Arrest of a 16-year-old boy arrested on suspicion of murder in November 2021. David was a looked after child who had been the victim of criminal exploitation. Learning includes: developing positive, strengths-based relationships with parents and carers supports safety planning; robust, child centred, and focused support plans must be in place for Special Guardians and these need to be regularly reviewed and adapted; children and young people at risk of criminal exploitation need consistent professional involvement and relationships; safeguarding agencies need to regularly review their approach to child criminal exploitation by listening to the experiences of young people and applying this learning to practice; contextual safeguarding meetings should have the same 'status' in safeguarding partnerships as child protection case conferences; practitioners need to develop their understanding of culturally sensitive practice and consider how a young person might experience oppression, discrimination, and risk. Recommendations include: test and evaluate the use of contextual safeguarding meetings; pilot a 'child safeguarding pathway' for exploited children and use the evidence to inform future practice; consider learning from other safeguarding partners and agencies who have developed effective contextual safeguarding practice, particularly implementing 'Signs of Safety' as a practice model; develop a safety planning toolkit which supports practitioners in their child criminal exploitation work; children's social care to test out having a single social work practitioner to support children experiencing exploitation; consider how to implement a trauma informed approach to practice, including how to support staff with vicarious and secondary trauma and develop arrangements for critical debriefing.
      
 Title:  Local child safeguarding practice review: David. LSCB: Berkshire West Safeguarding Children Partnership Author: Ian Vinall Date of publication: 2023  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.                           1          Berkshire West Safeguarding Children Partnership Local Child Safeguarding Practice Review     David October 2022           Independent Review Author – Ian Vinall       2  Contents  Section Title Page Number 1 Introduction 2 2 Chronology 3 3 Emerging Practice Themes - March 2018 to March 2020 5 4 Emerging Practice Analysis - March 2020 to November 2021 13 5 Summary of additional learning 16 6 Evidence of good practice 17 7 Conclusions 17 8 Recommendations  19  1. Introduction  Introduction to David 1.1 David is a black British 18-year-old man. At the start of the review process, he was aged 16. He has lived for most of his life with a family member.  People who know David have described him as being a lively, polite, thoughtful young person with a wicked sense of humour.  1.2 Pre-birth David was exposed to his mother’s substance misuse and his childhood experiences were one of disrupted attachments and physical neglect. David was removed from his mother’s care and placed into foster care aged 2 years and by the age of 6 years he had been in 6 different foster placements. 1.3 He moved into the care of family members aged 6 under a Special Guardianship Order (SGO)1 and they have remained as his main carers. However, David has also been in foster and residential care placements since 2018. David has 3 step siblings and there has been contact between them. Throughout 2019 and 2020, David was missing from his care placements and his family home and had there were ongoing concerns that he was being criminally exploited. In early 2020, David was seriously assaulted, and he sustained a head injury which required a significant operation and induced sedated state to enable his recovery. There are long term effects of this injury.  1.4 In November 2021, David was arrested for murder and remained on remand until his trial in the summer of 2022. Introduction to the Review 1.5 This local child safeguarding practice review was completed in two parts. The first part of the review focused on the events in David’s life from 2018 to March 2020. Following David’s arrest for murder in November 2021, the review author was asked to review David’s circumstances from March 2020 to November 2021. The chronology, review learning and recommendations have therefore been combined into one document.  1.6 Following government advice regarding the Covid-19 pandemic, the Rapid Review was progressed via written submissions only in March 2020. The Berkshire West Safeguarding Children Partnership completed this work following David’s assault and the panel agreed for a Local Child Safeguarding Practice Review to be carried out. It was felt strongly that local safeguarding partners had an opportunity to learn from David’s experiences and his involvement with services. A Review Panel was appointed and has met five times. David’s main carers and his birth father were interviewed for the review and provided significant insights into their experience of services and support. Attempts were made to engage David in the review, but he declined. Written records from the local authority, together with 1:1 interviews with practitioners who have worked with David contributed to this review together with a Practitioners Learning Event. There was a positive willingness to be  1 Special guardianship orders (SGOs) are orders made by the family court (or the Family Division of the High Court) which confer parental responsibility on the special guardian for a child up to the age of 18. SGOs were introduced by amendments made to the Children Act 1989 by the Adoption and Children Act 2002 and were described as a new legislative option for providing legal permanence for those children for whom adoption was not appropriate (Department of Health, 2000).  3  open and transparent throughout the review process. Practitioners and family members were able to comment on what worked well for David and what did not.  1.7 The Berkshire West Safeguarding Children Partnership requested an updated report following David’s arrest for murder in November 2021. The original review had not been published or widely shared and it was felt that there was an opportunity to review any impact of the previous review process, report, and recommendations on practice. The terms of reference were agreed as follows: • What has happened since the conclusion of the review in March 2020 to November 2021 and identify key episodes? • Taking into account that the outcomes of the previous Local Child Safeguarding Practice Review have not been published or widely shared, how has the process of the review influenced or changed practice and what obstacles remain? • How effective have the agency responses and interventions been in the last 18 months to safeguard and address David’s increasing level of exploitation and offending?  The methodology for this updated review was agreed as follows:  • Joint chronology to be pulled together from March 2020 to November 2021. • Identify key episodes and interview relevant practitioners and managers. • Review strategic and operational developments in child criminal exploitation in Wokingham and bordering authorities since March 2020. • Engage David and appropriate family members  2. Chronology March 2018 – March 2020 2.1 David experienced the breakdown of his SGO carers relationship in early 2018 and the carers report not being able to manage David’s behaviour prior to their separation. The carers self-referred for support via the Adoption Service in March 2018.  2.2 Practitioners were aware that since June 2018, and possibly before this date, David had been a victim of criminal exploitation and was involved with drug dealing. He was himself using cannabis as a coping strategy. There were several indicators of his criminal exploitation including unexplained money and clothing, additional phones, threats from adults, missed curfews, missing episodes and money laundering. David had been arrested for 3 allegations of robbery, possession of a knife and BB gun and involvement in drug supply. Agencies know that David was the victim of at least 2 physical assaults from other groups of youths prior to his significant injury and threats of violence were a regular concern. David was the subject of early help and child in need plans and many multi-agency meetings, including specific meetings regarding children and young people at risk of criminal and/or sexual exploitation. There has been good information sharing at these forums, but this did not extend into the wider support network. There is evidence that the action planning and follow and follow through of actions had not been consistent. 2.3 David had considerable instability in his care during the review period including being cared for by his SGO carers, maternal grandmother, 5 emergency foster placements and 3 periods of activity based residential care some distance from his home authority. There is evidence that he was both exploited and exploiting others in the last of those residential placements. His birth mother, from whose care he was removed, continues to reside with his maternal grandmother. The issues relating to David’s removal from her care remain present now. David has been very consistent in not wishing to be away from his family and resented his periods in care. 2.4 David was at high risk of exclusion from school owing to his behaviours and despite his placement moves, he remained on roll at his senior school. David’s school have remained consistent in David’s life, and he has a positive relationship with one member of staff in particular. David had a number of different social workers and other professionals working with him during the review period.  4  2.5 In February 2020, David moved to another foster placement with a plan to reunify with his special guardianship carers. This plan was in its early stages when David was seriously assaulted.  March – May 2020 2.6 Following David’s serious assault in March 2020 and his significant period in hospital, he was made the subject of a child protection plan and he was discharged to the care of his sister in another part of the country. This was described as a ‘family arrangement’ and therefore there was no legal status given to this arrangement. In mid-April and then on one further occasion, David absconded from his sister’s home. On the second time, he went missing for 7 days and was located in another part of the country. Concerns were raised about his involvement in “county lines drug running” and at least 3 police areas raised concerns about his risk to himself and others. In early May, David became the subject of an interim care order and secure order, and he was placed in secure accommodation. The local authority care plan was described as ‘triple planning’ and included a return to his SGO carers, family members or residential care. In June 2020, the secure order was extended for 3 months.  August – September 2020 2.7 The local authority applied for a 6-month extension to the secure order which was opposed by his guardian and David’s family. The court refused the order and David was moved to a residential unit with a reunification plan for David to return to the care of his SGO carer.  There was ongoing work with David and the carer to ensure this arrangement had the best chance of success. David was still considered at high risk of criminal exploitation and remained on the EMRAC monthly meeting. October – December 2020 2.8 Introductory and overnight visits took place with his SGO carer, and he returned home in late November. The final care plan, including attendance at college, was agreed. However, the college closed because of the pandemic and concerns were raised about David’s ‘unstructured’ time. There were several occasions when David was not at the family home and the carer was concerned about the number of times David was out of the house. David had access to 2 mobile telephones.  January – March 2021 2.9 David was made the subject of a 6-month supervision order following the conclusion of the local authority care proceedings and was a child in need. There were a further 2 Section 472 strategy meetings and 2 child in need reviews held in this period. There were concerns about David’s presentation and attitude and it was believed he was running a ‘drug line’. A decision was made to hold a ‘contextual safeguarding meeting’ to consider the risks to David outside of the family home. This was a new initiative but did not hold the same weight as a child protection planning meeting. In late March, David presented at hospital with injuries which prompted a further section 47 strategy discussion.  April – June 2021 2.10 David was flagged to another police area and concerns raised about his county lines activity. The decision was made in May to hold an initial child protection case conference because of the escalating risks to David and he was made the subject to a child protection plan in June under the category of at risk of physical harm. David’s case was transferred internally to the child protection team. June – September 2021  2.11 David’s SGO carer had found knives and weighing equipment in his bedroom. This followed a 2-day missing period and a suggestion that David returned home with someone he met in secure accommodation. A decision was made by children’s social care not to extend the 6-month supervision order as David was subject to a child protection plan. The SGO carer was reporting not feeling safe in her house as a result of David’s activities. Alternative care was considered. In August there was a police report that David had been involved in a robbery at knifepoint. The police searched David’s home address and found £1000 and 5 mobile telephones. In September there were 2 occasions where David became very distressed, upset, and  2 Section 47 of the Children Act 1989 5  angry fearing that he would be physically harmed and beaten by others. On the second occasion, David had mentioned to the police that he was in ‘real trouble with lots of enemies’ and was crying in the back of police van. The risks were not considered ‘new risks’ and there was felt to be a robust support plan in place, so no further action was taken. October – November 2021  2.12 David was not attending college and his SGO carer was struggling to care for him and keep him safe. She felt at risk in her own home and requested David be accommodated. A professionals meeting was held with colleagues in Reading to consider the contextual risks and David’s association with others. No placements were identified for David. He was arrested on suspicion of murder in early November.   3. Emerging Practice Themes – March 2018 to March 2020 David’s and his carers experience of services and support  3.1 David’s childhood history and his experiences of childhood trauma had little bearing on the development of an effective Special Guardianship Support Plan when he was placed with them in 2010. The referral from children’s services who placed David with his carers in 2010 informed the family’s ‘host local authority’ that ‘no welfare issues’ were identified. With no detailed plan of support and guidance his carers were tasked with caring for him with limited support, guidance, and advice.3 Despite this, his carers have demonstrated love and commitment in the face of the challenges they have experienced.  3.2 Most children going through the care system have suffered significant harm and therefore any future care giver must have the resources, skills, and support to enable them to care for children who have experienced significant trauma. Whilst keeping children within family groups is consistent with good practice, this must be with appropriate levels of understanding of children’s experiences and the likely impact of those experiences as they grow up. Best Practice Guidance has been published by the Family Justice Council regarding the provision of Special Guardianship Orders4 and the expectations on local authorities to support effectively SGO carers.  3.3 David’s carers have highlighted that throughout his childhood he presented with behaviour challenges, but this increased as he reached adolescence. The couple separated in early 2018 sighting David’s behaviour as one of the reasons for their separation. However, they have both remained committed to him and he continues to reside with the female carer.  3.4 David’s carers approached the adoption support service themselves in early 2018 and a support plan was developed including direct work with the family. The assessing social worker very quickly identified the risks associated with the criminal exploitation of David and referred appropriately to children’s services.  3.5 Both carers report feeling let down by professional support agencies. They described feeling judged, not listened too and when asking for help they did not receive it. They both felt unable to manage David’s behaviour and risks and struggled with putting boundaries in place. The couple report attending many meetings but felt little was done to provide practical and emotional support. The couple became aware of the risks of criminal exploitation of David, particularly with his presentation, but felt agencies were not able to put a coherent plan in place. Their frustrations with the lack of support, the increased risks, and the perceived judgement on them of failing, led to them asking for David to be accommodated. The carers describe being physically and emotionally exhausted with the situation. 3.6 There did appear to be a lack of compassion for the SGO carers and some professional frustration at their willingness to engage in support and safety plans. There was a professional view that the carers wanted a ‘quick fix’ behaviour change from David and the only solution was him being placed into care. Their own guilt about letting down David was not considered when they ‘disrupted’ care arrangements with promises of David returning home. The dynamics in the family and professional relationship was not reflected upon  3 Special guardianship review: report on findings Government consultation response December 2015  4 Special guardianship BPG report.docx (judiciary.uk) 6  in supervision or professional discussions. Behaviour management and relationship building became the focus of interventions without considering the ability of the carers or David to effectively respond to that intervention. 3.7 David and his carers were involved in discussions about his care arrangements and David was given opportunities to contribute but did not always engage with planning for him. Some of those plans developed were unrealistic, such as suggesting David should not be in contact with gang members and reflected a lack of knowledge of what safety planning could be put in place.  3.8 It was clear that David was very reluctant to return to the care system and his disrupted placements in 2019 are evidence of his ability to sabotage those arrangements and return to the care of his family. It is possible that he may have been re-traumatised by the thought of returning to the care system which let him down so badly in his early childhood.  3.9 The carers are clear that the support now being provided is positive but was only put in place in response to the significant assault that saw David hospitalised.  Learning Point: The impact of individual practice approaches can have a significant impact on case direction, family engagement and safety planning. Children’s social care need to enable opportunities for learning and reflection from other practitioners when managing children who are exploited and focus on ‘harm outside of the home’. Organisational changes to practice have not been embedded across the system since the previous review was concluded.  Learning Point: Parents and carers managing children and young people’s complex needs, behaviour and risks need compassion and understanding. Developing positive, strengths-based relationships with parents and carers support safety planning.   Learning Point: Robust, child centred, and focused support plans must be in place for Special Guardians. They need to be reviewed and adapted to the needs of the child as they grow older.  Trauma informed and relationship-based practice 3.10 There has been an increased recognition and understanding of the impact on young children of adverse childhood experiences5. David experienced chaotic and inconsistent care before the age of two and was deprived of consistent love, safety, and security until the age of six. Trauma informed practice has focused on neuroscience, the impact on the brain of adverse childhood experiences and the biology of stress. It links adverse childhood experiences to future emotional and physical responses to stimuli. It sees behaviours as well-developed coping strategies to stress. This approach moves professionals away from pathologizing children and adults to understanding why behaviours occur, understanding what has happened to them and why they behave in the ways they do (Penna 2020)6. The trauma informed approach has been well developed in some local authority areas and is based on a trauma informed, relationship-based methodology. 3.11 Evidence would suggest by the time David moved to his SGO carers; he was already struggling to ‘connect’ to any care givers. Those working with the family propose that David would have developed mechanisms at a young age to not trust adults for fear of being further let down. There was some reparative parenting provided by his SGO carers, but they were undertaking this task with no support and limited understanding of trauma.  3.12 From the age of six, David had some level of family stability despite these challenges. He reports as having a deep longing to be part of his family and it was highly unlikely that foster or residential care was going to be successful.  5 Trauma-Informed Social Work Practice, Jill Levenson, Social Work, Volume 62, Issue 2, April 2017, Pages 105–113, 6 Guide to trauma and a trauma-informed approach. Author: Sue Penna 15.1.21 Community Care   7  3.13 David was positively described as an engaging and polite young person, but this persona was reported to hide a deep vulnerability and a mistrust of adults and social workers in particular. David’s own experiences of trauma and his emotional and behavioural responses were not the prime focus of plans and interventions. 3.14 The focus on ‘fixing’ the immediate issues, particularly with care placements and behaviour management techniques, took little account of David’s history and the experiences of his carers. Expectations placed upon on him, and his carers could be seen as unrealistic.  3.15 From 2019, the whole system around David, including his care givers, were in a state of heightened anxiety and stress and everyone was responding to immediate and daily risks. The agencies involved with David were in a constant cycle of crisis, with professionals constantly reacting. This level of heightened anxiety impacted on those professionals involved.  The deep anxiety that David was likely to be seriously injured or killed was real for practitioners and his carers. 3.16 The impact of managing the heightened risks on individual practitioners and the wider safeguarding system was not well considered. The professional frustration at the carers for not fully engaging with support, the lack of a coherent and agreed safety plan and the constant managing of the daily risks and issues led to a level of compassion fatigue. The sense of hopelessness in trying to safeguard David was evident and was pervasive. The high levels of risk being managed by the safeguarding system led to high levels of anxiety. These levels of risk and anxiety can be well managed by a safeguarding system that is functioning well and when there is agreement and a shared accountability about how risks can be mitigated against. When the system becomes overwhelmed, with no shared accountability, the system becomes fractured and leads to professional disagreement and a lack of shared accountability for the risk. This effectively led to the social worker and their team manager feeling overwhelmed with the constant, almost daily risks, and issues. At no point did the safeguarding system collectively stop, reflect, challenge, and support each other in understanding how the heightened risks had impacted decision making, accountability and responsibility.   3.17 Secondary or vicarious trauma7 has been the subject of research and practice guidance. This consideration is less well developed in safeguarding practice. Whilst individuals described feeling well supported by their managers and senior leaders, this did not lead to a shared sense of responsibility and accountability for David across the safeguarding system.  3.18 The level of openness and honesty from practitioners in the Practitioners Learning Event should be encouraged and supported across the safeguarding partnership. Understanding the impact on practitioners and consequently the safeguarding system on managing high risk situations could have real benefit in collectively managing highly complex children’s situations.  3.19 During the period of this review, the local authority was in a state of flux with a number of interim senior managers in children’s services and partnership working had been impacted as a result. This scenario added to the effectiveness of joint working and accountability. This situation has shifted with a permanent management team in the local authority and a recognition that better joint accountability and working together is needed.  3.20 In the period between March 2018 and March 2020, David had several social workers and practitioners working with him. Some of those had developed strong and effective relationships with him and he had developed real connections with some. Systems, procedures, processes, enforced team changes and David’s care status all led to many changes in his professional network. This prevented real opportunity for those who David engaged with and trusted, to really work alongside him consistently.  3.21 David has been unable to share detail and speak about his experiences of child criminal exploitation. This could be for the fear and anxiety about the likely consequences of disclosing such information. A finding from the National Child Safeguarding Practice Review Panel in their report in 20208 highlighted that  7 Secondary trauma and compassion fatigue: a guide to support managers and practitioners, Lori Goossen, 19 July 2011 8 ‘It was hard to escape’, Safeguarding children at risk from criminal exploitation. National Child Safeguarding Practice Review Panel 2020.  8  children and young people require a ‘strengths based, relationship driven approach’ and that building a trusting relationship is key to successful engagement with this group of children. In David’s case, practitioners expressed their frustration with the ever-changing key workers. Particularly frustrating were those practitioners who developed a very positive relationship with David, only to be removed from his professional network because of his ‘status’ in practice systems.  Learning Point: Repeated changes of worker will have a negative impact on engagement. The local authority is encouraged to test out new approaches to case management that ensures the child and family remains with the same worker.  Learning Point: Safeguarding professionals need to work in a culture where an understanding of secondary or vicarious trauma is the norm and agencies actively promote good self-care matched with multi-professional supervision and support, particularly in case work that is high risk and complex.   Learning Point: Children and young people at risk of child criminal exploitation need consistent professional involvement and relationships. Changing professionals who work with children, young people and families should be based on the needs of the child and family rather than the organisational parameters.  The understanding of child criminal exploitation, thresholds, and the shared accountability for managing risk. 3.22 There remains no statutory definition of child criminal exploitation, but the government defines child criminal exploitation where ‘an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child or young person under the age of 18. The victim may have been criminally exploited even if the activity appears consensual’. This is a wider definition than ‘county lines’ which are drug dealing networks and gangs exploiting children and young people to move, hold and sell drugs. Safeguarding children and young people in these circumstances is seen as the priority, seeing the child first and the criminal activity second.  3.23 Between June 2018 and March 2020, David had been the victim of 5 previous assaults prior to the significant assault in 2020. He had 78 police reports, 23 reported missing episodes, 5 child protection reports, and a ‘Risk Management Occurrence’ related to child criminal exploitation. There were 20 police ‘intelligence reports’ referring to weapons, drugs, and gang association. None of these intelligence reports were shared beyond the police and there is an acknowledgment that these should have been referred through to the MASH. 3.24 When David was first referred to the adoption support service there was an appropriate referral made to children’s services by the adoption social worker highlighting the concerns related to criminal exploitation. The initial child and family assessment completed had a distinct lack of information about David’s history and his early childhood and how those early experiences impacted upon him. David’s self-report that he was not involved in county lines drug running and not being criminally exploited appears to have been accepted. There was an appropriate completion of a Child Exploitation (CE) Indicator and Analysis Tool which highlighted his high risk. The subsequent referral to early help support after the conclusion of this assessment appeared incongruent with the identified risk. Whilst people working with David have been unable to delve deeper into his role in criminal exploitation his childhood experiences make him highly vulnerable to exploitation.   3.25 David reported his involvement with gangs and expressed his fear and anxiety more than once to practitioners working with him. David has been clear that to engage in conversations about his gang activity would place him at significant risk and therefore he chooses not to discuss those issues with safeguarding professionals. That identified fear is clearly indicative of his coercion into criminal activity and its consequences for him.  3.26 Based on the available evidence, David had become involved in county lines drug running and was being groomed into moving, storing, and dealing drugs on the behalf of others. County lines and the exploitation 9  of children and young people to distribute drugs is described as an extremely lucrative business model, operated, and enforced by gangs through fear9. Professionals are unclear at which point David became involved in child criminal exploitation, but evidence of drug dealing, and the provision of designer clothing was evident early in his teenage years. Children’s services believed that most of David’s criminal associations were within 2 local authority areas and there was an assumption made that David was not involved in county lines drug running. There did not appear to be a well-developed policy or strategy for managing the risks associated with child criminal exploitation in the borough and a lack of professional understanding about how to mitigate or manage the risks. David himself told practitioners working with him that ‘professionals’ knowledge of exploitation was outdated’. 3.27 The assessments written about David consistently refer to David placing himself at risk of harm and whilst highlight the risks presented, this language is indicative of a child who has made effective choices to be involved in risk taking activities rather than being coerced into doing so. This subtly changes the perception of David and his active involvement in criminal activity. David’s consistent view that he was not being exploited may have reinforced this view, but this use of language needs to be carefully considered as it reinforces the view that David makes informed choices. Research undertaken on victims of child criminal exploitation highlight that the majority of children and young people fail to realise they are being manipulated and exploited. Their view being that their criminal activity is one of ‘choice’ and that by complying, gangs will respect them and give them a sense of belonging. This is challenged in that the use of violence and intimidation exerts control and a level of ownership over the young person from which it is difficult to escape.10 3.28 The role David’s carers played was key to his safety however the initial focus on family relationships, parenting behaviour and behaviour management techniques alienated them. Despite the risk assessment tools being completed and highlighting high risks of exploitation, the interventions focused on the presenting family dynamics. This led to resentment and frustration from his carers. The changes in social worker did not assist this situation with no practitioner developing an honest and empathic relationship with the carers.  3.29 Subsequent Section 47 enquiries and accompanying assessments maintained the view that David’s situation should be managed via early help and child in need arrangements, The Section 47 enquiry held in April 2019 concluded with a request for an initial child protection case conference but in discussion with senior managers it was agreed to keep the case at child in need level. The threshold document in the local authority was updated in August 2020 so it is not clear whether David was assessed under a different threshold criterion.  3.30 David’s exploitation and risk exhausted the resources of agencies locally and in particular the police. There was clearly a disagreement between the police and other agencies as to whether David was a perpetrator of criminal activity using up valuable resources or a victim of criminal exploitation. This professional disagreement led to pressure being applied to remove David from the borough to alleviate the risk. There were ongoing discussions about whether the threshold was met for a Secure Order when David was a looked after child and this plan was supported by his carers. The threshold for a Secure Order was not considered met and therefore never actively pursued.   3.31 Decisions to place him out of borough were made quickly and were based on placement availability rather than whether those placements would meet his needs. His social worker was proactive in ensuring those placements were appropriate, yet David was very reluctant to engage with a plan to remove him to another part of the country. He was distressed by being away from his family. This again reflected agency anxiety about holding risk effectively.   9 Hesketh, RF and Robinson, G (2019) Grafting: “the boyz” just doing business? Deviant entrepreneurship in street gangs. Safer Communities. ISSN 1757-804 10 Grace Robinson, Graduate Teaching Assistant, Edge Hill University, 2017  10  3.32 There was a genuine wish to alleviate the risks by placing David away from his criminal exploiters and any potential assault, but this was always a short-term solution. The sense of safety being geographical distance took little into account of David’s criminal exploitation and his risk to be being exploited or to engage in this activity across the country. These decisions took no account that David was highly likely to be involved in county lines drug running locally and that this might have presented an opportunity to his exploiters to further develop their network. David’s behaviour in the last residential placement evidenced his ability to exploit other young people in the home.   Learning Point: Gang culture and identity need to be better understood by the professional network. The sense of belonging, identity, and criminal ways of earning money are intertwined and need different approaches to addressing the risks.  Learning Point: The reliance on out of borough care needs to be seriously considered against other alternative care planning considerations. Care options, including the child remaining with family members, needs to be robustly risk assessed and regularly reviewed. Whilst risks can be mitigated against, all agencies need to be able to ‘hold’ the risk for children and young people.  Learning Point: Child criminal exploitation is consistently changing and adapting its ‘business model’ and safeguarding agencies need to regularly review their approach to safeguarding children and young people in this context. Professional agencies need to take time and resource to hear and listen to the experiences of children and young people who have been criminally exploited. This learning should be applied to practice development. Training alone will not address professionals understanding of the issues and how to respond.  Information sharing and the impact of meetings. 3.33 Processes to strategically safeguard children subject to criminal and sexual exploitation were in place in the local authority through a monthly multi-agency meeting that reviewed the risk assessments and safety plans for children and young people. The meeting had a good level of representation and had strategic oversight of children who were being exploited in the borough and did share information about David and his situation. This forum was partly successful in that it identified and mapped individuals and groups and developed actions for agencies to support the management of the risk. There was, however, a lack of intelligence sharing from the police and the actions being taken for disruption of the criminal activity. This resulted in safety planning and interventions that were flawed.  3.34 This forum was not a case management forum and the professional network appeared confused and unclear as to its purpose. A referral to this forum was seen as part of safety planning for children rather than a strategic group to address places, networks, and disruption activity and therefore from a practitioner’s viewpoint, it had limited impact. It was felt that the forum did not jointly hold accountability for the risks, and much was placed on the responsibility of the social worker and children’s services.  This forum had healthy differences of opinion but then lacked a shared ownership and accountability for the risks and coherent safety planning. Differences of professional opinion were encouraged but this added a layer of complexity that then hindered effective multi-agency planning. The proposal to move David out of the borough was one area of disagreement between forum members, with the police particularly advocating this approach.  3.35 There was also evidence that forum members did not follow up and follow through with identified actions and the forum itself did not hold those services to account. There were no escalation routes if agencies did not comply with actions.  Therefore, assessments and interventions drifted, and decisions lacked multi-agency ownership. It was not clear who the forum was accountable too and what governance arrangements were in place to oversee its work. The safeguarding partnership, the community safety partnership, the office of the police and crime commissioner, public health and the youth justice board all have vested interest in this forum, but it was unclear what governance and audit arrangements were in place to review its effectiveness.  11  3.36 This forum has subsequently been the subject of review and there have been changes to reflect some of the feedback about its effectiveness. It appears to still rely on the chair to follow up the actions of partner agencies. 3.37 Outside of this forum, David was the subject of a large number of other professional meetings, some of which he and his carers were invited to be part. The carers reported feeling frustrated and angry with these meetings as from their perspective they achieved little. This led to withdrawal of the carer’s involvement in these meetings. There was also professional disagreement about the care planning and some practitioners reported never seeing any minutes of meetings held. Some agencies working with the family were not being informed of changes to his care plan or changes in practitioners working with him which led to professional frustration. There was no opportunity in these meetings to just highlight the shared professional anxiety and professional responsibility being felt by practitioners. When something unexpected or worrying occurred, the default position was to hold a meeting, but the purpose and outcomes were unclear. There remained a disconnect between school, the adoption support service, the youth offending service, and children’s services when the risks escalated for David. The focus on risk management, daily reports and placement searches led to communication between those agencies suffering as a result. 3.38 David was referred to the National Referral Mechanism (NRM) in late December 2019, but it is not clear as to the purpose of this and whether there were expectations of the NRM to support safety.  3.39 The local authority has implemented a ‘signs of safety’ approach11 as their practice model. This includes using the framework in professional meetings led by children’s services. The view of practitioners is that whilst it has assisted safety planning for some children, the implementation and use of the approach has been mixed.  This approach has been well evaluated and the most recent report from the What Works Centre for Children’s Social Care12 offered some critique of the approach which is helpful in considering its effectiveness in working within contextual safeguarding, ‘..signs of safety, is primarily a psychosocial intervention and to ensure that it is practiced in a manner that does not reinforce existing inequality, the wider social, political, and economic contexts within which the families exist should be explicitly recognised and addressed in practice (Featherstone et al. 2018)’. There is ongoing evaluation being carried out between the Contextual Safeguarding Practice Network and Signs of Safety leads to see how these two approaches can work together13 and it may be helpful for the Safeguarding Partnership to be involved in that research.  Learning Point: Intelligence gathering across the safeguarding partners and other agencies requires clarification and consistent application. If this approach is intended to safeguard the child or young person and members of the public, the agencies need to have a more formal framework in place.  Learning Point: Contextual safeguarding meetings should have the same ‘status’ in the safeguarding partnership as child protection case conferences.  Learning Point: Strategic forums considering risks to children of exploitation need to reach out to authorities who have a more advanced understanding of child criminal exploitation to share learning. Whilst quarterly pan authority forums exist that discuss data and trends, the strategic forums that consider exploitation for children and young people living in the borough, placed in the borough or who have strong links between the local boroughs should be the subject of shared updates between those strategic forums.    Learning Point: Effective meetings at all levels require a clarity of purpose and effective action planning. A ‘strengths based’ approach to facilitating meetings will go some way to address anxieties regarding risk and  11 The Signs of Safety practice approach created by Andrew Turnell and Steve Edwards (Turnell and Ewards,1999) sought to address the default paternalism or colonisation of child protection systems where professionals believe they know what is wrong and what must be done to solve the problems. 12 SoS systematic review GD Edit.docx (ctfassets.net) 13 Signs of Safety and Contextual Safeguarding Key Messages for Practice February 2021 12  safety planning. Children and young people’s situations can be very unpredictable yet there needs to be a realistic discussion about risk and risk management.  Learning Point: Effective meetings at all levels require a clarity of purpose and effective action planning. A ‘strengths based’ approach to facilitating meetings will go some way to address anxieties regarding risk and safety planning. Children and young people’s situations can be very unpredictable yet there needs to be a realistic discussion about risk and risk management.  Learning Point: Communication and information sharing leads to more enhanced safety planning. Intelligence across the safeguarding system needs to be appropriately and proportionately shared to enhance understanding and lead to more effective safety planning and risk management.  Cross authority working 3.40 David has lived with his main carers and his maternal grandmother in 2 local authorities that border each other. David’s missing episodes, offending, drug running and involvement in gangs, crossed between both local authorities. He also lived in other local authorities in the country. There was no available evidence of joint or cross borough working to mitigate the risks for David and others involved in criminal exploitation. There were handovers to local services in local authorities, but this repeated a pattern of new practitioners becoming involved without a good understanding of David and his needs. The ‘ownership’ of young people placed outside of their home local authority needs to be reinforced.  3.41 The multi-agency arrangements in place to strategically safeguard young people at risk of exploitation did not liaise or work across other multi-agency partnerships. This led to no joint intelligence gathering and safety mapping. One of the local authorities appears to have developed more effective safeguarding arrangements for young people at risk of criminal exploitation yet there appeared no mechanisms for joint work or learning across the local authorities.  Culturally aware practice 3.42 David describes himself as black and the assessments refer to him as white and black African. His SGO carers and his birth mother are white, his father is black African. Culturally aware practice could have led to a consideration of David’s safeguarding risks and needs, in the context of his race and culture, yet this was not considered in any of the assessments undertaken and does not appear to feature in multi-agency safety planning, David lived in a predominantly white demographic. The fact that he is a young black person in this context should have been better understood. The practitioners working with David feel more needs to be done to inform culturally aware practice at all levels and challenge perceptions and unconscious bias. 3.43 The Child safeguarding Practice Review Panel produced a report in 2020 entitled ‘It was hard to escape, safeguarding children at risk from criminal exploitation’. This report highlighted that ethnicity and gender were factors in criminal exploitation and that boys from black and minority ethnic backgrounds were more vulnerable to harm from criminal exploitation. ‘Culturally competent practice places children’s well-being and their protection within their cultural context, Absence of cultural competence can lead to inaccurate assessments and decision making’14. 3.44 David has explored his own identity with practitioners. Significantly, he has raised that family breakdown brings him closer together with other young people involved in gang activity than their race, culture, or ethnicity.  Learning Point: Practitioners need to develop their understanding of culturally sensitive practice. They need to engage with opportunities for learning and understanding. Practitioners need to consider a young person’s identity and how those young people might experience oppression, discrimination, and risk. This should form part of assessments and interventions.   14 The Child Safeguarding Practice Review Panel Report 2020 13   4. Emerging Practice Analysis – March 2020 to November 2021 4.1 David’s carers refused to sign an agreement for David to become ‘looked after’ under Section 20 of the Children Act 1989 and therefore David was moved to his sister’s address under a ‘family arrangement’. This effectively meant that the local authority was not legally bound to support care planning for David after his discharge from hospital following his significant injury. This arrangement, despite the carers refusal to sign paperwork, did place the local authority in a difficult position. There was no legal basis to this arrangement and no viability assessment was undertaken as part of a Regulation 2415 placement arrangement. Without this framework, this arrangement was highly likely to fail and with a matter of weeks the arrangement had broken down.  Learning Point: Moves for young people to family members needs to be formalised. Local community and statutory services need to be engaged before the placement is made to ensure effective safety and care planning is in place.  Learning Point: When children move to other local authority areas as part of a care plan, children’s services in the ‘home’ local authority should continue to effectively manage the care plan in consultation with the care placement and ‘host’ authority to ensure effective care planning and risk management.    4.2 Senior leaders in children’s social care were involved in the subsequent decision making regarding the applications to court, however, there were reported disagreements as to how to proceed and front-line staff described feeling ‘left to it’.  4.3 The decision to make an application to court for the secure order and interim care order was based on the increasing risks to David from harm outside of the home, including his missing episodes and the hospital attendances with injuries. However, this approach had negative connotations for David’s carers, who felt judged and criticised in the process. The court application, whilst justified given the increasing risks, pushed David’s carers into a repeated position of defensiveness and mistrust of the local authority. It presented unhelpful barriers to the working relationship. They felt the process was a judgement on their care of David and it left them feeling that ‘they were not fit to care for David’. Given their experiences of services and support up to this point, this further reinforced this perception for them.  4.4 David’s period in secure accommodation was considered a success. He was described as engaging and stable and work was undertaken with him on gang culture and drug running. His carers felt that David had ‘turned a corner’. David consistently denied ever being exploited or coerced in any way. He repeated that services should do ‘less talking’ and do ‘more looking’. This statement suggested that services be more observant of what was happening in and around David’s world and spend less time in meetings discussing the risks. This insight was very helpful in considering how best to safeguard yet did not feature in safety planning. David described services as ‘reading off a script from Top Boy16’ rather than understanding the reality of his situation. Despite this period of stability, there remained some evidence of his engagement with drug and gang culture and on one occasion in secure accommodation, he was found with £200 in cash. Some professionals felt that David was ‘biding his time’ and he would swiftly return to criminal activity once he returned to the community. This was balanced against the sense from his carers that he had made significant progress in secure accommodation despite their initial concerns. David and his carers significantly influenced the decision to end the secure order in September despite the local authority view that this should be further extended. This led the local authority to carefully plan the next steps.  4.5 The relationship between David and his carers has been consistent and they have maintained their support of David throughout. They have been exposed to and experienced considerable distress, challenge and criminal activity way beyond their previous lived experience and have lived in a constant turmoil of guilt and shame. David is desperate not to feel abandoned by his family and they have maintained their position  15 https://www.legislation.gov.uk/uksi/2010/959/regulation/24/made 16 Top Boy is a British television crime drama series focusing on gang culture which first aired in 2011  14  of love and care for him, possibly to the detriment of themselves. Relationships with professionals are important and it is disheartening that the local authority chose to move David’s case between the children’s looked after service and the child protection team again, therefore severing professional relationships and the sense of ‘start again syndrome’. This has been a shared frustration from the carers and some practitioners. Equally, there has remained some irritation from practitioners about how they have felt ‘manipulated’ by David and his family.  There were professionals who maintained their involvement throughout this timeframe, and it was positive that the looked after reviews and child protection case conferences were chaired by the same Independent Reviewing Officer. There was also some consistent mentoring support for David from 2 practitioners during this period which at times, he engaged with.  4.6 The triple planning for David during the care proceedings was appropriate yet it was clear that he wished to return home to his carers.  Some of the planning at that time, did seem a little disjointed. The police did not agree with the transition home, and they did not feel fully consulted before this decision was made. David’s mentor also did not feel David should return to his community and may be had more insights into the risks presented than was given credit. Clearly, the local authority and the court recognised the risks of David returning home and the alternatives available to keep him safe were limited. This presented decision makers with limited options and the decision was deemed child focused yet other options were considered ‘riskier’.  The transition arrangements and his time in residential care following the conclusion of the secure order were well considered and supportive. As soon as David had access to a mobile telephone as part of a reward system, his cooperation with the plan began to wane. There was in place a robust plan of support to manage David’s transition home including college and support arrangements yet there was a view that the plans set out for David post secure accommodation were ‘service led rather than family led’.  4.7 This tight plan sadly fell apart following the Covid-19 restrictions, through no fault of any agency and David began disengaging with support. As soon as David returned to the care of his carers in November, he almost immediately began engaging with his ‘county line’ and became quickly involved in old behaviours. The decision to transfer him yet again to another team because his care status changed, indicated children’s social care’s lack of flexibility, and was not based in the development of relationship-based practice. There was a slight sense of relief experienced by practitioners at the point of transfer and whilst this was not the reason behind the decisions, it is understandable given the risks and needs associated with David and his family.  4.8 Whilst the transition plan was robust, the sheer number of professionals involved and the expectations on the family to engage with support services led to a disengagement from family members. The introduction of new services and professionals had the perverse effect of pushing the family away rather than engaging them in intervention. There were ongoing meetings held about David to assess the risk including the EMRAC meeting which considered attempts at disruption activity.  The voracity of that activity is difficult to judge as there is limited available evidence that any proactive work was undertaken to disrupt the county line and through the chain of command. EMRAC is still viewed by practitioners and managers as a formality rather than supporting operational practice and this perception needs to change. It is not clear how the MAPPA and EMRAC processes dovetail and this may an opportunity for further consideration.  4.9 The relationship between the family and the police remained strained throughout and whilst there were positive attempts at engaging the carers, trust and confidence had waned. They presented as occasionally hostile to police involvement yet equally feeling guilt and shame particularly when police would raid the house in search of evidence. The carers had invited this arrangement to help with the safety and support plan, but again this had the reverse effect on professional confidence. 4.10 The safeguarding department in Thames Valley Police are responsible for managing child criminal exploitation risks. The teams are geographically based and work primarily to that locality. These local policing arrangements all work differently depending on the needs of the locality, but this can lead to a difference in practice and approach, including the naming of different meetings with the same functions. Whilst this may be appropriate, it can lead to some confusion from partner agencies about the roles and responsibilities of local policing arrangements.  15  Learning Point: Thames Valley Police need to consider their current arrangements for the safeguarding department and consider how effective having different arrangements in localities works for consistency.  4.11 There has been an attempt to remain balanced and victim focused, yet there remains evidence that the police considered David a criminal first and a victim second. The approach taken was ‘catch and convict’. The intention being that they could disrupt his involvement in the county line and therefore make him safer.  When David was ‘stop checked’ by police however, there was always no evidence of criminal activity. This targeting of David does not seem to have been seen by officers in the context of his ethnicity and how this approach by police may have been perceived by David, thus potentially alienating him further from police who were wanting to provide safety.  4.12 The approach to intelligence gathering was fractured and lacking and despite regular operational meetings, this issue was not resolved. Expectations were placed onto the police for intelligence gathering and disruption activity yet there was not an arrangement in place to share intelligence amongst professionals who had contact with David and his family. Whether this was the role of EMRAC is not clear but subtle and innocuous intelligence was being gathered daily and this was not routinely shared in the agency network and particularly with the police. There is an agency perception that the police were involved in operations to disrupt the county line, but they were not involved or informed of these operations. There were some perceived frustrations with the police about their lack of proactivity. The police would argue that at times in meetings with other professionals, they were the last to know about incidents or information which could add value to the intelligence gathering around David which made their role much harder. 4.13 There were no harsher consequences or restrictions placed upon David to contain his behaviour and this was felt to be a missed opportunity. The police accept there should be more focus and drive in tackling the ‘exploiter’, but this cannot be undertaken in isolation. This does require an honest, open, and trusting relationship with professionals and families to achieve this. David’s carers feel that the police could have done more to safeguard David and that the police knew he was associating with some very dangerous criminals.  4.14 As the risks escalated, David once again became the subject of a child protection plan, yet it has become clear that David was involved in criminal activity far ‘deeper’ than the professional network understood. The team manager and the social worker alongside partner agencies developed a very robust and clear safety plan which included opportunities to meet cross borough to address the safety issues for several young people involved in criminal exploitation. This was a very positive development, and these meetings were maintained up until David’s arrest. The approach of the team manager and social worker had a positive influence on the engagement of the carers and refocused the risks and safety planning for David outside of the family home. The social worker worked alongside the carers and there were regular contact arrangements put in place in the agency network to highlights issues, risks, and challenges. The carers were fully engaged in this plan, which included the searching of David’s room by police when required. This sensitive and relationship-based approach to the carers ended when David’s case was again transferred to the looked after children service following his youth custody. 4.15 Significantly, there were two days in September 2021, where David had broken down and disclosed the level of vulnerability he was experiencing. David expressed fear and anxiety to his SGO carer as he was worried that he would be physically assaulted at college because he owed money to someone. He returned home and his carer called the police as David was emotionally distressed, shouting, screaming and head butting his wardrobe. The police conducted a voluntary search of his bedroom and found a kitchen knife, expensive clothing, and equipment for cannabis use. David did not wish to return home and police interviewed him in the back of a police van. David requested that they switch off their body worn cameras and then he disclosed that he was in serious trouble, that he ‘wanted to kill himself’ and that he was ‘done’. He was crying into his hands. Police took him to the male carers address and reported that, in all their time working with David, they had never seen him behave in this way. Once this information was passed to his social worker the following day, David had retracted all the statements, denying any knowledge.  The police 16  safeguarding team for Wokingham made an NRM17 referral as the local response officers delayed this process. The NRM referral has confirmed that David is being exploited. It is not clear as to why the response officers that day did not consider David’s vulnerability and use their police protection powers to safeguard him. David returning to the care of the male carer may have been seen as offering safety, yet the description of David and his disclosures was a clear missed opportunity to proactively intervene in his life and potentially safeguard him. The safety planning did not involve any precipitating plan should David disclose and present as vulnerable and this may have influenced decision making that evening.   Learning Point: Safety planning for children and young people being exploited should include statements of ‘agency intent’ if a child or young person discloses their vulnerability to exploitation.  4.16 There have been a number of initiatives and working party’s on contextual safeguarding and there has been increased learning for individuals in safeguarding agencies, yet operational practice has not significantly changed since the last review concluded. Practice and procedure have not been embedded into practice and the agencies remain challenged by working with this cohort of children and young people. Leaders have not grasped the opportunity to be more creative and flexible in their approach and some practitioners have remained isolated, not listened to and unsupported.  4.17 Building upon the initial development of ‘contextual safeguarding meetings’ which were initiated in David’s case by the Independent reviewing Officer, the safeguarding partnership might wish to consider piloting a bespoke ‘child protection pathway’ as recommended in the Independent Review of Children’s Social Care18.   4.18 Whilst not part of this review process, there have been significant challenges for the family and professionals to work alongside the prison estate since David’s arrest. This may well be an issue that needs addressing post David’s trial.  5. Summary of additional learning 5.1 Safeguarding professionals need to be cognisant of victim blaming language. 5.2 Escalation processes need to be embedded in the safeguarding system at all levels to ensure effective challenge of decision making.  5.3 Schools and local communities have a key role to play in the support of children and young people involved in child criminal exploitation and they should form part of both operational and strategic safety planning.  5.4 Critical debriefing sessions should be available to the professional network where opportunities for open and honest reflection can assist in supporting practitioners and their managers in risk management.  5.5 Safeguarding partners should produce and then share accountability and decision making ‘trees’, so agencies can be clear about where escalation issues can be raised.  5.6 The Covid-19 pandemic impacted and influenced the transition plan significantly yet there was no contingency plan in place should this fail. 5.7 David and his carers developed some strong and positive relationships with some social workers. With the focus on ‘harm outside of the home’, the carers felt less judged and alienated from engaging in safety planning.  5.8 In a bid to ensure the plan was robust post the Secure Order, many professionals became involved. This was overwhelming for the family and did not add value to the interventions.  5.9 Harsher consequences, restrictions, and deprivation of liberty alongside effective and focused rehabilitation in order to break the cycle of criminal exploitation should be considered as part of any safety plan.   17 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support.  18 The Independent Review of Children’s Social Care (May 2022) 17  5.10 The local authority had commissioned appropriate ethnically diverse mentoring arrangements. 5.11 Some interventions had not been the subject of monitoring through care planning meetings.  5.12 Culturally sensitive practice, cultural sensitives and strengths needs to be reinforced by senior leaders and pervade policy and procedures.  5.13 An analysis of the role of EMRAC alongside MAPPA might assist in safety planning.   6. Evidence of good practice 6.1 Some practitioners have developed strong and meaningful relationships with David, and he engaged with them well. They have been persistent in working with him.  6.2 There has been consistent support and therapy funded through the adoption service.  6.3 David’s school have been a consistent part of his adolescence and have provided ongoing support. 6.4 Practitioners who have worked with David have been committed to keeping him safe and want to achieve the best for him.  6.5 David was given opportunities to be involved in his care planning.  6.6 Practitioners have been open, honest, and reflective in the review process.  6.7 Some practitioners have a good understanding and more up to date knowledge of child criminal exploitation and could be used to mentor others.   7. Conclusions 7.1 Professionals have invested heavily in supporting David. He is well liked and there is much affection for him. This is coupled with a deep anxiety of him being seriously injured or killed. Professionals have felt distress and frustration with not being able to make his situation safer.  7.2 The incident that led to this review had been predicted by David, his carers and the professionals working with him. The seriousness of the incident and the injury to David was a shock to the safeguarding system locally and it has reverberated around the safeguarding system since that time. However, whether this was preventable is subject to conjecture. There is learning from his situation which can influence assessment, planning and intervention with David and other young people involved in child criminal exploitation in the future. 7.3 David’s situation has prompted significant reflection, changes to process and procedure and to a better understanding of child criminal exploitation. It has also led to more coordinated, considered, flexible and proactive care and safety planning for David. His SGO carers report that the support they are receiving now should have been in place before his injury and feel this was only in response to the incident itself.  7.4 The review has highlighted a number of factors that influenced practitioners and practice at the time. Whilst not in the remit of this review, the decision to place David with his family members under an SGO without a robust plan of support and therapy was flawed. It took no account of David’s early childhood experiences, his complex coping strategies and how therefore he should be therapeutically parented. This left his SGO carers vulnerable, leading to them feeling emotionally, mentally, and physically exhausted. This scenario reinforces the need for expert assessment and judgement as to the suitability of family members resuming the care of highly traumatised children without the necessary understanding, guidance, and ongoing support.  7.5 The safeguarding partners have recognised that there understanding of child criminal exploitation at a multi-agency level was lacking. Whilst individuals in the network had well developed understanding of this form of exploitation this did not result in effective multi-agency joined up assessment, planning and interventions. The assessments undertaken focused heavily on the child and carers relationship without fully recognising or understanding the risk and influences outside of the family home. Assessments did not result in effective multi-agency safety planning where child criminal exploitation was a significant risk factor and thresholds for intervention were confusing. There seemed little confidence in the child protection 18  process in mitigating the risks for David and limited flexibility in developing standalone and nuanced arrangements such as contextual safeguarding meetings which had the same status as the child protection case conference. This has been an area of development in the local authority but there remain some frustrations as to its efficacy if not given equitable status to child protection planning.  7.6 David’s safety and welfare was the cause of much joint discussion and consideration. Some information was shared, yet what happened as a result of that information being shared to support safety planning and intervention was less clear. At times, agencies were working in isolation of each other with poor or non-existent communication. David’s school had a key role to play in the management of risk but were excluded from some discussions and were not party to other significant information about David and his circumstances.  7.7 Agencies and children’s services in particular, were caught in a daily spiral of reactive practice and risk management. This sense of helplessness and what to do next to alleviate risk, impacted on individual practitioners and the safeguarding system. The shared ownership of the risk became fractured and professional disagreements emerged about how best to keep David safe. The social worker and their manager were left holding an unacceptable level of risk. Professional support and supervision were available to practitioners and senior leadership teams in safeguarding agencies were aware of David, yet this did little to alleviate the impact on practitioners working with him. There appeared to be a shared sense of helplessness. Secondary or vicarious trauma and its impact on individuals and the system was not considered at the time and there was no opportunity for the multi-agency network to stop, reflect and plan together proactively. The honest reflections of practitioners about compassion fatigue when working with highly complex risk is crucial to ongoing learning. This also helps practitioners understand the lived experiences of carers in those circumstances and how they might behave and react to situations out of their control.  7.8 The multi-agency strategic forum discussing children and young people at risk of exploitation did not appear to add value to the risk management strategies and became as ‘stuck’ as the other professionals in the network. Practitioners understanding of the forum was confused and the repeated statement that this was a ‘strategic group’ missed the reality of managing David’s risk every day. This group appeared somewhat devoid of ideas to manage the risks, despite the availability of best practice guidance and toolkits to support safety planning. The professional disagreements that emerged from this meeting and the lack of shared ownership of the risks may have been a reason for this lack of coordination. Similarly, ever changing senior leadership would have influenced decision making and effectiveness.  7.9 The authority has made changes to this forum, but this appears to be work in progress rather than fully functioning and performing well. There have been additional strategic forums set up in the borough in recent months, these include an exploitation subgroup, focusing on key data, trends and themes linked to exploitation and how this influences the development of local services and a Pan Authority Partnership Group undertaking similar activities. Operationally, there has been a number of initiatives developed to address the needs of children and young people who could be or are being exploited. 7.10 Decisions regarding David’s safety and welfare were made in the context of available information at the time. The short-term strategy of moving David from the borough was designed to alleviate the risks, but this did not take into account the clear evidence that David was involved in drug running and likely county lines activity. The search for suitable placements for David became the focus of interventions. 7.11 David’s significant injury became a trigger point for action yet there were other occasions where David showed vulnerability, anxiety, and worry. These trigger points of vulnerability were an opportunity to get alongside David, particularly those with whom he had developed positive relationships. Yet the lack of flexibility shown in the allocation of work, processes and procedures led to unhelpful changes in practitioners working with David.      19  8. Recommendations 8.1 Statement: Shared accountability and responsibility for safeguarding children and young people should be reinforced through the safeguarding partners, the Community Safety Partnership and other strategic multi-agency forums.  8.2 The safeguarding partners alongside other relevant agencies should test and evaluate the use of contextual safeguarding meetings.  Task and Finish Groups should devise methods that enable the co-production of safety planning with children, young people, parents, and carers alongside the school and local community.  8.3 The safeguarding partners (children’s social care, integrated care board, and police) working alongside the Serious Violence and Exploitation Group should consider piloting a ‘child safeguarding pathway’ for children exploited and use the evidence to inform future practice and staffing changes. 8.4 The safeguarding partners should consider working across and learn from other safeguarding partners and agencies who have developed effective contextual safeguarding practice, particularly in implementing Signs of Safety as a practice model. 8.5 The safeguarding partners alongside other relevant agencies and working collaboratively with other strategic forums should develop a safety planning toolkit which supports practitioners in their work with children and young people criminally exploited. This should include safe and effective plans for children and young people exiting exploitation. 8.6 Children’s social care are encouraged to test out having a single social work practitioner for children experiencing exploitation.  8.7 The safeguarding partners with the Community Safety Partnership should review the multi-agency forums set up to address exploitation across the safeguarding system and build in quality assurance arrangements to evaluate their role and function including evaluating the impact on children and young people and the effective use of assessment tools to evaluate risk.  8.8 The safeguarding partners alongside other relevant agencies should consider how to implement a trauma informed approach to practice across the safeguarding system, including how to support staff with vicarious and secondary trauma and develop arrangements for critical debriefing post incident. 8.9 The safeguarding partners should reassure themselves that practitioners are using culturally sensitive and racially aware safeguarding practice through a process of multi-agency audit. This should include the voices of children and young people.  8.10 The safeguarding partners should undertake a review of all children in the Borough who are subject to exploitation to assure themselves that safety planning is effective, and enforcement and disruption activity is ongoing.   8.11 The safeguarding partners should review the existing agency escalation policy and include references to multi-professional meetings.  8.12 Thames Valley Police should review and identify the differences in practice in the safeguarding department and develop a plan for consistency. 8.13 Thames Valley Police should develop a clearer framework for intelligence sharing amongst practitioners working with children and young people who are exploited, including expectations of safeguarding partners. This should include details about intelligence sharing from the police to other agencies.  