of 18 years and not just those in a specific age group. It is clear from the referrals that were made to specialist services that Child R’s vulnerability to child sexual exploitation (CSE) was acknowledged. However, there were problems in how some aspects of follow up help and support was provided. A significant factor was that referrals were made to specialist services that were not commissioned to provide their service in the area that                                         4 Step by step guide to frontline practitioners Department of Education 2012  Page 13 of 60 Child R lived and therefore cross boundary referrals were dealt with. In spite of that, there were attempts by individual practitioners to try to offer advice and help.   57. Child R was the subject of six initial assessments by CSC although none progressed to more comprehensive core assessment. As a result of one of the assessments Child R was helped through a child in need (CIN) plan that involved the CAPSS (child and parent support service) but she was never assessed and managed as a child at risk of harm.  58. Although there was recognition that aspects of Child R’s behaviour and lifestyle represented risk, it was not escalated or formalised through any of the multi agency assessment and intervention in relation to CSE or missing from home (MFH) frameworks (beyond the processing of information reports). Some of this reflected Child R’s apparent reluctance to engage with some people and services but it also appears to indicate a mindset in terms of how some older children who present with challenging or complex behaviours are helped. There was action taken for example by the police in issuing the abduction notices to older men that are referenced later in the report.   59. It also reflects the additional complications that arise when children live on the geographical boundaries between different services as well as navigating transition points for example between child and adolescent mental health services and with adult provision. Child R lived on the boundary of a much smaller unitary authority that has had to develop strategies and services to focus on children at risk of sexual exploitation although these are services primarily intended to work with young residents of that unitary authority. Child R was not a resident although was known to and received some support from those services.  60. There was shared knowledge that Child R was repeatedly missing from home, was increasingly using alcohol, was involved in a succession sexual relationships with adults and had been assaulted and raped.    61. Child R also instigated incidents which included making at least one allegation that had no foundation. It is clear that by late 2012 and upon turning 16 that Child R became more adamant about asserting independence and went missing from home for more extended periods and refused to return home. By that stage all services had limited powers (or duties) to try to override those views and wishes.   62. There is a pan Lancashire child sexual exploitation (CSE) checklist that identifies behaviours associated with CSE. These include:   a) Missing from home or care; b) Physical injuries;  Page 14 of 60 c) Involvement in offending; d) Repeat sexually-transmitted infections, pregnancy and terminations e) Absent from school; f) Change in physical appearance; g) Evidence of sexual bullying; h) Vulnerability via the internet and/or social networking; i) Estranged from their family; j) Receipt of gifts from unknown sources; k) Recruiting others into exploitative solutions; l) Poor mental health/self-harm; m) Thoughts of or attempts at suicide.  63. The checklist also identifies vulnerabilities that include:  a) Chaotic/dysfunctional household; b) Parental substance use, mental health issues and criminality; c) Domestic abuse and/or neglect; d) History of abuse; familial sexual abuse, risk of forced marriage, risk of ‘honour’ based abuse, physical and emotional abuse; e) Recent bereavement or loss; f) CSE gang association; g) Friends/association with sexually exploited young people, for example at school; h) Learning disabilities; i) Unsure about their sexual orientation / family unaware; j) Homelessness; k) Lacking friends from the same age group; l) Living in a gang neighbourhood; m) Living in residential care; n) Living in hostel, bed and breakfast or a foyer; o) Low self-esteem or self-confidence; p) Young carer.  64. As will become clear in reading this report, Child R’s circumstances reflected more rather than fewer of the factors identified in regard to behaviour and vulnerability although is also important to acknowledge that not all of the factors applied to Child R (and rarely do for children and young people who are sexually exploited). Although it is apparent that some of the people in contact with Child R recognised issues such as CSE it is less evident that other processes including the statutory assessments were able to identify this or the other risk factors as clearly.   65. When processes such as the missing from home protocols and the statutory assessments were invoked they did not provide a good enough opportunity to reveal the full extent of Child R’s circumstances in regard to history, need and risk. For example, the traumatic events in Child R’s early life were largely unknown to everybody who was in contact with Child R. There was also a  Page 15 of 60 supposition that Child R primarily needed therapeutic support such as counselling rather than seeing that as one aspect of what should have been a more holistic approach that for example addressed more assertively the risk factors.   66. The exploitative nature of the relationships was not sufficiently or consistently enough identified or explored through more sustained enquiry and assessment.   67. There is no evidence that Child R was targeted by a gang or organised network of abusers. What Child R experienced was emotionally and sexually exploitative serial relationships that in large part arose because of her vulnerability that arose from her emotional history and lifestyle. Child R had experienced significant early childhood trauma that was not known about in enough detail by those undertaking assessments and trying to help.   68. With hindsight, any one of the six initial assessments could have been used to enquire more extensively into Child R’s history and circumstances. The focus of the assessments along with other inquiries that for example arise through the missing from home protocols focussed on Child R appearing to be ‘safe and well’, some reluctance to acknowledge risk and a belief that the family would be able to safeguard Child R. There was a general lack of a holistic approach in these as well as other contacts that took place through education, health and specialist counselling services.   69. The behaviour management approach taken by services such as the schools were largely and not unreasonably focussed on managing Child R’s disruption to pupil’s education. This was further complicated by the introduction of revised behaviour management arrangements in one of the schools that had the effect of accelerating the transfer of Child R from that school. Those arrangements were introduced by a head teacher and no longer apply and were not used by any of the current head teachers.   70. The provision of counselling was in isolation from other services, and was constrained by an apparent misunderstanding by some counselling services about what could or could not be discussed for example whilst criminal proceedings were taking place and along with all the other services had very little historical information and perspective within which to understand Child R’s behaviour and general circumstances.   71. The intention is to highlight the opportunities for learning and improvement. The comments take account of the significant dilemmas and challenges that will face all professionals in criminal justice, education, health or specialist services in trying to provide advice and help to a young person who by their action and behaviour can put up barriers.    Page 16 of 60 72. Many people would acknowledge that working with troubled and vulnerable teenagers is difficult. Most people would probably agree that earlier help and support is often more likely to have an influence on later life circumstances. Some of the earlier experiences that Child R had been through such as traumatic childhood bereavement probably had an influence on Child R’s emotional well being as a teenager. There may also be other significant aspects of Child R’s history that are not known about.   73. The rape of Child R in July 2010 was the single event that had most impact on Child R and had repercussions for the rest of her life in terms of the stability and durability of her education placements, her relationships with peers and others, as well as the emotional and psychological harm.   74. The impact of such an experience for any young girl would have been traumatic but for Child R it was compounded by her previous experiences and relative lack of resilience. Resilience is a generic term that in this context describes Child R’s emotional and psychological resources (Child R’s internal world) as well as the external factors that included relationships with significant people such as friends and family.  75. The extent and duration of trauma and difficulty in Child R’s life prior to the rape was largely unknown until the review. Although Child R socialised with a diverse range of people Child R appears to have not had any significant long term friendships since moving to Lancashire. There was also trauma and difficulty within Child R’s family.   76. Having support from significant friends (as opposed to a succession of more casual acquaintances), along with having a positive participation in education are two very significant sources of resilience that were not available to Child R.   77. Aspects of Child R’s behaviour represented a challenge to services such as schools. Support that included behaviour management were influenced and affected by factors such as a change in school policy or key personnel.   78. Child R’s need for emotional and therapeutic support following the rape was recognised although there was misunderstanding about how to manage this in parallel to the criminal proceedings against the person who was convicted of the offence. This centred on a belief on the part of counselling services working with Child R that the rape could not be discussed at all until the criminal proceedings had been completed several months later.   79. The delivery of counselling support was seen essentially as confidential and person centred on Child R; this inadvertently led to some misdirection of counsellors. For example Child R was capable of providing information that was not factual. This is not to criticise Child R who was dealing with so many difficulties in her life.   Page 17 of 60  80. There are significant changes and developments taking place in regard to how some services and processes operate. For example a multi agency safeguarding hub (MASH) is now established in Lancashire. This brings to together the key statutory services to manage contacts and referrals in regard to children and young people. The arrangement involves far more coordination of enquiries. The vulnerable child reports that are referred to in the report have been replaced with new arrangements for the protection of vulnerable people.   81. The multi-agency and specialist Awaken Team in Blackpool incorporates the Western Division of the Lancashire Constabulary which includes parts of Lancashire as well as all of Blackpool and South Fylde. The CSC component of the Awaken Team only covers Blackpool. This is the reason that on a joint visit by the team a nurse member of the team was used who, although commissioned to work in the Blackpool area only, did often assist with cases from the entire district covered by the Awaken Team. (In addition, health staff were drawn from Universal services of school nursing, sexual health outreach services and CLA Nurses when the need arose.) An alternative would have been a referral to Lancashire CSC for a joint visit that would have involved a social worker from a non-specialist team.   82. Under new organisational arrangements being implemented by the Lancashire Constabulary from April 2014 the new 'West' division will be created. It is the old 'A' Western division together with 'B' Northern Division which incorporates, Lancaster, Morecambe up to the Cumbria and North Yorkshire Boundaries. In the south of the division is Fleetwood, Cleveleys, Poulton Le Fylde and all the villages in Wyre up to Lancaster. The Awaken and Breakthrough staff will have full cover from all agencies right across the West division. Breakthrough social workers (Lancashire employed) will now cover the South Fylde area.  83. Accompanying the organisational changes there have also been changes to some working practices for example in regard to how information is recorded. For example, Child R had a paper file; now the system is very different. Within the police Sleuth (police investigation and work management system) where the PVP (protection of vulnerable person) database is, there is a CASEMAN computer database. All CSE children, enquiries, investigations are now all on CASEMAN and the enquiry/investigation is updated electronically and time stamped. Any message, comment or enquiry can be placed on there. The CASEMAN is overseen by supervision and it flags to them the date for review etc. They in turn have time parameters to review it. Should the enquiry be made now, it could go on CASEMAN and be tracked.  84. The referral from CAMHS to the adult single point of access service occurred because Child R had become 16. The referral and subsequent response from  Page 18 of 60 the mental health practitioner who completed a mental health initial assessment was prompt and sensitive to Child R’s needs. Child R was killed shortly after the adult service had become involved and therefore the review can only provide very limited opportunity for identifying any learning in regard to how such transition is managed.   85. Given the difficulties that occurred in regard to co-ordination of different children’s services the introduction of further services and the extent to which the adult and children’s system can link and be managed by a lead professional is an area not explored by this review.  There is learning identified in later sections for example in regard to conduct disorder, delivery of multi-systemic working and supporting individuals with long term psychological difficulties.   86. The final chapter of the report describes the most significant issues identified by the review group for the purpose of improving practice and services. Theses are focussed on the identification of children and young people who are at risk of sexual exploitation, improving the quality of assessment and managing systems for children who are regularly missing from home.   1.14 Child R   87. Child R had five older half siblings and two older step siblings. Child R lived with her parents and a half-brother. The family had previously lived in the Greater Manchester area before moving to Lancashire while Child R was still at primary school. They did not have previous connections with the area. Child R had a friend that Child R had met when they had both started at a nursery although they saw less of each other after the family had moved to Lancashire. This appeared to have been Child R’s only significant friendship; although Child R had a wide circle of contacts none of these appeared to be long term. For example, when Child R went missing from home Child R would often be located in a new place and with different people and who were very often much older.   88. Child R and her parents all used social media. No other hobbies or interests are known in regard to Child R. It was Child R’s use of social media that provided the opportunity for Adult 1 to make initial contact a few days before he murdered Child R.   89. One of Child R’s parents had a serious illness that involved extensive and invasive medical treatment over several years.   90. Child R does not appear to have had any consistent friendships although had numerous contacts with young people and adults. Child R used social media to make contact with other people. Some of those contacts were with older males. It was also a source of bullying.    Page 19 of 60 91. According to Child R’s parents, she had one childhood friend who she had occasional contact with after moving to Lancashire. When Child R was still at primary school aged nine when a friend was killed in a road accident. That death coincided with the suicide of a maternal relative.   92. It was shortly after this early traumatic experience that Child R had the first contact with CAMHS in June 2006 when Child R was presenting with behavioural problems and specifically had a preoccupation with fire and a desire to be burned. Child R had not attended the funeral of the friend who it is believed was cremated; Child R’s parents had felt that Child R would be too young to manage that experience. With hindsight, the deaths marked a significant event in Child R’s life that was largely unknown by the various services that had contact with her subsequently. There was also a period of significant and life threatening illness for one of the parents.  93. The second very significant traumatic event for Child R was the rape that occurred in July 2010 when Child R was 14. It was from 2010 that Child R began to come to the notice of several different services and it was when Child R for example began to regularly use alcohol and drugs.   94. Child R was the subject of ten reported crimes with the first having occurred in February 2008. There were seven assaults alleged, a rape that resulted in a prosecution.   95. On some occasions Child R’s behaviour posed a risk to others and included sometimes making serious allegations about other people that were malicious.   96. Child R was the subject of more than ten vulnerable child referrals (VC). These included the following:  a) 13th November 2009 this was the first referral to the Awaken Team and refers to the incident described earlier; Child R was interviewed and discrepancies were identified in the account provided;  b) 5th July 2010 when a member of the public intervened after finding Child R being raped by an adult male and in an intoxicated condition; the male was subsequently convicted; CSC completed an initial assessment and closed the case on the basis that there was no ongoing involvement required from CSC; the Awaken Team had also closed any continuing involvement;  c) 9th July 2010 Child R had met an 18 year old male from Birmingham.  An SC1 to CSC was submitted5;                                          5 The SC1 is a police referral form.   Page 20 of 60  d) 8th February 2011 police officers attended an incident where Child R told them the root cause of issues with the family were their excessive drinking. Child R’s parents reported that Child R was in a relationship with a male which Child R denied. An SC1 was sent by email to CSC;  e) 28th February 2011 Child R reported having been locked in the house by the parents. The police attended Child R’s home and the parents admitted they had done this to prevent Child R from going missing. Child R showed the officer both arms which had slash marks and said that this was self harming due to living at home. There had also been an argument between Child R and father and Child R had had scalded a hand when chased through the house. An SC1 was sent via e mail to CSC;  f) 25th November 2011 Child R had been reported missing from home and whilst absent had been assaulted by an ex partner; Child R’s mother was requesting the involvement of other services as she was at the ‘end of her tether. An SC 1 was sent by e mail to CSC; an initial assessment was completed in early December 2011 and recommended the development of a CIN plan through the parenting support service;  g) 7th February 2011 Child R had been reported missing and upon returning a police officer noted Child R had suck or bruise marks to the neck; Child R denied that anything sexual had happened. The following day Child R’s mother reported that Child R had been involved in sexual activity. A section 2 abduction notice was served on the offender6; an investigation commenced with the Aquamarine Team7 and an SC 1 was sent by e mail to CSC;  h) 14th February 2012 Child R was reported missing from home. An SC1 was sent to CSC;   i) 29th February 2012 Child R’s mother rang to report that Child R was in a relationship with a male aged 29 years. The male had previously been                                         6 Child Abduction Warning Notices (formerly known as Harbourers Warning Notices) issued under section 2 of the Child Abduction Act 1984 (as amended by the Children Act 1989) are a useful tool enabling the police to disrupt the criminal or undesirable activities of adults who are associating with young people against the wishes of the young persons' parent(s) or local authority carer. Section 2 covers offences committed by a person not connected with the child, who unlawfully takes or detains a child under the age of sixteen. The offence can be prosecuted either way. The maximum penalty on indictment is seven years. The notices tend to be used where arrest/prosecution for any substantive offences is not available or is not appropriate at that time.  7 Operation Aquamarine is a dedicated team of police officers trained to investigate rape and sexual assault cases and provide victims with the support and care that they require.    Page 21 of 60 arrested for sexual offences. A section 2 abduction notice was served on the male. Child R did not disclose any sexual activity. An SC1 was sent by e mail to CSC;   j) 4th September 2012 concern was expressed regarding Child R who was now aged 16, having a relationship with an adult.  Child R’s mother had reported that Child R was in East Anglia; an SC1 was sent to CSC;   k) 15th November 2012 concern was expressed by Child R in that the adult who raped Child R was due to be released from prison the following year (this did not relate to any specific notification or date); Child R was described as ‘not dealing with this very well’. Child R’s mother was requesting assistance to help Child R deal with this. An SC1 was sent to CSC.  97. There is no record of what action was taken in regard to the majority of the VC reports. Information about other contact between Child R and services is summarised in chapter 2.  1.15 Adult 1  98. Adult 1 is an only child. He was first referred to child psychiatry services when he was only six years old. He was aggressive, breaking property and hurting other children. He was diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD)8 and was placed on a prescription for Ritalin (used to treat attention deficit disorder) (ADD). He was also referred to paediatric services in early 1997 in regard to the possibility of encopresis (soiling) associated with physiological or neurological causes. Adult 1 received treatment through to 2000.    99. Subsequent educational assessments indicated that although he did not have problems with numeracy or literacy he had difficulties in regard to his social and emotional and behavioural skills. When he was ten years old Adult 1’s behaviour and aggression was causing concern along with what was described as sexual touching. He appeared to have a lack of understanding about what was acceptable. He appeared to be quite isolated from peers rarely playing with other children outside of school and with few lasting friendships. He was still being prescribed Ritalin   100. Unusually, Adult 1 had been placed in a pupil referral unit (PRU) from May 1999 until July 2001 whilst still at primary school and never returned to mainstream education. He was placed in a residential specialist school when                                         8 Oppositional defiant disorder (ODD) is a disorder where children have disruptive and oppositional behaviour that is particularly directed towards authority figures, such as parents or teachers.   Page 22 of 60 he reached secondary education in September 2001 and remained at that school until he went to college in September 2006 where he completed a course in the care of small animals until July 2008.   101. An educational psychology report in November 2000 acknowledged that ten year old Adult 1 had significant problems with his behaviour and social relationships and that his ‘interaction skills, communication skills, and social imagination and ability to think flexibly are not at a level normally associated with a child of his age and academic ability’. The assessment included completion of the Devereux Behaviour Rating Scale that placed Adult 1 at the 98th percentile9. The same report concludes that this will effect his development of relationships and ability to behave appropriately but the psychologist did not ‘feel confident regarding the cause of those difficulties’.  The assessment provided guidance on teaching strategies and recommended support through CAMHS.   102. He continued to have difficulties in his interaction and relationships with other pupils. In September 2001 he was placed in a specialist school for children with emotional and behavioural difficulties where he remained until he went to a local college in September 2006. In addition to the diagnosis of ADHD Adult 1 displayed behaviour indicative of being on the autistic spectrum10. Adult 1 was the subject of allegations of inappropriate touching of another pupil.   103. In April 2005 the head teacher of the school reported an incident involving 14 year old Adult 1 and an eight year old pupil. A strategy meeting two weeks after the incident decided that Adult 1 did not have the mental capacity to establish criminal intent. The incident was not pursued any further by the police or any other service.  104. In May 2005 when Adult 1 was aged almost 15 years old, he was no longer displaying symptoms of ADHD but was diagnosed with depression. In September 2005 now aged 15, Adult 1 was referred to the GRIP service regarding his sexually inappropriate behaviour (following sexual advances to                                         9 Devereux Behaviour Rating Scale is used to help objectively evaluate the behaviours of children and adolescents who may be exhibiting moderate to severe emotional disturbance. It is a method of determining to what degree behaviours may be considered extreme in relation to other similar pupils. The scale has four subscales: interpersonal problems, inappropriate behaviour, depression, physical symptoms and fears. Adult 1’s scores were very significant in three areas: interpersonal problems, depression and physical symptoms and fears and significant in inappropriate behaviour and feelings.  The total scale standard score was 134 on the 98th percentile.  10 The spectrum is a group of pervasive developmental disorders that have a triad of impairments relating to social interaction, social communication and social imagination. There are other characteristics that differ that include factors such as learning difficulty, behaviours and language.   Page 23 of 60 fellow pupils at school). The referral to GRIP was declined because the service was focussed on children under 13 who were living in Blackpool11.   105. The final review at school in July 2006 reported that although Adult 1 had made ‘significant progress educationally and medically’ there had been far less progress in ‘helping him to accept responsibility for his own actions’.  106. In October 2006 Adult 1 was discharged from CAMHS. He was 16 years old. He was regarded as having recovered from ADHD and from his depression.  107. Adult 1 was at college from September 2006 until July 2008. Although Adult 1 was the subject of warnings for plagiarism on two occasions there was no other concern recorded about his behaviour whilst at the college.   108. In late May 2009 Adult 1 who was almost 19 years old used an air rifle to shoot at four horses in a local field. One of the horses was injured. The police arrested Adult 1 at the scene and after he had been interviewed and had made a statement admitting the offence he was cautioned for an offence of criminal damage.   109. In late October 2010 Adult 1 who was 20 years old sexually assaulted a female who had been at college with him. He admitted the offence but CPS recommended that no prosecution should be pursued because they felt ‘there was no realistic prospect of prosecution’.   110. There were no further incidents reported until the sexually motivated killing of Child R in early 2013.   111. Information from the trial of Adult 1 revealed that he was using social media to lure young people to the commercial premises where he killed Child R.   112. Adult 1 had initially met Child R some months previously whilst in Blackpool. Child R was with another person that Adult 1 had known. There was a brief discussion during which Adult 1 mentioned that made contact with Child R via a social media website four days before the murder.                                           11 The Group Intervention Panel (GRIP) is a multi-agency, short-term, early intervention initiative working with children and young people aged 8-17 years believed to be at risk of becoming involved in crime or anti-social behaviour. It aims to divert children and young people from developing patterns of persistent or more serious offending. (GRIP is a Youth Inclusion Support Panel - YISP). It is not clear why the referral to this service was made at that time.    Page 24 of 60 1.16 Cultural, ethnic, linguistic and religious identity   113. Child R’s family is white British. Child R’s parents are not in employment.  114. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007). Child R did not live in those districts. The majority ethnic group is white (97.4 per cent), which covers White British, White Irish and Other White.   115. Child R lived on the boundary between the county and a much smaller unitary authority. The unitary authority has very high levels of deprivation. It is ranked the tenth most deprived area of 326 districts and unitary authorities in England. The area has the lowest levels of achievement for children in education and is below the national average for England. The numbers of children and young people not in education employment or training (NEET) is high.   116. The 2011 mid-year estimates show that the proportion of the population aged 0 to 19 years old in the area of Lancashire where Child R lived is lower than across the county as a whole.  117. Rates of drug and alcohol abuse and smoking amongst young people in Lancashire have improved but remain worse than the England average. The eevidence of high rates of binge drinking in Lancashire is provided by the high number of alcohol specific hospital admissions of young people. The rate of admissions in the North West is much higher than the England average and some parts of Lancashire have rates around double the England rate. The area where Child R lived and the Ribble Valley are the only districts with rates below the England rate. Alcohol-specific hospital admissions of young people in the area that Child R lived are much lower than the England average. The area rate is currently the lowest in the whole of Lancashire.  118. There were 178 victims of CSE in the area that Child R lived in 2012/13. The teenage conception rate for the area is below the England average. The under-16 conception rate for the area has reduced but is still well below the England average. The proportion of young people testing positive for Chlamydia in the area has reduced and is below the England average.  119. The performance of children in the area that Child R lived in the Foundation Stage has improved and is better than the England average. The performance of the area pupils at Key Stage 1 and Key Stage 2 tends to be  Page 25 of 60 higher than England, regional and county performance. The performance of the area pupils at Key Stage 4 tends to be better than the England, regional and county performance.   120. A pupil attitude survey of young people in the area suggests that there are a large proportion of pupils that enjoy their education at school.  121. The overall absence rate from the area schools has been improving since 2009 and is still better than the England average. The proportion of persistent absenteeism (i.e. proportion of pupils missing 15 per cent or more of the school year) has increased but is below the England average.   122. The 2011/12 data demonstrates a large decrease in the number of permanent exclusions in the area secondary schools, however the proportion of exclusions remains higher than the Lancashire average and north Lancashire comparators.  123. 2011/12 saw a decrease in fixed term exclusions, along with a reduction in the number of days lost through exclusion. The area holds the second lowest rate of fixed term exclusions across Lancashire, and records the lowest number of days lost through exclusion.  124. The proportion of the area children aged 16 or under, and between 0 and 19, living in poverty was lower than the national, regional, and county average but above the county average. The area had the lowest proportion of child poverty when compared to the neighbouring northern districts.  Page 26 of 60 2 Synopsis of agency involvement   125. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the child, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later sections of the report.   126. Therefore, the summary does not contain every contact with Child R; for example Child R was reported as missing from home on 28 occasions between September 2007 and late 2011. Child R also experienced considerable disruption to their education which arose from transfers which are summarised in the report.   127. Child R was generally seen as a pleasant, confident and sociable young girl who was already quite ‘streetwise’ around the local community by the time she went into secondary education. This general presentation remained fairly consistent and may have hidden Child R’s feelings of vulnerability and emotional distress. Child R’s was a friendly individual. For example the local police community support officer (PCSO) had regular contact and chats with Child R who was often out and about in the local area. Child R often attended a youth club run by the PCSO. There were no particular concerns about Child R although Child R was seen as being susceptible to pressure from peers which are not particularly unusual for young adolescents.   128. Child R began to experience bullying at school and at Child R’s mother’s request Child R was transferred to another school during year 812. This was initially a positive move with Child R apparently making some friends. However by year 9 Child R’s attendance and behaviour were beginning to become problematic. This coincided with the introduction of a new behaviour policy in one of the schools that had escalated pupil transfer or exclusion more quickly; this policy no longer applies. Child R moved school again in 2008. This and all the other subsequent transfers in school were due to behaviour and relationship difficulties that Child R had at school.  129. It was in September 2007 when Child R was 11 that a report of missing from home (MFH) was made to the police. Child R lit small fires in the bedroom in November 2007. Child R had wanted to know what it was like to be burned; this appeared to be linked to the cremation of the friend whose funeral Child R had not attended. Bereavement counselling was recommended to help Child R in regard to the friend’s death. The first initial assessment by CSC was completed in December 2007 which resulted in a                                         12 This is the eighth year after the initial reception into education and is the second year of stage three in the national curriculum and is therefore a significant stage in any child’s education.   Page 27 of 60 family support referral to a family centre to help Child R ‘regarding routines, anger management, guidance and boundaries’.  130. In February 2008 Child R was the victim of an assault by several pupils at school that was reported to the police. In April 2008 the family support service began their work in response to the referral in regard to helping Child R with bereavement counselling and anger management; there were eight sessions of work between April and the end of 2008. There were also separate support sessions for Child R’s parents to help with responding to Child R’s behaviour. During the initial sessions Child R disclosed being bullied and information was passed to the school.   131. At a review of the family support work in July 2008 that involved Child R aged 12 and both parents, there was a disclosure of concern by the parents about Child R making contact with people through social media. Further work was scheduled to help Child R keep safe by making Child R aware of the dangers of such contact and there was also separate work with the parents in regard to parenting a teenager.   132. The family support service ended their involvement in November 2008 having concluded that the initial problems in regard to fire setting and relationship difficulties had been resolved. None of the family had attended the final review meeting that arrived at that conclusion.   133. The victim support service had their first contact with Child R in early April 2009 in relation to an incident of Child R being bullied by another young person who was due to start attending the same school at Easter.   134. In June 2009 the second initial assessment was opened by CSC. The assessment was in response to a referral by Child R’s mother to CSC. Child R who had just become 13 had been missing from home on three occasions in recent weeks. Mother described Child R as having eloped with another pupil from school and that Child R was on the verge of exclusion. Neither Child R nor mother responded to an appointment letter and the referral was closed without any assessment work being completed; mother has no recollection of receiving the appointment letter. The electronic record system was updated to show that an assessment had been opened and closed and therefore completed within timescales13. There was no further contact or follow up with Child R’s mother.                                           13 At this time there was a national assessment framework that was being monitored at local and national levels; a key performance indicator (KPI) was meeting timescales for completing either an initial or core assessment.  The coalition government has changed arrangements and placing responsibility on local areas to develop their own frameworks and measures of effectiveness.   Page 28 of 60 135. In early July 2009 the PCSO (police community support officer) made a referral to the PAYP (positive activities for young people)14.   136. In November 2009 Child R made allegations to the police of being coerced to pose naked on a social media website. These allegations were investigated which included input from the police high technical crime unit who showed that the downloading had followed explicit ‘chat’. Child R’s mother contacted the Awaken Project operated by the police and CSC to report that Child R was being bullied as a result. Child R was advised about not making false allegations. Child R’s parents were advised about Child R’s use of the internet and social media.   137. A referral was made by the police officer on the Awaken Project to CSC in November 2009 and a third initial assessment was opened. Child R stated that work on keeping safe had already been completed by CSC and did not want to repeat the work. It was noted that Child R’s attendance at school was sporadic. The assessment was closed on the 7th December 2009 with no further action recommended.   138. The police officer on the Awaken Project contacted the school where the head teacher confirmed that the bullying was being addressed by the school but that it was exacerbated by Child R alleging that another pupil had a picture on their phone; when the phone was examined no image was found.   139. In the first half of 2010 there were a number of assaults and confrontations with other pupils. The victim support service had contact in early March 2010 in relation to an assault on Child R which mother had reported was a one off incident. The same service was involved again in early April 2010 following another assault by another pupil at the same school as Child R who had been injured.   140. In the summer of 2010 Child R’s family moved to another house within the same locality and still geographically outside Blackpool and in Lancashire.   141. In June 2010 the young people’s service (YPS) had been notified of 14 year old Child R missing from home and had contacted Child R’s mother to have parental consent to talk with Child R ‘to complete the paperwork’15.                                          14 Structured activities (including sports and physical activities, attending clubs and societies and volunteering activities) that enable young people 13-19 to voluntarily participate in, or initiate, planned and purposeful activity that holds clear health, learning or social and personal development aims. This will normally involve practitioners or peer-leaders who engage with young people on a one to one or group basis 15 This reference to paper work appears to refer to the county wide joint protocol for managing reports and information about children missing from home (or care). The protocol requires return  Page 29 of 60  142. At a meeting with Child R and the YPS, Child R described the circumstances for leaving home having been because of an argument over behaviour in school; Child R had stayed at a friend's house, but would not say who the friend was. According to the account Child R had walked straight there and had not spoken to anybody else.  Child R admitted to receiving and ignoring several calls from the police and mother before switching the phone off. The YPS worker suggested that the phone was kept on and for Child R to at least tell parents that things were ok, or to text them with the same details.  Further analysis is provided later in the report.  143. Child R had gone missing on previous occasions and each time for a similar reason; an argument with parents followed by Child R leaving the house and ignoring telephone calls. The YPS workers explained about the problems in Blackpool regarding some young people disappearing, and that they were trying to ensure that Child R remained safe.   144. Child R talked about having trouble in controlling temper and wanted to see the school counsellor again; YPS agreed to arrange this. Child R had previously seen the counsellor ‘once or twice’.  145. In July 2010 Child R was raped by a 22 year old who was subsequently convicted 18 months later following a police investigation that also identified that Child R was sexually vulnerable from contacts with other young males and included using alcohol. Victim support also tried to offer support; according to their records Child R was having nightmares and was being subjected to cyber bullying. Child R was awaiting an offer of an alternative school placement. Child R’s phone had been taken by the police as part of their investigation.   146. The implications of the rape were very significant; the male was the boyfriend of a student at the same school as Child R, the crime became widely known and led to relationship difficulties and confrontations between Child R and peers. Child R was the victim of an assault by several other young people. Eventually Child R’s school placement broke down when the school sought to have Child R transferred.  147.  Child R’s parents believe that the rape was the single significant event from which Child R went on to develop other difficulties. Although there was recognition that Child R required counselling and therapeutic support in regard to the rape, this was postponed on the understanding that it could not begin until the criminal process had been completed. This was a misunderstanding within the counselling service about the rules and                                                                                                                interviews to be completed and also describes a tiered approach to calling intervention meetings if a child goes missing more than five times in a 90 day period or 9 times in the same period. There is analysis in the final chapter about the lack of escalation that occurred in regard to Child R.   Page 30 of 60 guidance that the Crown Prosecution Service (CPS) together with the police comply with.   148. The counselling service provided support but did not address Child R’s feelings and emotions in regard to the rape; this did not happen until after the trial had been completed. Discussion of the rape would not have been allowed prior to the trial but the guidelines that applied at the time16 and in the current national and local protocols allowed victims to discuss their feelings and emotions.   149. The counselling service did not consult with the specialist police officers who believed that appropriate counselling was in place. The counselling approach (not the police) in this case was on the basis that such work could compromise evidence for the criminal trial17.  The CPS has recently published a new national protocol for prosecuting cases involving the sexual abuse of children that came into force in January 2014.  150. The psychological and emotional damage of a rape, especially on a young adolescent is explored in further detail in later analysis in this report.  A past or current history of physical, psychiatric or social problems appear to make it more likely for an adolescent to develop severe depression, psychotic behaviour, psychosomatic disorders, suicidal behaviour and acting out behaviour associated with alcoholism, drug abuse and/or sexual activity. Child R presented with several of these behaviours. Prior to the rape Child R had already had significant trauma and had already received help through CAMHS.   151. Less than a week after the rape, the school made a referral to the Awaken Project to report that Child R had disclosed having contact via social media with an 18 year old from Birmingham and was also having unprotected sex with other young people the same age as Child R. The Awaken Project closed their involvement with Child R the same day; this seemed to be based on an understanding that the Aquamarine Team was involved with Child R; the closure record also stated that Child R and parents had been advised about the risk from the internet and mobile phone use of social media.  152. CSC completed the fourth initial assessment on the 14th July 2010. This noted that 14 year old Child R had informed CSC about drinking alcohol.                                         16 Provision of Therapy for Child Witnesses Prior to a Criminal Trial: Practice Guidance; Home Office, CPS and Department of Education; 2001. 17 The guidance is accessed http://www.cps.gov.uk/publications/prosecution/pretrialadult.html . The key issue with regard to pre-trial discussions of any kind is the potential effect on the reliability, actual or perceived, of the evidence of the witness and the weight which will be given to in court. Pre-trial discussions may lead to allegations of coaching and, ultimately, the failure of the criminal case. It should also be borne in mind that the professionals concerned may themselves be called to court as witnesses in relation to any therapy undertaken prior to the criminal trial.   Page 31 of 60 The rape allegation was associated with Child R having been plied with drink. School attendance was 49 per cent. The initial assessment recommended that a referral to GRIP would be made and the case was closed to CSC; in the event the referral was not accepted. The school were notified of the CSC assessment and decision to close their involvement.   153. Child R was in contact with a number of different professionals through the police and education services. Child R was using alcohol on a regular basis and was continuing to go missing. Child R was disclosing risky behaviour some of which was not reported to the police or to CSC. For example in September 2009 Child R had disclosed, in confidence, to a teaching assistant that a sexual encounter had been interrupted by a male’s father who assaulted Child R and their own child.   154. This information was recorded on the school’s internal system but was not discussed or reported to any other service or professional. Two weeks later a health mentor and a youth worker were also made aware of the same information and again this was not discussed outside of the school. At the end of September 2010 Child R who was aged 14 had a contraceptive implant fitted.   155. By November 2010 Child R was on a final warning from school because of persistent truanting. Child R was planning to take GCSE’s and to then secure an apprenticeship with an interest in becoming a chef.   156. At the beginning of January 2011 Child R was experiencing episodes of fainting that would recur on a regular basis.   157. In February 2011 Child R was referred to the pupil welfare services and was transferred to the pupil referral unit (PRU)18. The PRU is part of alternative education provision and falls within the scope of services that provide education other than at school is intended to help a return to a mainstream school setting. This referral to the PRU was however the beginning of Child R’s transition from mainstream education. It was this transition that Child R’s parents felt introduced Child R to other young people who were experiencing a range of problems and needs and had exacerbated matters for their child.   158. Child R was by this stage presenting as a very troubled young person who was in regular arguments and conflict with peers and continued to be subjected to bullying through the internet and social media. Child R was difficult to engage with at the PRU and did not seem very confident; this was in contrast to the more outgoing and sociable young person that for example                                         18 This is an establishment maintained by a local authority which is specifically organised to provide education for children who are excluded, sick, or otherwise unable to attend a mainstream or special maintained school. There are 13 pupil referral units in Lancashire.  Page 32 of 60 the PCSO had dealt with in 2009. Child R was walking out of lessons and was becoming sexually explicit in her conversations.  Child R was referred to the local sexual health team for additional support. Child R was also going missing from home.   159. Child R attended the epilepsy clinic with mother and was seen by a consultant paediatrician who as well as making arrangements for physiological examinations also suggested that Child R made another appointment with the counsellor as a major adverse life event could be an underlying cause of the present symptoms.  160. In mid March 2011 CSC completed the fifth initial assessment; this appeared to be in response to the vulnerable child notification from the police. The assessment concluded that the parents were being ‘protective’ and were able to safeguard Child R (who was continuing to go MFH). The parents had disclosed that they had cut back on alcohol knowing that Child R was upset about this. The assessment noted that Child R was attending the PRU and that the criminal trial regarding the rape had been delayed causing further upset to the family. The assessment led to no further action by CSC and the case was closed.   161. Child R’s mother told the victim support service that she was hoping that Child R could change schools; they had concerns about the people that Child R was mixing with.   162. In May 2011 Child R was referred to the local young people’s counselling service and Child R attended the first session at the end of May 2011 when Child R was advised that discussion about the rape was not possible due to the pending criminal proceedings. The consequences of the rape were discussed in regard to the difficulties that Child R was having in relationships, sleeping and eating. The sessions also allowed Child R to talk about the difficulties that the family had in knowing how to support Child R and in response to the reaction of the perpetrator’s family.  163. At the fourth counselling session in early July 2011 Child R discussed an impending school visit to the prison where the perpetrator was in prison; this appeared to be a fabrication on Child R’s part. At the sixth counselling session Child R described the sessions as being helpful in providing a space to talk without being judged and did not have to hide behind a mask. The counselling was suspended over the school holidays until September 2011.   164. In July 2011 Child R was awarded compensation under the criminal injuries compensation scheme which was paid into a trust fund for Child R’s benefit. In July 2011 Child R transferred to the ACER service (alternative and complementary education and residential service) in the unitary authority as a day student. Child R’s absence from education had required a contact by the pupil welfare service which involved a home visit and a subsequent letter  Page 33 of 60 giving notice of legal action if Child R’s attendance did not improve. Following the letter there was a significant improvement in Child R’s attendance.   165. Efforts to re-establish the counselling in late September 2011 were not successful. Although Child R expressed a wish to resume, no arrangement was agreed by Child R to the offers made by the counsellor. The counselling service formally closed their involvement in November 2011.   166. Child R was not in education (although not removed from roll) from September 2011 until December 2011. Child R was now deemed to be the responsibility of the county education services. Child R had been offered a place at a local college but was permanently excluded when Child R made threats to other students who Child R’s parents’ state had been abusing and harassing Child R via the internet. Child R’s parents felt they had to be very persistent in getting an offer of education to be made. A place was made available at a second PRU. This involved attending for one afternoon a week and for the rest of the week to be spent in a work related learning (WRL) placement.   167. In October 2011 Child R had gone missing from home and had phoned home to say that having drunk alcohol Child R did not know the location to be collected from. The police managed to locate and return Child R home.  168. In November 2011 Child R was the victim of assault and battery by an ex-boyfriend.   169. In December 2011 the local child and parent support service (CAPSS) became involved through a child in need plan (CIN).   170. Child R began work in a day nursery in January 2012 although this ended in February after Child R had been challenged about smelling of cigarette smoke and having inappropriate conversations about lifestyle with other workers (drug use, alcohol use and being raped).   171. At the end of November 2011 the police made a further referral to CSC after the latest MFH and Child R’s parents feeling that they were at the end of their tether. This was the 17th incident of MFH. A sixth initial assessment was completed; Child R had commenced drinking again after a period of abstinence. Child R had begun to have blackouts. Child R was associating with older males. Child R’s parent's illness was in remission. The outcome of the assessment was that a child in need plan (CIN) would be developed involving the child and parenting support service (CAPSS) with weekly sessions to be offered for Child R. The first session was in mid January 2012.  172. In January 2012 a further appointment at the counselling service was offered although Child R did not arrive (DNA). A second appointment was  Page 34 of 60 offered for late February 2012 but when that was another DNA; the counselling service closed their involvement for the second time.   173. In January 2012 the education diversity service arranged for a college placement for Child R although this broke down almost immediately due to Child R’s poor relationships with other students.   174. In early February 2012 Child R told mother after the 18th incident of MFH that Child R had been raped while MFH; Child R was 15 years old. This was reported to the police who had discovered Child R the previous evening with two adults and had served section 2 abduction notices19. The allegations were subsequently withdrawn.   175. At the end of February 2012 Child R was referred to Addaction the young people’s substance misuse service.   176. In late March 2012 Child R went to the GP with mother. The presenting problem was intentional self-harm having taken an overdose the previous week but Child R had also been making cuts to the arms.  The patient history recorded was being sexually assaulted in 2010 and again in 2011. Child R was having flashbacks and had low self-esteem and wanted to die and had taken an overdose the previous week but had told mum. The GP was told that Child R’s behaviour ‘went off rails’ after the rape in 2010 and Child R doesn’t see the point in being good as people can do what they want. Child R reported having no definite plans to kill them self but Child R said wished to die.  177. The GP made an urgent referral to CAMHS (child and adolescent mental health services).  During the first CAMHS session three days later with a CAMHS psychologist Child R was ambivalent regarding personal safety and made reference to future attempts at suicide using a different method.   178. Child R was reported to be disappointed that counselling was not working and had feelings of wanting to die for 80 per cent of the time, feeling ambivalent about living, felt hopeless about the future, had an erratic sleep pattern, poor appetite and had lost weight. Child R had self harmed since the                                         19 Section 2 covers offences committed by a person not connected with the child, who unlawfully takes or detains a child under the age of sixteen. The offence can be prosecuted either way. The maximum penalty on indictment is seven years. Child Abduction Warning Notices (formerly known as Harbourers Warning Notices) issued under section 2 of the Child Abduction Act 1984 (as amended by the Children Act 1989) are a useful tool enabling the police to disrupt the criminal or undesirable activities of adults who are associating with young people against the wishes of the young persons' parent(s) or local authority carer. The notices tend to be used where arrest/prosecution for any substantive offences is not available or is not appropriate at that time.   Page 35 of 60 rape July 2010, but had not cut since Jan 2012.  Child R’s perception of the problem was it this was due to being raped July 2010 and then a further attack in February 2012 when the police and CPS did not prosecute after Child R had withdrawn the complaint. Child R talked about feeling left with more negative thoughts and feelings. Child R reported having been to the Safe Centre20, but felt that this was of no real help. Child R felt unable to trust anyone, and had in the past been missing from home, and walked around the streets. Child R admitted to occasionally drinking alcohol, but denied drugs or any other substance. A further session was booked in a month’s time.   179. Child R was not assessed as being a risk to others. Child R was identified as being vulnerable due to their level of understanding and placing them self at risk, by absconding and walking the streets alone. The psychologist felt that Child R was willing to engage with services and appeared to have the ability to develop friendships. Child R still had feelings of wanting to die.    180. The second CAMHS session (Child R missed the previously scheduled second session) was with a senior practitioner. Significantly, it was coincidentally two weeks before Child R’s 16th birthday; the protocol is that young people aged 16 or over are referred to adult mental health services rather than CAMHS.   181. During the session Child R presented with several significant issues. Child R had suicidal ideation (a medical term for thoughts about or an unusual preoccupation with suicide) with violent and impulsive plans (to hang from a pier), extreme anger that was externalised, use of alcohol and drugs to manage emotions. Child R had a poor body self image, was reported to have lost weight, at times being sick. Child R was impulsive and physically aggressive to peers. Child R had an overwhelming urge to self harm, but was resisting those urges, but had used self harm as a control mechanism, following sexual assaults. Child R discussed the recent bereavement following the death of a friend (first name was given) who had died as a result of an accident; this incident had exacerbated Child R’s low mood. Child R also had sleep problems and flashbacks, to many years ago after witnessing a friend killed in a hit and run accident (referred to in earlier sections of this report). Child R also had flashbacks to the sexual assaults.  182. Following the CAMHS session the senior practitioner made a referral to the Single Point of Access for adult mental health services in the county because of Child R’s age21. CAMHS would continue to be involved until the                                         20 The SAFE Centre offers medical examination, advice and support to women, men and children who have experienced sexual assault or rape and is operated by the Lancashire Teaching Hospitals NHS Foundation Trust 21 This is the single point of access for adult mental health services and is through telephone, fax or post. Referrals are triaged by a mental health practitioner.  Page 36 of 60 referral was accepted by the Single Point of Access Service. At around the same time, Child R was discharged from the epilepsy clinic.  183. The initial assessment by the Single Point of Access was that Child R should be referred onto the Crisis Team although that service was not able to accept a referral because Child R was not yet 16 years old.  184. In early May 2012 Child R had her last session with CAMHS because of the referral made to the Single Point of Access, and Child R and mother both felt overwhelmed with appointments as they were also seeing a family support worker alongside the addiction worker every week.  185. In the first week of May 2012 the CAMHS senior practitioner made another referral to the Single Point of Access to activate the referral to adult mental health services. Child R had made three attempts to self harm in the previous six weeks. An initial assessment was completed at Child R’s home by a community mental health nurse (CMHN) two weeks later. Child R was discharged from CAMHS at the beginning of June 2012. Child R was diagnosed with post traumatic disorder. A recommendation was made for Child R to participate in cognitive behavioural therapy (CBT). A referral was made to the young people’s counselling service.   186. Child R’s behaviour at the PRU was continuing to be problematic with swearing and being rude. Child R was also continuing to regularly go MFH.   187. Child R and mother completed the Strength’s and Difficulties Questionnaire at the end of July 2012 and technical report was completed and a diagnostic prediction made of high risk to Child R from a behaviour disorder and of medium risk from an emotional disorder.   188. During a home visit by the CMHN in mid August 2012 Child R reported that everything was fine and that they had ‘managed to sort everything out’.  Child R continued to report positive improvements during an out-patient appointment at the end of August 2012 that included sleeping much better and that there had been no further incidents of self harm. At the end of August 2012 the CMHN discussed closing involvement now that a referral had been made for counselling. Mother agreed that Child R might be better seeing a counsellor and that this would then not have ‘too many agencies involved’.  189. The day after this conversation the counsellor made a no access home visit to Child R. At the beginning of September 2012 Child R again went MFH. Child R declined to go home having now become 16 years old. Child R was staying with an older male who was suspected of dealing in drugs. This caused particular distress to Child R’s parents who have commented that they felt unsupported in being able to persuade Child R to return home.    Page 37 of 60 190. A CIN review meeting at the beginning of September 2012 was informed that counselling had started although there is no recorded evidence that this had happened despite the efforts of the service to set up appointments. Child R had left the county and was reportedly in East Anglia according to a telephone call from Child R. The next telephone contact was allegedly from the West Country. Child R was due to go to college. The CAPSS (child and parent support service) closed their involvement in mid September 2012. The substance misuse service had resumed contact with Child R.  191. The victim support service had their last contact with Child R in late September 2012 after Child R had been assaulted by another female.   192. Child R returned home in mid September 2012 and made contact with the counselling service and attended a counselling session in mid September 2012. During the counselling session Child R alleged a third rape. This was discussed with a member of the Awaken Project. This contact was included in the mental health records but a record was not made by the Awaken practitioner. According to the record, Child R had named an individual who was known to the police and to the Awaken Team. The Awaken partnership worker acknowledged that Child R had a right to make a formal report although this did not happen. There was no further follow up in respect of the allegations.  193. The Young Addaction service closed their involvement at the end of September 2012 and referred Child R to The Hub (another substance misuse service in Blackpool for young people).   194. In January 2013 the counselling service wrote to Child R offering an appointment for counselling. The appointment was not kept. Child R contacted the counselling service to apologise for the DNA and asking for a new appointment. Child R was killed later that same day.      Page 38 of 60 3 Analysis of key themes for learning from the case and recommendations  195. Any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable young people and families has to understand why things happen and the extent to which the local systems (people, processes and organisations) help or hinder effective work within ‘the tunnel’22.   196. This chapter sets out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The findings are framed using a systems based typology developed by SCIE.   197. The purpose of using the following framework is to identify the underlying patterns that appear to be significant for local practice in Lancashire.  a) Cognitive influence and human bias;  b) Responses to incidents and information;  c) Tools for informing professional judgments and decision making;  d) Management and agency to agency systems. 198. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to the key findings:  a) Does the Board accept the finding?  b) How is the Board to take this forward? If not, to explain why.  c) Who is best placed to do this?  d) What are the timescales for response?  e) How and when will it be reported?  199. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published.                                          22 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight.  Page 39 of 60  3.1 Cognitive influence and human bias Definition and response to risk for older children; recognition of abuse and risk to teenagers from outside their home;    200. This part of the analysis explores how people working with Child R processed information and attributed meaning or interpreted aspects of behaviour and what it represents in terms of work with vulnerable adolescents who are at risk.   201. The way that people think about the behaviour of another person and how they interact with them has an influence on how information is processed and their judgments are formed. Professionals undertake training and development, and are often very experienced, although they can be subconsciously susceptible to these influences. Further complications arise in working with young people able to articulate views, wishes and feelings that for example may minimise risk.   202. In this particular case, although there was a recognition that Child R was at risk from aspects of behaviour and circumstances, this did not lead to Child R being defined and helped through multi agency frameworks as a child at risk of significant harm although Child R did receive extensive support from many different people and services although this was generally confined to working in agency silos.  Child R was also seen by many people as resilient with a positive personality that may have masked underlying needs and emotions and feelings of low self image.   203. The serious case review has collated and analysed information from disparate sources that has revealed a fuller picture of Child R’s circumstances than was available to the people who were trying to help Child R.   204. Vulnerable or troubled adolescents whose lifestyle represents a risk of harm can be a reflection of their underlying needs and difficulties rather than a choice of lifestyle associated with adolescent experimentation and developing greater independence. This is a fundamental principle that needs to inform how vulnerable or troubled adolescents are advised, helped and supported.   205. Child R engaged in risky relationships went missing from home and engaged in other harmful behaviour. This was recognised but the response was generally limited to offering advice. Not all of this can be attributed to the difficulties of service delivery described in other parts of the report.   206. The fact that adolescents are less dependent on carers and have the capacity through their behaviour and their general demeanour and interaction to encourage or reject advice, help and support makes it a challenge for any professional and parent.    Page 40 of 60  207. A differential bias in how the needs and risks facing teenagers has been the subject of academic discussion and highlighted in an early examination of serious case reviews that took place in England in 2001-200323. The authors of that study commented that in general, there appeared to be a range of assumptions about adolescents in relation to abuse and neglect which lead to different perceptions of them from younger children who are suffering similar significant harm.   208. Older children are generally thought to be better able to take care of themselves, can avoid physical harm, keep out of the way or ask for help. There can also be unspoken assumptions that perhaps they have in some way brought the difficulties on themselves or that they have at least in some way contributed to the situation they find themselves in. This appeared to be the source of some of the conflict that Child R experienced with other students and some other people. It can also make them a target for more predatory sexual and emotional behaviour.   209. Evidence from this case as well as in national studies, non-attendance at school or involvement in substance misuse can elicit a limited response amongst professionals which focuses solely on the adolescent’s behaviour and not on the wider circumstances in which they were growing up and the triggers for why they behave and interact with their world.   210. There are often family and environmental factors that need a more in-depth assessment and a more coordinated planning of services that may reveal a threshold of concern about harm requiring a child protection plan. Child R was the subject of a CIN plan but not an in-depth assessment that managed to collate information about relevant history and trauma and coordinate the perspectives and involvement of different professionals.   211.  The child protection system has been primarily designed to assess risk within the home and a parent's capacity to safeguard and protect their child from harm; this was reflected in the assessments that focused on a judgment as to whether either of Child R’s parents were a risk rather than a wider view of both risk and the sources of resilience that were available to Child R.   212. For teenagers such as Child R, risk exists in their peer groups, schools, neighbourhoods as well as increasingly online; these are all potentially environments that can provide opportunity for harm that any professional and parents struggle to tackle and are demonstrated in this case.                                          23 Improving safeguarding practice Study of serious case reviews 2001–2003; Rose W and Barnes J; The Open University  Page 41 of 60 213. Child protection systems are generally built to protect children from adults who seek to hurt them. The Children’s Commissioner for England’s report and the separate NPSCC toolkit published in November 2013 demonstrate that young people are also harmed by their peers. In this case, Child R was sometimes a perpetrator of harm as well as on others being a victim.   214. When teenagers have been harmed in their peer groups, schools, neighbourhoods, or online, individuals and organisations can be reduced to moving them rather than making those spaces or environments safe for them. In Child R’s case, matters were exacerbated at times when Child R had instigated or aggravated situations. Such behaviour was difficult to manage in a PRU and therefore was much more problematic in a much larger secondary school environment.   215. Professionals are struggling to identify this form of abuse and when they do it is far from clear how they are meant to respond to the child who has been harmed and the child who has caused the harm.  Issues for the LSCB to consider in regard to learning and improvement   1. Is there sufficiently good understanding about the nature of risk taking behaviour by vulnerable teenagers and thresholds for escalation into formal risk assessment and management processes?  2. Is there systemic bias about using the safeguarding frameworks to assess and manage risk to older children?  3.2 Responses to incidents or information Dangers of working too much in the moment without any context of history or other agency knowledge; purpose and function of reports about incidents such as MFH; the focus and outcome of assessments of vulnerable teenagers whose lifestyle and ideation represent risk of harm;  216. Child R experienced very significant levels of trauma that were largely unknown to the professionals in contact with Child R. Histories of even relatively minor health or developmental issues can impair parent-child interaction and relationships which can be further compounded by other factors such as high use of alcohol.  217. There was never a full history taken for Child R and the family and therefore a great deal of information still remains out of view. Information that has become clear during the SCR includes the early experience of bereavement and an extended period of grief reaction for Child R. This coincided with the suicide of a relative and the apparently sudden move of the family to Lancashire which disrupted an early and apparently significant childhood friendship for Child R. There was also a serious and long term illness for one of Child R’s parents.   Page 42 of 60  218. These were all important factors that deserved more exploration (if they had been known about) when for example a statutory assessment was opened on six different occasions rather than progressing to a core assessment.   219. There was an optimistic expectation that Child R’s parents were able to respond to Child R’s behaviour and difficulties. Although advice and support in regard to parenting was provided there was not enough attention to exploring the style of parenting and how this related to Child R’s needs.    220. Deficits in regard to how parenting assessment and support was provided in regard to Adult 1 during childhood were identified in the expert report for the review.   221. Although there were efforts to involve Child R in a youth club and positive activities that offered the potential for social support and resilience outside of school these became disrupted through relationship difficulties with peers.   222. As Child R developed into adolescence additional needs and behaviours became manifest in respect of risk taking, extreme mood swings, withdrawal and disruption.   223. For the most part, all of this was looked at through a behaviour management perspective that focussed on reducing Child R’s disruption. Matters were further compounded by changes to some of those structures that had the effect of accelerating Child R’s transfer from at least one educational setting. Those arrangements do not apply now.  224. The collation of the inter-agency chronology and the gathering together of practitioners for the analysis and learning event in November 2013 provided evidence of the extent of contact that had taken place across several different services and locations.   225.  What also became clear was the extent to which people were largely unaware of contact and involvement by other professionals. Some of this reflected an ethical or philosophical stance for example in regard to providing counselling and preserving absolute confidentiality to Child R.   226. This provided opportunity for Child R to present variations or emphasis on different aspects of information. For example Child R gave accounts of being in court for the sentencing of the adult convicted of raping Child R.    227. The absence of a good enough overview of information was a significant theme to come from the practitioners’ event. Other phrases such as being more persistent and tenacious in following up concerns and information and making a fuss about gaps in information came up more than once.  Page 43 of 60  228. Other issues were a reliance on information being provided by Child R and the family rather than taking a more inquisitive approach. The processing of at least ten vulnerable child reports and the six statutory initial assessments did not lead to significant additional information being revealed.   229. The MFH protocol was not fully invoked; this requires the escalation of enquiry as well as oversight by more senior managers if a child or young person is frequently missing from home. Revised national guidance has been published by government and will be considered by the LSCB. This is described in further detail in the next section of the analysis.  230. In spite of this extensive range of contacts and reports, nobody achieved a true overview and the focus remained on responding to the immediate presentation of behaviour.   231. More rigorous collation of the information would have created clearer opportunity to identify the degree of need and risk more accurately more completely.   232. The introduction of the MASH and the implementation of revised reporting arrangements in regard to vulnerable people will provided a greater degree of oversight.   233. Previous serious case reviews have highlighted issues in regard to the importance of enquiring into the individual and family history of children and families.   Issues for the LSCB to consider in regard to learning and improvement   1) Is there sufficient clarity and understanding that the missing from home (MFH) protocols apply to children who go missing from home irrespective as to whether they are children who are looked after by the local authority or live with their family, friends or other private arrangement?   2) Are arrangements in place to ensure that contact and referrals in regard to vulnerable teenagers through the MASH are processed and followed up through the relevant risk assessment frameworks?  3.3 Tools for informing professional judgment and decision making The use of risk protocols and frameworks for identifying and following up vulnerable young people; using information for escalation and adaptation of intervention strategies;    Page 44 of 60 234. A serious case review will by the nature of the circumstances under which such a process has been commissioned have to examine the judgments and decisions that were influential in a particular case. Simply using hindsight to challenge historic decision making does not help identify how improvements can be achieved.  235. Decision making is of crucial importance.  Professional judgment of the different practitioners but particularly in the police and CSC represents complex ethical and legal considerations in regard to the use of any statutory powers or duties and especially when working with young people who will have an increasing sense of independent thought, feelings and wishes.    236. Professional judgments should be based on having relevant knowledge and sound reasoning applied to the circumstances and attributes of the child and their family.  That is why issues such as the conduct of assessments and taking adequate histories are so important.   237. Assessment tools should support the comprehensive gathering or ordering of information, to indicate if there is an increased possibility of harm, to guide analysis or to support multi-professional working as well as gathering data for monitoring and service development purposes.  238. A starting point has to be the purpose and understanding of any work processes and protocols that are used to help identify children who are either at risk of significant harm or are in need of services to prevent the impairment of their health or development.   239. There are three significant frameworks that applied to Child R’s circumstances. The first, in the order of chronology, is the MFH joint protocol. The framework describes the action to be taken by the police and local authority when a child or young person (under 16) goes missing from home (or care).   240. Key stages of the process describe the initial reporting and response to locate the child and then a graded response that is intended to identify children at higher levels of risk. The procedures require the police to make a referral to the local authority if there is evidence of the child being sexually exploited or at risk of significant harm. A referral, via the VC police form was sent to CSC on at least ten occasions between November 2009 and November 2012.   241. Not all of those referrals appear to have been logged by CSC; at least they did not show on the chronology of agency contact prepared for the SCR.  An initial assessment was completed on six occasions by CSC (and there was an initial assessment by the mental health service point of contact); this never progressed to a more detailed core assessment.    Page 45 of 60 242. CSC is responsible for deciding whether a return to home interview is undertaken; this was apparently done on two occasions although not by a social worker. The return interviews are locally mandatory if the child has been missing for more than 24 hours; the majority of Child R’s MFH were for shorter periods.   243. A mandatory return interview is required if the child is MFH on two or more occasions or there are mental health issues or a crime has been committed. Child R had been MFH on 28 occasions was exhibiting symptoms of emotional and psychological distress and was on several occasions located with adults some of whom had sex with Child R under the age of consent. The purpose of the interviews are to;   a) To better understand the reasons why the child went missing; b) To explore the circumstances which led to the missing episode(s); c) To inform future prevention strategies; d) To inform any future missing person investigation; e) should that person go missing again; f) To learn of the activities, associates, risks and victimisation involved in the missing episode, and where possible to address those risks with appropriate and proactive strategies such as the use of the harbouring warning notices under the Child Abduction Act (see previous supporting footnotes and were used in this case); g) To identify and address any harm the child has suffered including harm that may not have already been disclosed as part of the safe and well check.  244. The MFH protocol also describes an escalation policy.  After five episodes within a 90-day rolling period there should be a first stage intervention meeting. This level of intervention meeting is described in the protocol as the crucial stage in avoiding serious escalation and must, therefore, be given high priority by all concerned. Within four working days of the last episode (reaching the threshold level) these meetings must be held and representatives from each organisation or interested party must be present.   245. The meeting should be chaired by a children’s services manager. After nine episodes within a 90-day rolling period there must a second stage intervention meeting. Within four working days of the last episode (reaching the threshold level) these meetings must be held and representatives from each organisation or interested party must be present. The meeting should be chaired by an independent reviewing officer (IRO) or a children’s services manager, and attendees should include:  a) Child (subject to discussion about appropriateness); b) Team manager; c) Social worker or relevant lead professional; d) Local Police Missing Person Coordinator and  Page 46 of 60 Champion; e) Parent and or carer, residential unit manager or fostering manager; f) Person who conducted return interview if different to above; g) Other relevant professionals (for example health,    education, Youth Offending Teams).  246. The guidance explicitly states that any agency or professional who has increased or serious concerns for a child’s well-being or safety then they may call a multi-agency strategy meeting at any time, regardless of the number of missing episodes.  247. Further strategies should continue to be managed by the senior manager for the area in which the child lives until the risks to the child have reduced and/ or the missing episodes have been reduced or ceased. If there is no reduction in the missing episodes the senior manager must take responsibility for escalating the case up the management hierarchy.  248. It should be noted, however, that the volume of missing episodes is not the only reason to launch an intervention or to escalate the level of intervention. The following are examples of other reasons to initiate or escalate interventions:  a) Any case where the risks involved in even a single future missing episode is very high; b) Cases where it has been identified that immediate action is necessary to ensure the well being of the child.  249. None of this escalation policy was applied in regard to Child R and it was not apparent that practitioners had been aware of the full protocol. The only consistent application of the protocol was by the police who completed the safe and well checks after each episode of MFH. The fact that Child R was frequently located well within 24 hours may have contributed to seeing the protocol and framework as not applying to Child R’s circumstances.   250. The MFH protocol draws attention to the risk to children who go missing that includes sexual exploitation and abuse. The point is made even more strongly in national guidance issued as recently as 201324 that children who are most vulnerable to sexual abuse and exploitation are those children like Child R who regularly go missing from home.                                           24 Statutory guidance on children who run away or go missing from home or care; June 2013. The guidance makes a distinction between children who go missing and those who are absent. Missing: Anyone whose whereabouts cannot be established and where the circumstances are out of character or the context suggests the person may be subject of crime or at risk of harm to themselves or another’; and  Absent: ‘A person is not at a place where they are expected or required to be’.    Page 47 of 60  251. This is not to suggest that one causes the other but does highlight the heightened risk that goes alongside the other factors that contributed to Child R adopting a risky lifestyle. These were not conscious choices but a reflection of emotional and psychological difficulties that were exacerbated by factors such as substance misuse. The local protocols for CSE described in some detail in earlier sections of the report are the second important framework relevant to this case.   252. The local protocols for CSE in Lancashire are set out in the online safeguarding procedures and have been used to good effect with other young people as evidenced in the regular and routine reports to the LSCB.   253. The procedures include a specific referral form for recording information and for reporting to specialist professionals and groups. The protocol is a more useful framework for dealing with an organised network rather than the individual circumstances of a child such as Child R and serial relationships. There is also an additional dimension as far as defining and sharing a common understanding about what constitutes sexual exploitation.   254. The third framework that has relevance to Child R concerns statutory assessments. Up until April 2013 there was a national assessment framework that distinguished between initial and core assessments. Following the publication of the latest Working Together in March 2013 the responsibility for developing a framework rests with local authorities. The learning from this case is that none of the assessments were adequate for discovering Child R’s history and circumstances.   255. There was an apparent reliance on Child R being ‘safe and well’ after returning from MFH and Child R’s parents were regarded as not posing a risk to Child R. This contributed to the assessments never exploring the underlying reasons and circumstances for Child R’s behaviour and lifestyle. There was also high reliance on counselling providing an outlet for Child R to discuss problems. That was hampered by misunderstanding about what could or could not be discussed in regard to the rape for example.  256. Effective assessment involves knowledge and skills in areas such as child development, emotional and psychological needs of children, retrieving research and other knowledge from electronic sources, appraising its quality and relevance, synthesizing the findings, disseminating knowledge to guide judgments, and applying knowledge appropriately in individual decisions about client care. It also involves talking with other relevant people and collating and analysing information.   257. A fourth and additional area of learning relates to relationship abuse. Risk factors are used to guide prevention work, to identify people who could be at  Page 48 of 60 risk. The risk factors of becoming involved in an abusive relationship can be the same as person who is experiencing abuse.  a) Experience of violence in the home;  b) Depression in childhood;  c) Poor mental health;  d) Problem drug and alcohol misuse from early age;  e) School non-attendance;  f) Disruption of family unit / being ‘in care’;  g) Sexual relationships;  h) Having a child as a teenager;  i) Poverty; j) Sexual exploitation and sexualised risk taking.   258. It is important to think about things that can protect young people from being involved in a violent relationship. Some key protective factors are:   a) Achievement at school;  b) Parents being aware of the young person’s activities and relationships;  c) Having a safe haven;  d) Support from positive role models;  e) Confidence, self-esteem, being able to stand up for themselves;  f) Sense of physical, emotional and economic security;  g) Belief that others have high expectations of them;  h) Participation in engaging and challenging activities ; i) Sense of belonging;  j) A strong support network.   259. All schools should be aware of and addressing relationship abuse. While anti-bullying policies are common, a specialised policy that addresses the unique aspects of abuse in young people’s relationships is critical to appropriately safeguarding young people. Central to safeguarding is the teaching through sex and relationship education of what constitutes a healthy relationship. Implicit within this is the challenging of stereotypes such as female passivity and male aggression and the recognition that relationship abuse can happen to anyone, no matter what their gender, social background or sexual orientation.  260. The MFH and CSE arrangements in Lancashire are now overseen by senior managers and are the subject of regular reports to the LSCB.   261. The establishment of a MASH in Lancashire is a very significant development in recent months and will create improved opportunities to develop effective help to children who have similar circumstances to Child R. The collocation of key services such as police and social workers with other  Page 49 of 60 specialist staff will create better opportunity to collate information across several different services and reduce the silo working. The MASH will routinely create combined chronologies that can highlight risk more quickly than was available previously.   Issues for the LSCB to consider in regard to learning and improvement   1. How does the LSCB assure itself that systems of training and quality assurance are sufficiently effective in ensuring practitioners are accountable for their compliance with relevant professional standards and safeguarding protocols that include those for MFH and CSE in regard to older children who maybe resistant to help and intervention?  The diagnosis and response to conduct disorder in childhood;  262. The expert forensic psychiatric report in regard to Adult 1 indicates that he had an undiagnosed conduct disorder from early childhood. Conduct disorder presents with repetitive and persistent patterns of behaviour in which the basic rights of other people are violated.   263. The same report draws attention to how conduct disorder commonly coexists with other mental health problems and that ADHD is particularly prevalent. Adult 1 was diagnosed with ADHD (but not conduct disorder).   264. A diagnosis of conduct disorder is strongly associated with poor educational performance, social isolation and increased incidents of substance misuse and contact with the criminal justice system in adolescence. Conduct disorder is also associated with a significantly increased rate of mental health problems in adult life.   265. The importance of diagnosing conduct disorder arises in regard to the risks to the emotional and mental health of the child and anticipating some of the longer term difficulties they may face. The expert report discusses the proven value of multi systemic approaches as well as using medication such as Ritalin which was prescribed long term for Adult 1 during childhood. There is encouraging research evidence that early identification and treatment of conduct disorder can be effective in preventing the onset of other disorders in later life.   266. The expert psychiatric evidence draws attention to the NICE evidence for promoting the development of more effective interventions.    267. This multi-systemic approach is an intensive treatment focusing on all aspects of an individual’s life and environment including the school and the family. It also focuses on strengths and increasing the individual’s responsibility, it targets sequences of behaviour. The components of this type of treatment approach include broadly;  Page 50 of 60  a)  Parent training aiming to improve parenting skills. There are many randomised controlled trials suggesting that it is effective for children particularly before they are ten years old; b)  Parenting interventions based on social learning theory address the parenting practices identified as contributing to conduct problems; c)  Individual skills and anger management. Most of the programmes to improve child interpersonal skills derive from cognitive behavioural therapy (CBT); d)  Educational interventions; e)  Peer group skills.  268. The development of Adult 1’s sexually inappropriate behaviour in adolescence should have resulted in a referral to the FACTS team25.   Multi agency arrangements that can deliver sufficiently integrated help to higher risk children  269. The expert report commissioned for the SCR identified shortcomings in relation to multi agency working and this is reflected also in the analysis in regard to Child R.   270. Both received significant intervention although this was not integrated with other local and specialist services such as CAMHS. The assessments that were completed on both Child R and Adult 1 when he was a child and adolescent were single agency. In regard to Adult 1 he was the subject of some very thorough educational assessment and support although this was done in isolation from the local CAMHS. Both Child R and Adult 1 presented with significant psychological difficulties that were not satisfactorily assessed. Referrals were not made.   271. In regard to Adult 1, his behaviours became less visible in later adolescence and probably reflected the fact that he was in placements where he was under less scrutiny.   272. NICE published guidance in 200626 in regard to the efficacy of parent education and training programmes in the management of children with childhood conduct disorders. The guidance recommends that group based and individual programmes should be available.   273. It is recommended that all parent-training/education programmes, whether group- or individual-based, should:                                          25 Forensic Adolescent Community Treatment Service for high risk young people. 26 Parent-training/education programmes in the management of children with conduct disorders  Page 51 of 60 a) be structured and have a curriculum informed by principles of social-learning theory; b) include relationship-enhancing strategies; c) offer a sufficient number of sessions, with an optimum of 8–12, to maximise the possible benefits for participants; d) enable parents to identify their own parenting objectives; e) incorporate role-play during sessions, as well as homework to be undertaken between sessions, to achieve generalisation of newly rehearsed behaviours to the home situation; f) be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development, and are able to engage in a productive therapeutic alliance with parents NICE Technology Appraisal;  g) adhere to the programme developer’s manual and employ all of the necessary materials to ensure consistent implementation of the programme.  274. Programmes should demonstrate proven effectiveness. This should be based on evidence from randomised controlled trials or other suitable rigorous evaluation methods undertaken independently.  275. Programme providers should also ensure that support is available to enable the participation of parents who might otherwise find it difficult to access these programmes.  Issues for the LSCB to consider in regard to learning and improvement   1. Does the LSCB have sufficient information through the relevant specialist partner agencies about the numbers of high risk young people with conduct disorder to establish the extent to which current arrangements are better able to identify and refer high risk young people to appropriate services?  3.4 Management and agency to agency systems  Coordinating support for children and young people across boundaries and in criminal proceedings; transfer and longer term support to young people with childhood mental health needs as they move to adulthood.  276. Child R’s parents raised their concerns about the delay in being able to access to counselling in relation to the rape. It has been apparent that there had been some professional reticence and caution about not talking with Child R about the rape until the criminal trail had been completed. That took almost 18 months.   277. The CPS had already published guidelines for supporting children who have been victims of sexual assault or exploitation. This guidance is principally  Page 52 of 60 addressed to people and organisations involved in the investigation and prosecution of criminal cases although aspects of the guidelines should offer support to improving future arrangements for children such as Child R.   278. The guidelines require thought to be given to how support will be provided before, during and after criminal proceedings. The CPS guidance Provision of Therapy for Child Witnesses Prior to a Criminal Trial is clear that the best interests of the victim or witness are the paramount consideration in decisions about therapy. There is no bar to a victim seeking pre-trial therapy or counselling. Neither the police nor the CPS prevented therapy from taking place prior to the trial in this case and is very well understood by the police. The Investigative Training Centre (CID training) even include it on the Tier 3 (Specialist Witness Interviewing).   279. The guidance draws attention to specific issues that included consultation with the CPS at the outset about the need for and provision of counselling and deals with particular matters that include for example the problems that will occur if a therapist is attempting to distinguish between fantasy and reality. This was a particular area that was not properly resolved within the counseling service in respect of Child R.   280. The review has highlighted issues in regard to delivering services across boundaries in respect of vulnerable children; this includes identifying and working with children at risk of disruption to their education, children at risk of sexual exploitation and delivery of metal health support to teenagers.   281. The review has also been made aware of several counseling services being reduced or removed. This has led to increased waiting lists before young people can access counseling from services such as the SAFE centre. The availability of services that can provide appropriate therapeutic help to children and young people who have been affected by traumatic events and experiences is an important part of promoting emotional and psychological well being. Many of those services are subject to reductions in resources that lead to delays in providing help and are also increasingly operating on a time limited basis.   282. About five per cent of children aged 5-10 display behavioural problems which are sufficiently severe, frequent and persistent that they justify diagnosis as a mental health condition: conduct disorder. A further 15-20 per cent has problems which fall below this threshold but are still serious enough to merit concern.  283. A wide range of risk factors may be implicated in the early development of severe behavioural problems. Particular importance attaches to adverse influences within the family environment, such as maltreatment and harsh, inconsistent or neglectful parenting.    Page 53 of 60 284. The availability of appropriate services that can assess and develop parenting support programmes are an integral part of responding to the needs of troubled children and young people. Parenting support programmes significantly cut the risk of children developing behavioural problems and becoming offenders in adolescence and adulthood, a new study suggests.   285. Analysis of research on the effectiveness of parenting programmes in helping address severe child behaviour problems, such as conduct disorder, concludes that they cut by around half the number of young children that meet the clinical threshold for diagnosis.   286. The analysis, by the Centre for Mental Health (CfMH), also finds that every pound spent on parenting support delivers £4 of annual savings to health, education and social care services.   287. The Centre for Mental Health report, Building a Better Future27 finds that the average cost of delivering a 12-week parenting intervention, such as the Triple P and Incredible Years programmes, is £1,300.   288. In comparison, it calculates that the annual costs of severe behavioural problems is £5,000 in funding additional health, social care and education services for young children, and in youth justice interventions for those over 10 years old. The estimated lifetime cost of behavioural problems is £260,000 compared to £1,300 cost per child of a parenting programme.  289. Children with severe behavioural problems are many times more likely to develop drug addictions, leave school with no qualifications, be imprisoned and become a teenage parent.  Issues for the LSCB to consider in regard to learning and improvement   1. Does the LSCB have sufficient information about the availability and appropriateness of services to provide sufficiently rigorous parenting support in regard to children presenting with severe behavioural difficulties?  2. Does the LSCB have sufficient information about the availability of counselling and therapeutic support for children dealing with significant trauma including CSE and childhood bereavement?  3. Is the LSCB satisfied that there is sufficient clarity and understanding on the part of counselling services providing pre-trial support to children and young people who have been victims of sexual crimes?                                           27 Building a Better Future, Parsonage, Khan and Saunders January 2014 Centre for Mental Health  Page 54 of 60 4. What arrangements will be necessary to ensure that the county and unitary local safeguarding children boards are both made aware of the issues and point of learning especially in regard to cross boundary access to services for vulnerable children and teenagers?    Peter Maddocks, CQSW, MA. Independent reviewer March 2014     Page 55 of 60 Appendix 1 - Procedures and guidance relevant to this serious case review Legislation  The Children Act 1989  Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act28 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need.  Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm.  These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998.  Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm.  The Children Act 2004  Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate.  The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes.  This section is the legislative basis for children’s trusts arrangements.                                          28 Local Authorities, including District Councils, the Police,  National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training     Page 56 of 60 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act29 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Safeguarding Procedures  The local safeguarding children procedures  The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review.  Other local procedures relevant to this serious case review  National guidance30  Working Together to Safeguard Children (2013)  The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable.  The guidance in respect of the Framework for the Assessment of Children in Need and their Families was replaced by the Working Together 2013.                                           29 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 30 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government.     Page 57 of 60 Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review.   Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008.  A step by step guide for front line practitioners (child sexual exploitation) 2012  The step-by-step guide complements, and should be read in conjunction with, the Safeguarding children and young people from sexual exploitation1 statutory guidance published in 2009. It is intended for frontline practitioners in the statutory and voluntary and community sectors (VCS). It outlines the actions they should take, as a minimum, if they suspect that a child they are in contact with is being sexually exploited.  Guidelines on Prosecuting Cases of Child Sexual Abuse (2013)  These guidelines published by the Crown Prosecution Service (CPS) provide guidance primarily fro prosecutors dealing with cases involving child sexual abuse and sexual exploitation. The guidelines include advice on the support that can and should be offered to the victims before, during and after criminal proceedings. Emphasis is given to establishing clear communication between the services and professionals working with victims.      Page 58 of 60  Statutory Guidance on children who run away or go missing from home or care (2013)  The guidance draws attention to the link between children who go missing from home and child sexual exploitation. The guidance is issued under section 7 of the Local Authority Social Services Act 1970 and describes strategic and operational guidance in respect of children who go missing from home or care.      Page 59 of 60 Appendix 2 Specific questions addressed by the expert   1. In regard to anticipation or prediction of any enhanced risk of harm to others, is there any information or evidence that is particularly relevant or significant in the history provided?  2. To what extent is there any evidence of a personality disorder in the subject’s adolescence and if so at what stage was this a diagnostic possibility and what would be the implications for the subject and for professional practice?   3. If there is evidence of a personality disorder is it possible to provide an opinion about the nature or cluster of the disorder? In particular please comment as to whether there was either evidence or a strong indication of the subject being a danger to others and what treatments or interventions would you have expected to have been developed taking account of any significant new developments in research or clinical and professional practice and understanding?  4. What is the significance of the Devereux Behaviour Rating Scale that recorded significant concern about behaviour in late 2000 (98th centile)? Under what circumstances is the scale used and to what purpose?  5. Please consider the incident in April 2005 referenced in the police chronology regarding the sexual assault of an eight year old boy and provide a view on the advice given that the perpetrator did not have mental capacity. In providing that advice, what measures or information would you expect to have been taken into account in reaching such a judgement?  6. What could explain the gaps in presentation of behaviours for example when attending college in 2006-08?  7. Is there significance in the fact that Adult 1 undertook a college course in the care of small animals and the subsequent incident of serious injury to horses?  8. Are there any other specific incidents or information contained within the bundle that deserves any particular comment or analysis for the purpose of learning?  9. Are there any lessons in regard to policy, professional practice on a single or multi-agency basis for risk assessment and behaviour management? This should include any advice on the training or use of tools or frameworks with severely disordered children or young people for professionals such as social workers and police officers who have particular statutory responsibility for identifying persons who can present a risk to children or young people.  10. Is there anything in the bundle that without the benefit of hindsight could reasonably be a predictor to the development of premeditated sexual violence?     Page 60 of 60  11. Is there anything in the bundle to indicate, without the benefit of hindsight, a capability of murder?   12. Is there any additional information or evidence that the review panel should be seeking?      The Lancashire Safeguarding Children Board is today publishing a Serious Case Review in respect of the case of Child R.   In January 2013 the body of a 16 year old from Lancashire was found in Blackpool.  She had suffered multiple stab wounds.  She had been lured to commercial premises on the pre-text of a being offered employment.  A 23 year old man was arrested and convicted of her murder.  The murder of a young person in these circumstances would not normally result in a Serious Case Review being undertaken, however the young person who was murdered had been known to a number of services and was known to be vulnerable.  The man convicted of her murder was also known to a number of services, had had a troubled childhood and his behaviour and history were of concern.  For these reasons a review was commissioned in order to ensure identification of any issues which could improve service responses in the future.  The review concluded that there was nothing to suggest that any individual or agency could reasonably have predicted these tragic events.  As is always the case however the review provided the opportunity to reflect and all the agencies involved developed action plans to ensure issues arising from this review were appropriately dealt with.  All those action plans have been monitored by the Board and have either already been completed or on target to complete within the agreed timescales.   The Report raised a number of issues for the Board itself to consider (see page 53) and information is provided below as to the Board’s response.  1.  The Board is not satisfied that there is a sufficiently good understanding about the nature of risk taking behaviour by vulnerable teenagers and thresholds for escalation into formal risk assessment and management processes.  In response the LSCB is undertaking a review of the training that is available to help practitioners understand why and how teenagers can and do engage in risky behaviour. As part of this training review, the extent to which practitioners understand how to escalate their concerns will also be examined The review includes examining the multi-agency training that is available from the LSCB and other partnership groups (such as Working Together with Families) but also within agencies themselves. The focus is be on whether training equips practitioners with a full and proper understanding of how to work with teenagers whose behaviour can put them at risk.   In addition the LSCB is piloting new methods for delivering learning messages to practitioners through '7 minute briefings'. One of these briefings will focus on teenagers, their risk-taking behaviour and how to work with them most effectively. It will also include details of where practitioners can seek advice and guidance.  The review and subsequent actions will ensure that the training and learning opportunities for all practitioners are equipping them with the right knowledge and understanding to most effectively safeguard vulnerable teenagers.  2. The LSCB considers that it is possible, as suggested by the review author, that there may be systemic bias about using the safeguarding frameworks to assess and manage risk to older children.  As part of the process of review of training and development the Board will ensure that practitioners understand the frameworks and processes that will best assist them in working with teenagers and their families and using them when appropriate.   3. The Board considers that procedures and protocols in place at the time of these events may not have provided sufficient clarity and understanding that the missing from home (MFH) protocols apply to children who go missing from home irrespective as to whether they are children who are looked after by the local authority or live with their family, friends or other private arrangement.  The Missing from Home and Care Protocol in Lancashire which was in place at the time this case was active is in the process of being updated and refreshed as a result of changes to national guidance. It did provide for a differential response to the child dependent upon their care arrangements. This has been revised and is to be re-launched.  The launch will be used to raise awareness of the importance of this area of work. The refreshed guidance ensures that emphasis is given to children who go missing from their family homes as well as to those that go missing from Care.  To coincide with the refresh of the protocol, an audit of responses to children and young people who go missing is reaching its conclusion and the findings of this audit will be reflected in the protocol and its launch. The findings from the audit will also be considered more widely by the LSCB and any relevant actions will be tasked to the LSCB Missing from Home or Care sub group.  4. The Board considers that the arrangements in place to ensure that contact and referrals in regard to vulnerable teenagers through the MASH are processed and followed up through the relevant risk assessment frameworks is still evolving and that care needs to be taken to ensure good practice is in place.  The Multi Agency Safeguarding Hub in Lancashire is evolving and developing and their development will be informed by the findings from this review. The LSCB requires regular evaluation reports from the MASH service to ensure their developments are delivering the best outcomes for all children and families, including vulnerable teenagers.  As the service is evolving, the LSCB has asked them to theoretically 'walk through' certain scenarios (for example, the incidents involving Child R), to establish how each incident would be managed. This will ensure that changes to the service continuously improve the way vulnerable teenagers are identified and safeguarded. It is clear that had the MASH been in place when the reports of Child R's vulnerability were generated by the Police the response would have been more robust and effective.   5.  The LSCB has mechanisms in place to assure itself that systems of training and quality assurance are sufficiently effective in ensuring practitioners are accountable for their compliance with relevant professional standards and safeguarding protocols that include those for MFH and CSE in regard to older children who maybe resistant to help and intervention.  The LSCB has a programme of quality assurance and performance management activity that examines how practitioners use protocols and meet standards. This includes the annual section 11 process but also specific thematic audits. The specific issues around MFH have been set out in response to finding 3. The CSE sub group of the LSCB regularly reviews practice around CSE and the findings from this review will be shared with them to ensure their audit and quality assurance work considers the issues from this review. Both sub groups, for MFH and CSE, have to report to the LSCB after every meeting to provide assurance about the rigour of their monitoring processes.   The Learning and Development sub group of the LSCB consider all findings from serious case reviews. They will be required to review multi agency training to ensure the findings from this review are reflected in the training they are delivering, and will also ensure their audit of single agency training assesses how agencies are disseminating the learning from reviews to their practitioners.   6. The LSCB acknowledges that at the time of these events arrangements were not in place to identify and ensure high risk young people were referred to appropriate services It did not monitor information through the relevant specialist partner agencies about the numbers of high risk young people with a conduct disorder.  The LSCB acknowledges that this review concluded that nobody could have predicted that Adult 1 would commit such a horrific act of violence. However, the LSCB has not previously requested data and information specifically about young people who may pose a high risk to others. As a result of this finding, a task and finish group has been established to consider the numbers of children involved and also the response to them. The LSCB will require this group to feedback their findings and will request agencies make any appropriate changes to better manage associated risks.   7.   The LSCB does not currently require agencies to provide information about the availability and appropriateness of services to provide sufficiently rigorous parenting support in regard to children presenting with severe behavioural difficulties.  There has been a significant amount of work undertaken through local partnerships to support practitioners who work with parents experiencing these challenges. For example, in March 2014 Lancashire hosted a conference for a targeted audience of practitioners around the emotional health and wellbeing of children and young people displaying difficult behaviour. The conference focused on what is currently available and where any gaps may be, but also on how to make practitioners and families aware of what is available to them. The conclusions from this conference will be available shortly.   The LSCB will seek further information from the Children and Young People's Trust about services that are available to support parents in these circumstances.   8. The LSCB does not currently monitor the availability of counselling and therapeutic support for children dealing with significant trauma including CSE and childhood bereavement.  The LSCB recently sought information about counselling services available to children who have suffered bereavement as part of a wider piece of work undertaken by the Child Death Overview Panel. However, this issue is much broader, and requires an analysis of wider counselling and therapeutic support to children and young people. As such, the group that is to review services for young people who may pose a risk to others (finding 6) will also be asked to consider this issue when reviewing services that are available.   9. The LSCB is concerned that this review found a lack of clarity and understanding on the part of counselling services in respect of providing pre-trial support to children and young people who have been victims of sexual crimes.   It is clear that the lack of understanding evident in this case resulted in a service which  not meet the needs of children and young people when they are extremely vulnerable.   The LSCB therefore plans to contact all agencies that provide counselling and therapeutic support to children and young people to seek assurance that they are aware of the guidance and would offer children and young people the emotional support they need when they need it.  10. The LSCB has put in place arrangements to ensure that the LSCB in the unitary council has also been made aware of the issues and points of learning from this review, especially in regard to cross boundary access to services for vulnerable children and teenagers.  The LSCB and individual agencies in Blackpool are aware of and have had involvement in the review. The LSCB in Lancashire has formally written to Blackpool LSCB to set out planned actions that apply to 'shared services' that work cross-boundary. However, Blackpool LSCB will also be made aware of all other findings so they can take whatever action they deem appropriate; especially for those agencies that only work in Blackpool.   25 September 2014  