Death of a 15-year-old boy in the summer of 2018. Frankie was fatally stabbed when attacked by a group of adolescent males in London. One young person was convicted of murder and four were convicted of conspiracy to cause grievous bodily harm. Frankie lived with his mother and two siblings; his father was in prison from 2016. Family was supported by a Child in Need Plan, following a social work assessment that identified concerns around involvement in crime. Frankie had a Referral Order for theft and knife possession and was permanently excluded from school in 2018. Frankie's social worker had concerns about his associations with gang culture. No evidence to indicate that Frankie's murder was gang related. Ethnicity or nationality are not stated. Learning and recommendations are integrated and include: ensure timely notifications to relevant persons when a child dies outside of the area in which they reside; improve notification processes for agencies when a child becomes the subject of a Child in Need Plan; review permanent exclusion processes within schools to reduce the potential for safeguarding risks to children at risk of exclusion; understand how to incorporate the concept of contextual safeguarding in the assessment of risk to children in the future; evaluate how partner agencies support families affected by gang association; assess how partner agencies share intelligence related to gang affiliations. Recommendation made to the National Child Safeguarding Practice Review Panel to consider a national thematic review because of the prevalence of similar incidents across the country.
      
 Title:  Frankie: serious case review: overview report. LSCB: Thurrock Local Safeguarding Children Board and Thurrock Local Safeguarding Children Partnership Author: Tom Savory Date of publication: 2020  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             FRANKIE  SERIOUS CASE REVIEW  Overview Report      Independent Author – Tom Savory THURROCK LOCAL SAFEGUARDING CHILDREN BOARD COMMISSION 2  Contents Chapter 1 ............................................................................................................................................. 3 Introduction ..................................................................................................................................... 3 Chapter 2 ............................................................................................................................................. 4 Initiation of the Serious Case Review ...................................................................................... 4 Terms of Reference ...................................................................................................................... 5 Scoping............................................................................................................................................. 6 Key Issues to Consider ................................................................................................................ 6 Agencies Participation ................................................................................................................ 7 SCR Frankie Panel and Meetings .............................................................................................. 7 Frankie’s Murder ............................................................................................................................... 7 A brief overview of relevant background in relation to Frankie’s contact with Thurrock agencies ............................................................................................................................ 9 2016 ................................................................................................................................................... 9 2017 ................................................................................................................................................. 10 Period of Serious Case Review: October 2017 – August 2018 .......................................... 11 From October 2017 ..................................................................................................................... 11 2018 ................................................................................................................................................. 12 Thurrock response to gangs and violence .............................................................................. 14 What needs to happen to ensure that agencies learn from this case .............................. 15 Local Learning Points – Areas for consideration by the Thurrock LSCP ....................... 15 Learning Point One ..................................................................................................................... 15 Learning Point Two ..................................................................................................................... 15 Learning Point Three .................................................................................................................. 15 Learning Point Four .................................................................................................................... 15 Learning Point Five ..................................................................................................................... 16 Learning Point Six ....................................................................................................................... 16 Learning Point Seven ................................................................................................................. 16 Learning Point Eight ................................................................................................................... 16 Learning Point Nine .................................................................................................................... 16 Learning Point Ten ...................................................................................................................... 16 Summary ............................................................................................................................................ 17 Glossary ............................................................................................................................................. 18    3  Chapter 1  Introduction  Having celebrated his birthday just weeks before, Frankie was only 15 years old when he became a victim of murder in 2018. At the time of his death he was the youngest victim of a fatal stabbing in London.   Following his murder, a Facebook page included the following tribute, “He was very talented and loved rapping, everyone that loved him knew this. He only brought joy into people’s lives, he was always laughing and joking”.  Frankie was known to various agencies at the time of his death, and he is described by the professionals who worked closely with him as being charismatic, polite, popular, very likeable, always laughing and joking.  Thurrock Local Safeguarding Children Board (LSCB) initiated a Serious Case Review (SCR) following the murder of Frankie. The review covered the period from October 2017 to August 2018. An Independent SCR Panel Chair was appointed, and an Independent Author commissioned to undertake the review and identify any learning in this case.  The Police investigation into Frankie’s murder identified that a number of young people had been involved. At the first criminal proceedings one young person was convicted of his murder, two young people were convicted of conspiracy to cause Grievously Bodily Harm (GBH), and one young person was convicted of perverting the course of justice.  Subsequently two further young people were convicted of conspiracy to cause GBH.  Based on all the evidence and information gathered throughout the Police investigation and criminal proceedings there is no evidence or intelligence to indicate that Frankie’s murder was gang related, or that the males who have subsequently been convicted had any affiliation with relevant gangs.   4  Whilst Frankie was known to have some association with gang culture within Thurrock, his murder was not predictable or gang related, it was a spontaneous act of violence resulting in the tragic loss of life.  Frankie at the time of the incident was not found to be carrying a weapon.  Frankie was a 15 year old who went out with some friends to a birthday party early on a Summer Sunday evening. Chapter 2  Initiation of the Serious Case Review  At the time of this incident Local Safeguarding Children Boards were in a transition period, following changes in Legislation to multi-agency safeguarding arrangements. A Rapid Review Meeting was held in July 2018, to review the information available. The Review Meeting members and Legal Adviser determined that the criteria for a SCR was not met. However, the prevalence of knife crime has become such a national issue, that Thurrock LSCB referred the case to the National Child Safeguarding Practice Review Panel (CSPRP) recommending a national thematic review be considered because of the prevalence of similar incidents across the country.  The information from the Rapid Review Meeting was considered by the CSPRP. At the time of this incident, the CSPRP was in the early stages of being established, and there were no plans for a national thematic review at that time. The CSPRP responded with a recommendation to consider a SCR. The case was carefully considered by the Independent Chair of Thurrock LSCB, who determined that although the statutory criteria for a SCR was not met, there was learning to be obtained from conducting a SCR and the decision was made that a SCR should be conducted under the transitional arrangements from Working Together 2015. A Multi-Agency SCR Panel was established to oversee the management of the review.  During the course of this review the Independent Chair of the Thurrock LSCB received correspondence from Edward Timpson (Chair of the CSPRP) early February 2019 advising that there was to be a national thematic review of adolescents and criminal 5  exploitation. It stated “We have received notification of a significant number of serious child safeguarding cases which raise issues which are complex and of national importance in relation to adolescents in need of State protection from criminal exploitation”. This also included an invitation for Thurrock LSCB to support this national review with the case of Frankie alongside other cases identified.   The arrangements and scope for the national thematic review were confirmed with the Independent Chair of the Thurrock LSCB mid-April 2019 and the decision was taken by the SCR Panel early May 2019 to co-operate with the national thematic. In May 2019 the National Panel Review Team attended Thurrock and met with practitioners involved in the case and updated on the details of SCR Frankie.  As a result, the methodology used in undertaking this review did not include submission of Individual Management Reports or convening a Practitioner event and relied on the information included in the Summary Reports and Chronologies submitted by agencies soon after Frankie’s murder (as set out below) and four meetings of the SCR Group (as set out below).  The family were invited to meet with the independent author however they did not respond to the offer to take part within this review.  Terms of Reference   1. This Serious Case Review will be undertaken by the Thurrock Local Safeguarding Children Board, being the Board area in which this young person/s normally resided (Working Together 2015). 2. An Independent Author has been appointed to undertake the Overview Report and make any necessary enquiries to establish the circumstances and any subsequent learning. 3. An Independent Chair has been appointed to oversee the Serious Case Review Panel and process who has not had direct involvement in the case. 4. The publication date of the final overview report will take into account the statutory responsibilities of any other statutory body or criminal proceedings.  6  Scoping  The scoping within this review was:- 1. The time period of the review will cover from October 2017 to August 2018. 2. There is a requirement to provide a detailed chronology and brief summary to show key episodes or events that each organisation was involved in with this family. 3. The scope of the Review, in respect of family information, to be limited to Frankie, any siblings and parents only. 4. The SCR Panel will examine all relevant information provided by individual agencies and professional’s reports. 5. The family to be informed that a Serious Case Review is to be undertaken. 6. As well as receiving reports from the statutory LSCB member agencies, the SCR Panel will request reports or disclosure of information from any bodies believed to have engaged or had involvement with the family as required. 7. Given the press interest of this Review, the Board have agreed a media strategy involving the media lead from the three Strategic LSCB Partner agencies (Police, Local Authority & Clinical Commissioning Group (CCG)). This is being led by the Local Authority Media Team. A proactive press release has been prepared. 8. The Panel will utilise the LSCB Legal Adviser to the Board and call upon any expert witness or adviser as required.  Key Issues to Consider  The key issues to consider were:- 1. Did all agencies work together effectively to safeguard these children? 2. Was the outcome preventable? 3. Were the safeguarding procedures followed appropriately? 4. Was the young person’s voices heard throughout agencies involvement?       7  Agencies Participation  The following Agencies were asked to provide a brief summary and chronology report. Essex Police - Brief Summary and Chronology NELFT - Brief Summary and Chronology CCG – on behalf of NHS England Primary Care – Brief Summary  Youth Offending Service - Chronology Metropolitan Police - Brief Summary and Chronology Children Social Care - Brief Summary and Chronology Secondary School - Brief Summary and Chronology SCR Frankie Panel and Meetings  The SCR Panel met on four occasions and comprised of the Independent Chair, Independent Author and the following Senior Representatives from agencies:  LSCB Business Manager  LSCB Learning & Practice Review Co-ordinator  LSCB Legal Adviser  Children Social Care  NELFT  Youth Offending Service  Metropolitan Police  Essex Police  Hospital  Clinical Commissioning Group – on behalf of NHS England Primary Care Frankie’s Murder  On the evening of his murder Frankie was attending a 16th birthday party in London. There had been an open invitation to the birthday party advertised on social media. As a result upwards of 300 young people had turned up at the venue.  8  Frankie was dropped off by car at the party at around 20:30 with a number of friends. When they arrived at the party, they could see that there was a long queue and they walked to a nearby street and then after a short time walked towards the party.   They queued for a few minutes. Initially they were told they could not enter but then were allowed access. By the time they entered the venue it was already overcrowded as it could only accommodate a maximum of 150 guests, and the host was asked to remove guests.   Following unsuccessful attempts by the host and family to remove guests, the decision was taken to end the party.   After leaving the party, Frankie and his friends stayed in the area.   As people were leaving the party into the surrounding streets there were reports of fights breaking out. It is reported that numerous calls were made to Police by members of the public, the first call being made at 21:05.   At some point around this time, there was an exchange involving Frankie and a small group of adolescent males, the circumstances surrounding this incident are not clear. However the situation was quick moving and the outcome was that upwards of 100, mainly male youths, started running up the road, with Frankie being chased by a group of male youths within the large running group.   Eventually the small group caught up with Frankie, surrounded him, and he tumbled onto the pavement, whereupon the small group set upon him.  The phone calls to Police stated that there was a large group of youths at the location and that it was ‘kicking off’, ‘youths fighting’ and ‘someone had been attacked’.  Frankie’s friends followed on and found him fatally stabbed. In the attack Frankie had received two stab wounds, either of which would have been fatal.  Despite the best efforts of paramedics and doctors, Frankie was pronounced dead at 22:21 hours, less than two hours after arriving for the birthday party.  9  The news of Frankie’s murder became widely reported through both social media and on the internet rolling news. However, interagency communication was limited. The Metropolitan Police contacted the Thurrock Emergency Duty Team (EDT) that evening informing them of the death of Frankie. However, it was not until the following morning, when Frankie’s Mother telephoned staff at his school to inform them of his murder and to cancel transport, that they became aware of his death. This was the first notification the school (Pupil Referral Unit (PRU)) received from any party – Please refer to Learning Point One.  Frankie’s funeral took place over two days, starting with a celebration of his life which was well attended with many family and friends. The Pastor talked about gangs and knife crime and of working with other families who have lost children through knife crime. He shared photographs of Frankie and led a walk of remembrance.  A brief overview of relevant background in relation to Frankie’s contact with Thurrock agencies  Frankie was one of three siblings having one older and one younger brother. They all resided in the same family home with their mother and father, and the family had been known to Childrens Services since 2007.  2016  Frankie was involved in a robbery of a bike and received a Community Resolution (CR).  According to the relevant charging standards guidance, robbery is too serious an offence for a CR without Youth Offending Service (YOS) intervention. As the CR had been issued by the investigating officer, this offence was not referred to YOS. Had there been a referral to the YOS, there would have been a TRIAGE (now called Community Resolution Plus) process, which would have resulted in a diversion/prevention intervention from YOS with Frankie – please refer to Learning Point Two.  10  During this period Frankie’s father was convicted for offences of fraud and received a custodial sentence of over six years. This left the parental responsibilities for him and his siblings to his mother – please refer to Learning Point Three.  2017  The Police had initial contact with Frankie’s older brother when he was a witness to a stabbing.    Frankie was arrested for possession of a knife and theft from person, where he placed a victim in a headlock and demanded that the victim give him his bag.  Subsequently Frankie appeared in Youth Court and pleaded guilty to theft from person and possession of a bladed article.   Although in fact this offence was a second robbery, he had not previously been referred to YOS for intervention as the first robbery had been dealt with by way of CR. As a result, there had been no opportunity for YOS to do the work with Frankie that might have diverted him from committing the second offence in 2017.  In the Youth Court proceedings in 2017, Frankie was assessed as low risk of further offending but a medium risk of serious harm (due to the nature of the offence) and a medium risk of vulnerability, due to his emerging association with gangs. He was made subject to a 10-month Referral Order.  Following sentencing, Frankie and his Mother attended the initial Youth Offender & Compliance Panel. Both agreed to comply with the conditions of the Referral Order and a contract was agreed consisting of the following:-  Streetwise  The weapons awareness programme  Offending behaviour sessions to address street crime, peer pressure, consequential thinking and joint enterprise.  In addition, Frankie would attend victim awareness sessions and undertake 12 hours of indirect reparation to the community. 11  Period of Serious Case Review: October 2017 – August 2018   From October 2017  Frankie’s mother and older brother were arrested for alleged money laundering.   During the Police search of the family home a large hunting knife with a black coloured balaclava was found in Frankie’s older brother’s bedroom. There was also a knife and a baton under Frankie's bed. This resulted in a referral to Children Social Care (CSC) which led to a social work assessment in October 2017.   The social work assessment concluded that the children's care needs were being met, there were no concerns in relation to neglect. However it identified significant concerns around the family involvement in crime which included Frankie and his older brother, including the possession of weapons, possible drug and gang affiliation, all of which made them and their younger sibling and mother vulnerable. The recommendation of the assessment was for the family to be supported under a Child in Need (CIN) Plan.  Health records indicate that the GP was requested to provide a report for the assessment but along with other health services was not formally notified that Frankie became subject of a CIN plan – please refer to Learning Point Four.  The subsequent CIN Plan was implemented in December 2017 which included regular (four-weekly) visits to be undertaken by the allocated Social Worker (SW), ensuring that the children were seen, and their wishes and feelings considered. The purpose of these visits was also to ascertain whether the children were being appropriately safeguarded by their Mother.   In line with the plan, CSC made a referral for Frankie’s mother to attend parenting classes to learn different ways of parenting. In addition, she was offered church group support, and a Family Group Conference.     12  2018   Children’s Social Care was supporting the family under a CIN Plan up to the time of Frankie’s death. However, the support services offered to his mother, in relation to parenting, were not what she said she wanted. She consistently maintained that things would improve when her husband returned home from prison.   The support being offered to the mother related to her parenting, however the social work assessment had concluded that parenting was ‘good enough’ and there were no concerns in relation to parental neglect. The risks being identified were risks from outside the home – please refer to Learning Point Five.  In the face of offers of support in relation to her parenting, Frankie’s mother moved from feeling she needed support to feeling professionals were judging her and her parenting skills. She subsequently declined all these offers of support.   Frankie’s school reported that he had large amounts of cash and expensive clothes. When asked about this he consistently claimed that the money was from his uncles and his mother always supported this explanation. His social worker was told that a maternal aunt, who lived locally, supported the family financially.  At the end of 2018 Frankie was accused of bringing cannabis onto school premises. Despite no evidence to support this allegation and Frankie’s consistent denial, he was permanently excluded by the school.   Having been permanently excluded by his secondary school, Frankie began attending the Pupil Referral Unit (PRU). His SW reports that Frankie wanted desperately to go back to mainstream education and he believed that if he stayed at the PRU too long, he would not be able to get the grades he needed to go to college to study Business.   Frankie’s SW went to see him at home, soon after he had started attending the PRU and she reports that he told her, "I do not think I belong there". Frankie said he wanted to go to University and become a businessman, and the PRU has confirmed he was capable of achieving the grades needed at GCSE to go to college – please refer to Learning Point Six.  13  Frankie’s SW spoke to him about his involvement in drill music1 and concerns about association with gang culture and he would always laugh and say it was about the music. He maintained that he did not carry knives and that he did not want to “go down that road, I do not want to go to prison”. He said that he never covered his face in the videos he appeared in, which he believed indicated his interest was solely in the music, and that he was serious about his music.  Frankie’s mother said that she had family in the area that were supportive and helped her when she was feeling low. She went on to say that when the boys were at home, she knew what they were doing but she felt helpless when they were outside. She said she did not know much about their friendship groups – please refer to Learning Point Seven.  Prior to Frankie’s death, his school attendance had improved to 96%, he engaged well with his social worker and after a few missed early sessions he had engaged well with the Youth Offending Service. Professionals were talking to Frankie, finding ways to engage with him and talking to each other about Frankie’s needs, in particular YOS, CSC and the PRU worked well together to support Frankie.  The last time Frankie was seen by his SW he said that he felt that he was achieving well at school and was still looking towards returning to mainstream. He has been attending his YOS appointments and felt that he was getting a lot out of it. He told his SW that he was able to talk to his YOS worker and was trying to put into practice what she suggested.   This was confirmed by his YOS worker who says that Frankie was “amazing” in sessions, that he engaged well, would go home and think things through, and when they did victim work, he felt “ashamed”. He attended his final Victim Awareness session at YOS in June 2018. He had completed his final reparation hours and was commended by the Reparation worker for his hard work. This was the last time Frankie was seen by his YOS keyworker and the draft letter of apology to the victim of his crime was discussed, and he was given the letter to take home to reflect on.                                                            1 Drill music is a style of trap music that originated in the South Side of Chicago in the early 2010’s. It is defined by its dark, violent, nihilistic lyrical content and ominous trap-influenced beats. 14  Thurrock response to gangs and violence  This review has identified how the Thurrock community is changing as families are relocated into Thurrock from London Boroughs because of the relatively low cost accommodation compared to London rental costs. Some local landlords with big property portfolios only work with London Boroughs. Local agencies are not always informed by the placing authorities and the issue of gang related rivalries is growing, as members of rival gangs are placed in the same areas – please refer to Learning Point Eight.  Thurrock partners are responding to these changes, and some of the gang related disruption activities have received coverage in the local media – please refer to Learning Point Nine.  Gang culture creates a web of affiliations between some gangs and violent rivalries between others. Anyone aligned with a certain gang, is a rival to anyone who is considered a rival to that gang. Gangs can be aligned or affiliated all over UK. Operating like a cartel, these gang affiliations create the conditions to control drugs supplies that will allow the gangs to move drugs in what have become known as “County Lines” – please refer to Learning Point Ten.  YOS has employed a Serious Youth Violence lead to upskill social workers in how to work with young people. Funds have been secured to fund mentoring for young people in the short stay school academy. Since Frankie’s murder, the relationship between the YOS and the PRU has been strengthened.  The Streetwise knife prevention programme has had a significant impact on reducing the reoffending rate for those young people undertaking the programme. YOS are undertaking a lot of training with schools, health agencies and other partners.  The Safeguarding Children Board has run the “Walk Online” roadshow educating children about the risks of gang affiliation which has reached over 3,000 primary school pupils. 15  What needs to happen to ensure that agencies learn from this case   Representatives of the Thurrock Local Safeguarding Children Partnership (LSCP) attended an event arranged by the National CSPRP in July 2019 when the emerging findings from the national review were shared.    The Child Safeguarding Practice Review Panel published its first national review in March 2020. This national review focused on safeguarding children at risk from criminal exploitation.   Thurrock LSCP will be arranging a Learning Event following the publication of this SCR and the national review report to consider the findings and agree how they can support improving practice with vulnerable adolescents in Thurrock. In particular the Learning Event will focus on those young people who are vulnerable to being drawn into gang related criminal exploitation. Local Learning Points – Areas for consideration by the Thurrock LSCP  Learning Point One  The current notification process under the SET Child Death Review arrangements (Section 9.7.17) should be reviewed to ensure timely notification of child deaths are received by the relevant persons when a Thurrock child dies outside of the area.  Learning Point Two  Essex Police should remind staff decision makers regarding the correct threshold for disposal in juvenile cases and the YOS referral process.  Learning Point Three  The Thurrock LSCP to lead a review of how all agencies respond to the impact on children when a parent is given a custodial sentence.  Learning Point Four  Thurrock CSC to ensure that Child in Need procedures includes a notification process to other relevant agencies when a child become the subject of a CIN Plan. 16  Learning Point Five  The Thurrock LSCP to lead the opportunity for local agencies to consider and find ways to understand how to incorporate the concept of contextual safeguarding in the assessment of risk to children in the future.  Learning Point Six  The Thurrock LSCP to engage with the education system to review the current process when permanent exclusion is being considered, to ensure that consideration is given to reducing the potential for creating additional vulnerability and safeguarding risks to children at risk of exclusion.  Learning Point Seven  The Thurrock LSCP to co-ordinate a review of local interventions currently available to support parents when identified safeguarding risks are outside the home. What do young people and their parents tell us about this?  Learning Point Eight  Thurrock LSCP to review data about families being moved into the area by other local authorities as part of their own gang disruption activities, and consider the role of the LSCP in liaising with the relevant LSCPs about how agencies can work better together to meet the needs of these families and manage risk.   Learning Point Nine  Thurrock LSCP to review how partner agencies respond to and provide support to those families and children affected by gang association. Could Thurrock LSCP, Adult Safeguarding Board and Community Safety Partnership build on the current work to develop a violence and vulnerability framework?  Learning Point Ten  Thurrock LSCP to review how well Partner agencies currently share intelligence related to gang association and affiliation. 17  Summary  Frankie’s murder was not predictable, and he was not murdered in Thurrock. Frankie was murdered by a stranger in London. However, the prevalence of knife crime inflicted on young people by young people has become an issue of national importance. The findings of the national thematic review, with which Thurrock has engaged, will be used to inform how Thurrock agencies review the local approach to tackling serious youth violence and contextual safeguarding risks.                          18  Glossary  Clinical Commissioning Group CCG Child in Need CIN Community Resolution CR Children Social Care CSC Child Safeguarding Practice Review Panel CSPRP Emergency Duty Team EDT Grievously Bodily Harm GBH Local Safeguarding Children Board LSCB Local Safeguarding Children Partnership LSCP Pupil Referral Unit PRU Serious Case Review SCR Social Worker SW Youth Offending Service YOS       