Death of a 15-year-old girl in September 2018 by suicide. Pippa was subject to a care order and lived in a care home at the time of her death. Learning includes: the importance of considering how childhood experiences can impact the behaviour and vulnerabilities of troubled adolescents; child sexual abuse in the family will often come to the attention of agencies because of a secondary presenting factor, which then becomes the focus of intervention; practitioners need to proactively assess and engage with all significant men in a child's life; where child sexual exploitation is suspected, risk assessments need to consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; professionals need to maintain a questioning and curious response to what they are told or what they see; a lack of knowledge among professionals about the evidence base related to risk indicators for adolescent suicide could leave them ill-equipped to discuss or recognise signs and respond accordingly. Recommendations include: support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents; ensure that agencies have systems which can evidence robust managerial oversight of actions, decisions and plans relating to work with adolescents; ensure that practitioners have regular supervision from a senior manager, safeguarding lead or an appropriate external source; provide learning and development opportunities about adverse childhood experiences, trauma and familial child sexual abuse; audit the effectiveness of meetings to ensure that they lead to improved and timely outcomes for children and young people.
      
    Serious Case Review No: 2022/C9342  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.      Pippa SCR/LR/03.02.2022/updated Final Report  1            Serious Case Review     ‘Pippa’     October 2019 Updated February 2022 Amended May 2022        Pippa SCR/LR/03.02.2022/updated Final Report  2 Acknowledgement   Language is a powerful tool for communication but we now know  that sometimes the way words and labels are used by social work professionals creates stigma and barriers for the children and young people with whom we work.   Language That Cares is a collaborative effort led by TACT, an adoption and fostering agency that aims to change the language used by professionals when referring to the care system and children’s experiences. Building on these collaborative efforts, the local Children’s Partnership has begun to change the language used to talk about all children needing help and support. Understanding that language is power, the Partnership is committed to doing all it can to ensure children are empowered by their experiences of needing support and/or care. This includes not only changing the language used by professionals but also thinking carefully about what is written down about the children including those who need help to live away from their own family for a time.   This report about Pippa was written in 2019, well before professionals understood the full impact of how professional jargon can impact on the lives and well-being of children in their care and/or with whom they work. Since then the Children’s Partnership has made clear its commitment to ensuring that the language used by all professionals is more personal, less stigmatising and easier to understand by children and young people.  They have been supported in their efforts by a group of care-experienced children and young adults who continue to work alongside professionals to ensure that it is they who dictate how their experiences are understood and described by social work professionals.   This report should therefore be read within the context of the changing social work landscape both locally and nationally.     Pippa SCR/LR/03.02.2022/updated Final Report  3 Contents  Overview  1. Local Safeguarding Children Boards and Serious Case Reviews  2. Circumstances which lead to a Serious Case Review  3. The approach used   4. Scope and terms of reference   5. Family Involvement  6. Summary of key periods in Pippa’s life   7. Analysis and appraisal of practice.  ASP 1: How well did professionals understand Pippa’s vulnerabilities?  ASP 2: Quality of Timeliness of Assessments  ASP 3: Professional Judgment and Decision-making  ASP 4: Extent to which agencies worked effectively together ASP 5: The voice of Pippa    8. Summary of Learning Points   9. Recommendations for Consideration  Appendix 1: List of agencies involved      Key Subject:    Pippa (not her real name)  Mother  of Pippa  MP Half Sibling of Pippa HSP Mother’s Partner 1  P1 (birth father of Pippa)  Mother’s Husband P2 (Birth father of HSP) Mother’s Partner 3   P3  Mother’s Partner 4 P4 (current partner)  MGM    Maternal Grandmother, separated from MGF   Maternal Grandfather KTP   Known to Pippa. [Male] through social media. Also known to Police and CSC  Area 1   Location of Pippa’s home town Area 2   Location where MP and P4 lived in 2017 Area 3   Location of Care Home 1 Area 4   Location of Care Home 2 Police Force A  covers Areas 1 and 4 Police Force B  covers Areas 2 and 3     Pippa SCR/LR/03.02.2022/updated Final Report  4   Overview  Pippa was described by all who knew her as a beautiful, bright and spirited young person. Whilst her behaviour could at times be challenging, aggressive and confrontational, Pippa could also be funny, and amusing. Known to be very insightful, Pippa surprised various professionals on different occasions with her astute observations on a range of topics including her analysis of how well staff were doing their jobs. She enjoyed singing and performing and was always happy to be the centre of attention. Family and professionals recall Pippa as being strong minded with an ability to resist doing anything she did not want to do but they also remembered times when Pippa was kind and thoughtful.   The death of any child is always tragic. It is especially so, when a child takes action, deliberate or otherwise,   which leads to their death.  We do not know what Pippa was thinking or what happened in the residential home where she was living, after she was given a drink sometime around 22.00 hrs the night before she died. Conversations with care home staff, with her grandparents and text messages to friends on that evening offer no clue as to Pippa’s intentions or give any indication that she was in any way troubled.   This review cannot identify a significant contravention or confirm any action by a professional that was a critical factor in what happened to Pippa. Her sad and tragic death is however, a reminder to all agencies of the complexities involved in understanding and assessing the risks facing young people. The circumstances of Pippa’s death could not have been predicted and there is much to evidence that most professionals working with Pippa did so with commitment, care, and tenacity. The learning from the SCR does however invite and require a better understanding by managers and practitioners in all agencies about the circumstances that can lead to a young person taking action which leads to their death and the interplay between childhood experiences, cumulative adversities, and risky behaviours in adolescence. Without this understanding professionals may not always recognise the emotional, psychological, sexual and physical risks young people can face. The review also offers a stark reminder to all agencies of the importance of robust assessments, effective plans and well managed reviews and meetings.     1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews1 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)2 at the time this SCR was commissioned were to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance, which accompanies legislation and underpins the work of LSCBs, set out its expectation that LSCBs should maintain a local learning and improvement framework so good practice can be identified and shared.  1.2. In situations where abuse or neglect of the child is known or suspected and children die or are harmed, local authorities and their partners are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce any future risk of harm to children. There is an expectation that these processes known then as Serious Case Reviews (SCRs) are transparent with the findings shared publicly.  2. Circumstances which led to this SCR  2.1. Pippa was subject to a Care Order3 when she died. She had been living in a care home for just under two months and was expecting to be moved when she was found in her bathroom having taken her own life. She was 15 years old. 2.2. A decision was taken by the independent chairperson of Local Children’s Safeguarding Board (LSCB) on the 27 September 2018 that Pippa’s death met the criteria for undertaking a Serious Case Review. (SCR)  3. The approach used  3.1. The board appointed an independent lead reviewer who had no prior connections to any of the agencies involved, to lead the review process and to produce the SCR report. A review team of senior professionals, representing the agencies that had been involved with the family was established; their role being to provide strategic information about their agencies’ involvement and to identify learning for their agency through the submission of an Agency Learning Report. This group met on four occasions and the agencies represented are listed in Appendix 1. 3.2. Other LSCB’s were informed of the SCR as Pippa was placed in residential care in other areas for a short period of her life.  3.3. Members of the review team identified frontline practitioners and first line managers who were known to, or had worked with Pippa and her family. These practitioners formed the ‘Practitioner’s Group’ and offered useful insights to support learning. This group met on 3 occasions.  3.4. At the start of the review, a time line of agency interventions was collated to illustrate multi-agency activity and who knew what and when. Agency leads were then asked to complete an Agency Learning Report, which described and analysed practice within their own agencies and which were presented to                                                              1 This Serious Case Review (SCR) was commissioned in line with 2015 statutory guidance ‘Working Together to Safeguard Children’. With effect from September 2019, the arrangements for undertaking reviews where a child has died or been seriously injured have been amended. They are now referred to as [local] Child Safeguarding Practice Reviews.  2 Children Act 2004, s14  3 A Care Order is an order, which places a child under the care of the Local Authority. This is otherwise known as a child ‘    Pippa SCR/LR/03.02.2022/updated Final Report  6 the review team for comment and challenge. Further data was provided through scrutiny of various assessments and agency records.  4. Scope and terms of reference  4.1. The review team agreed that the period under review would be from early December 2015 when Pippa made an allegation of physical assault against P4, to September 2018 when Pippa died.  4.2. At the first meeting of the review team and the practitioners group, key issues began to emerge and as the review unfolded, these lines of enquiry allowed a wider exploration of events, which helped the review team, understand what happened, when and why. With the benefit of Agency Learning Reports five ‘Areas of Specific Practice’ (ASP) were identified which the review team agreed would provide a framework for the appraisal of practice. These were:  ASP 1: How well professionals understood Pippa’s vulnerabilities.  ASP 2: The quality and timeliness of assessments  ASP 3: Professional judgments and decision-making  ASP 4: The extent to which agencies worked effectively together ASP 5: Pippa’s lived experiences    5. Family Involvement  5.1. The lead reviewer, accompanied by the Business Manager from the LSCB initially met with MP and P4 in the presence of MP’s solicitor and a paralegal from the same firm; with MGM in her own home and with MGF and his partner in their own home. The purpose of the initial meeting was twofold: firstly to talk with the family about the SCR process and secondly to gather their views about professional involvement in Pippa’s life.  A second meeting took place towards the end of the SCR process. MGM had arranged for a friend to be present for support. A separate meeting with MGF was attended by his partner, Pippa’s uncle and his long term partner. The meeting with MP and P4 was again in the presence of MP’s solicitor and the paralegal from the firm.   MP and P4 5.2. MP told the independent reviewer of the struggles she experienced with Pippa from a very young age and indicated that she felt she did not get the support she needed from agencies when it mattered. MP described how even when Pippa, around the age of 11 or 12, became physically violent towards MP and BP, the authorities did not step in to help. MP suggested that only when she expressed a worry that she might retaliate and injure her daughter in self-defence, did social workers began to take an interest in what was happening in the family. MP stated that after she moved to Area 2 to live near P4, she never received invitations to meetings about Pippa, was not kept informed of significant events in her daughter’s life and was not consulted by the local authority about key decisions that were made.   5.3. MP attended court when Pippa was made subject to a Care Order in February 2017, and stated she wanted to maintain contact with her daughter but was not helped to do so by the local authority. MP said she was not informed that Pippa had made a disclosure about P3, mother’s partner at the time, or that the police had chosen not to take any further action.  MP said she had always wondered if either of her children had been abused by P3 but had been told by social workers, after they had spoken with    Pippa SCR/LR/03.02.2022/updated Final Report  7 Pippa and HSP that ‘nothing had happened’.  MP said that Pippa ‘lied’ about lots of things and shared with the lead reviewer examples of when Pippa had told lies to ‘get her own way’.   5.4. MP acknowledged that her relationship with her daughter had always been difficult and she knew that Pippa, when she came into care, told social workers that she did not want contact with her. However, MP pointed out that when Pippa ran away she would often turn up at MP’s home in Area1 and later in Area2. MP said she had been advised by SW1 not to give Pippa money but to let them know of Pippa’s whereabouts which she said, she always did.     5.5. The lead reviewer was told that HSP had suffered because of Pippa’s behaviour and had not wanted any contact with his sister after she came into care. Both she and P4 stated their belief that MGF should have taken Pippa to live with them rather than let her go into the care system and this has caused friction in the family.  MP said that her mother had done as much as she could to care for Pippa and that she had strongly objected to Pippa living there because of MGM’s poor health. MP believes she has Pippa’s phone, which was sent to her through the post by CH2 with a note saying they ‘thought’ it belonged to Pippa.  According to MP, the police still have Pippa’s laptop and a password protected tablet which they removed from CH2.  Maternal Grandmother (MGM)  5.6. MGM shared her view that MP had not always been able to meet the needs of her children as they were growing up and this was particularly the case with Pippa, who MGM said, always wanted just to live with her mother and brother. MGM told the lead reviewer that MP struggled to be the parent Pippa needed, even with the support of social workers and the relationship between MP and Pippa became even more strained when P4 became involved with the family. MGM said she and MGF attended most of the review meetings when Pippa was in care but she could not remember her daughter attending any meetings after she moved to Area2, even though, according to MGM she was always invited. Although MGM said she felt supported by social workers and had good contact with Pippa’s school, she felt more could have been done by professionals to help with accommodation especially given that Pippa had to sleep on her sofa bed for over a year. MGM said she now had very little contact with MP and her grandson.  Maternal Grandfather (MGF)  5.7. MGF’s conversations with the lead reviewer reiterated most of what was said by MGM. MGF said with insight he wished he had done more to help Pippa, but said he had no issue with the professionals who were trying to help Pippa. He did feel more should have been done to help with accommodation but said professionals responded promptly when he reported seeing sexualised images on Pippa’s phone.  MGF also said he had reported his concerns about KTP who approached him at Pippa’s funeral. MGF said he and the wider family wanted to have contact but for whatever reason his attempts at contact with MP and HSP were always blocked.   5.8. There are clearly rifts and tensions within this family, but the review team is grateful to all the family members for their willingness to talk openly about Pippa and her life and the struggles they had in trying to care for her and keep her safe. Where appropriate, other comments made by family members are referenced throughout this report.        Pippa SCR/LR/03.02.2022/updated Final Report  8 6. Summary of key periods in Pippa’s life (from agency records and conversations)   Background information taken from agency records  6.1. According to agency records, MP’s relationship with P1, Pippa’s birth father, ended before Pippa was born.  MP married P2 and HSP was born when Pippa was three; MP told the lead reviewer that she suffered postnatal depression for a number of months after the birth of HSP. MP described Pippa as being a difficult child, who at 5 years old, was referred to CAMHS4 because of her behaviour problems at home and school.  6.2. Concerns about MP and P2’s lack of concern for Pippa’s emotional well-being as a young child led to a referral to Children’s Social Care (CSC) by CAMHS. According to agency records, although support was provided to the family by the local authority’s Family Support Team (FAST), the parents did not always engage with agreed work or keep appointments so work was not as effective as it might have been. Around this time, Pippa’s great grandfather died and she received grief counselling.  MP and P2 began to express concerns to children’s services about Pippa’s mental health.  6.3. It would appear that MP’s relationship with P2 ended sometime in 2011 and MP began a relationship with P3 who moved in with the family. An allegation by Pippa that she had been physically abused by P3 led to a child protection investigation by Children’s Social Care (CSC). The allegation was not however substantiated. Police records refer to Pippa running away from home around this time. 6.4. During the time P3 was involved with MP, P3 was arrested and charged with downloading indecent images of children and Pippa spent a short time living with her MGM whilst a second child protection investigation took place. Pippa eventually returned home but a third child protection investigation occurred when CSC learnt that MP was still in contact with P3 and he had access to both of her children.  At the ensuing child protection conference, concerns were expressed by professionals about MP’s negative attitude towards Pippa. Both children were assessed as being at risk of significant physical and emotional harm and were placed on a child protection plan under the category of emotional abuse. The plan remained in force for 8 months before CSC ended their involvement in May 2014.   6.5. Between June 2014 and December 2015, the family received offers of support from Early Help services in response to continued concerns about the behaviour of both children. MP told the lead reviewer that the services offered by the local authority did not help to change Pippa’s behaviour. Agency records refer to the fact that MP was spending more time out of the area with P4, whom she met sometime in 2015. Early help involvement continued but MP reported that Pippa’s behaviours were becoming increasingly violent toward herself and HSP. There are records of various allegations and counter allegations made by Pippa against MP and P4. MGM reported that Pippa would often come to stay when ‘tensions in the house’ were high and MP felt the family needed ‘time out’. Agency records describe MGM as frail but despite a disability, it seems she was happy to care for Pippa. Pippa's school attendance was described as good; her transition from primary to secondary school was relatively straightforward and she was regarded as a bright and able pupil despite her loud and challenging behaviours, which were often evident. School considered they detected traits of autism in Pippa’s behaviour and with MP’s                                                              4 Child and Adolescent  Mental Health Services     Pippa SCR/LR/03.02.2022/updated Final Report  9 agreement; Pippa was referred to CAMHS in October 2015 to be assessed for Obsessive Compulsive Disorder (OCD) and Autism. The referral was supported by the family GP.  Period 1: December 2015 – July 2016– (aged 12/13)  6.6. According to agency records and the maternal grandparents, Pippa lived at various times with her mother, HSP and P4, and sometimes with MGM during this period. MP told the review team that she continued to seek help from agencies to manage her daughter’s behaviour. With MP’s agreement, HSP and Pippa were made subject to a child in need plan. However, CSC concerns about Pippa’s welfare increased and when MGM’s health deteriorated and, according to agency records, MP and P4 refused to allow Pippa back into their home, Pippa became a Looked after Child in July 2016 and was placed with foster carers. (FC1).  Period 2: August 16 – February 2017 (aged 13) 6.7. Within a few weeks, Pippa was moved, at her request, from the foster placement as she indicated to her social worker she felt ‘uncomfortable ‘in the presence of the male foster carer. Pippa was moved in August to a second placement, with a single foster parent (FC2) and, according to agency records, had regular overnight stays with MGM and, very occasionally, with MP, HSP, and P4.  6.8. In September 2016, Pippa was made subject of an Interim Care Order but she stayed with FC2 until she was made subject to a full Care Order in February 2017. At the hearing, the local authority was directed by the judge to return Pippa to the care of MGM and to ensure suitable accommodation was found.  6.9. MP had at some time during this period moved out of Area1 to live in Area2 some distance away. A Looked after Child (LAC) review for Pippa was held on 24.10.16. MP’s apologies are noted on record. Pippa is recorded as having told the Independent Reviewing Officer (IRO) that MP would not take her calls  and hadn’t rang her ‘for ages’ so she wasn’t bothered about contact with her mum.  Period 3: March 2017 – July 2017 (aged 13/14) 6.10. Pippa began to go missing during this period and MGM told the school nurse and SW1 that she was struggling to cope with Pippa’s behaviour, describing her granddaughter’s refusal to say where she was going and with whom she  was spending  her time. MGM also described arguments about money and cigarettes going missing. MGF found explicit sexual images on Pippa’s phone and there was evidence that Pippa was planning to visit an unknown male she had met online. Police secured Pippa’s phone and laptop. It later transpired that Pippa had access to another mobile phone. Concerns began to emerge that Pippa could be a victim of online grooming. MP, HSP, and P4 had at some point  moved back to Area1, although according to records P4’s living arrangements seemed to alternate between Area1 and Area2. A LAC review for Pippa was held on 11.4.2017. Pippa continued to say she did not want contact with MP. SW1 spoke with HSP who confirmed he did not wish to see Pippa. MP did not attend the meeting but agency records confirm that apologies were sent via SW1. MGM and MGF attended. Period 4: August 2017 – December 2017 (aged 14) 6.11. Information came to light that Pippa had ‘a new boyfriend’ (KTP) who was known to Children’s Services. This was a young male who was thought to befriend ‘vulnerable’ females. SW1 referred Pippa to a multi-disciplinary specialist project (MDSP) in Area1 because of concerns about possible child sexual exploitation (CSE). MP told the lead reviewer that she was unaware of this referral or that there were concerns that Pippa could be at risk of CSE. Pippa was referred also to a specialised CSE project run by a    Pippa SCR/LR/03.02.2022/updated Final Report  10 large children’s charity. MGM continued to advise professionals that she could not cope with Pippa’s behaviour and plans were made to consider other placements. Towards the latter part of this period, MDSP records offer a view that that CSE risks were reducing. Pippa told her SW1 that she wanted to be in foster care.  6.12. A LAC review for Pippa was held on 1.10.2017. According to records, MP was invited to this meeting but did not attend. However, it appears she advised SW1 that she was willing to give support to her daughter through weekend visits but this would depend on bed space and P4, as contact visits would have to be supervised as per contact arrangements. An annual LAC assessment highlighted that Pippa’s behaviour was continuing to give cause for concern although MGM indicated she was willing to continue the placement ‘with support’. The assessment noted that MP had ‘limited contact’ with the local authority since the court proceedings.  Period 5: January 2018 – June 2018 (aged 14/15)  6.13. Following a multi-agency discussion, Pippa was removed in January 2018 from the MDSP process as risks of CSE were thought to have reduced. However, from February 2018, Pippa’s missing periods and school exclusions for unacceptable behaviour began to increase, and MP, who had occasional contact with her daughter, told MGM that she believed Pippa was involved with drugs.  During this period, Pippa presented on three occasions to A&E/Plastic Dressing Clinic for minor injuries which had occurred when she had gone missing and had apparently been drinking and taking substances. According to education records, Pippa was excluded from school for 3 days for writing inappropriate sexualised content in her English book.  SW1 was informed.  6.14. A LAC review for Pippa was held on 4.4.18. MP did not attend although it appears that Pippa by this time was occasionally visiting MP in Area2. MP told MGF that she had seen Pippa’s laptop and believed she was in contact with a known ‘drug dealer. This was reported by MGF to SW1. 6.15. Following an argument and a physical assault on MGM in May 2018, Pippa was moved as an emergency, to a residential establishment (CH1) in Area3, about 20 miles away from Area1. Staff concerns began to emerge about her sexualised behaviours towards other residents. Pippa disclosed to a member of staff that she had been sexually abused by P3 when she was a young child; this information was reported to her social worker two days later along with information that Pippa had also told a member of staff that she had had unprotected sex with an unknown male and had, on 5 occasions, had sex with another resident in CH1. SW1, who had worked with Pippa since early 2017, left the authority around this time and SW2 was allocated to work with Pippa.  6.16. A strategy meeting was held 5 days later, attended by Police Force B. A decision was taken at the end of the meeting, that police and SW2 would make further enquiries about Pippa’s disclosure of historical abuse. CH1 gave the local authority 7days notice to find another placement for Pippa because of her ‘sexualised behaviour’ and the risks she posed to other residents.  Period 6: July 2018 – September 2018 (aged 15)  6.17. Pippa was moved to a residential therapeutic home (CH2) for a 6-week assessment in Area 4 in mid-July. Pippa refused to engage with police regarding the allegation of sexual abuse by P3, and was told there would therefore be no further action. Pippa declined the offer of any support. Agency records suggest that Pippa enjoyed living in CH2; she continued to go to school, there were no missing episodes and no    Pippa SCR/LR/03.02.2022/updated Final Report  11 significant concerns raised about her behaviour, which according to CH2 could still be challenging. Two LAC visits by a ‘new’ social worker were made in July and August. Records indicated that Pippa was ‘happy’ in the placement but stated she did not want to engage in any therapeutic work.   6.18. Pippa was excluded from school on the first day of the autumn term for threatening behaviour towards staff and pupils. She was also challenged about arriving at school with purple coloured hair. She returned to school the following day without having changed her hair colour and was sent home again following abusive and aggressive behaviours towards staff and refusing to join a meeting to discuss her behaviour and the reasons for it. Staff recall it was almost as if she was deliberately seeking to be excluded.   6.19. Pippa spoke to both grandparents on the evening before her death, talking about Christmas and arranging to see MGM, a couple of days later. School friends reported that Pippa sent ‘run of the mill’ text messages the same evening, although CH2 records indicate that her phone was locked in the safe.   6.20. Agency records suggest Pippa went up to her bedroom after watching TV with other residents and later came down stairs saying she wanted a drink.  A casual member of staff on duty at the time, later told police that Pippa received a brusque and dismissive reply by another staff member at the time, although this is disputed by the member of staff concerned. CH2 records refer to a member of staff seeing Pippa later dancing in her room with her bedroom door propped open with a chair.    6.21. Pippa was found dead by staff the following day around 11.45 pm.   7. Analysis and appraisal of practice  7.1. The purpose of Serious Case Reviews is to support improvements in safeguarding practice. This means it is not enough just to describe professional activity in a case or to identify elements of practice that were problematic without seeking to understand why they occurred. The analysis needs to explore what systems were in place, which influenced professional activity and decision-making at key points in their work with Pippa.   7.2. It is also important to be aware how much hindsight can distort judgment about the predictability of an adverse outcome. Once the death or a serious injury to a child is known it can become too easy to look back and conclude that certain assessments or actions by professionals were critical in leading to that outcome. The review team were mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and, importantly, what systemic factors in place then, might still be impacting upon practice in 2019.  7.3. The examination of single and multi-agency working with Pippa and her family has identified some single and multi-agency learning which, alongside some important reflections about working with adolescents may assist in improving services in the area in order to reduce, wherever possible, the very real risks to which vulnerable adolescents are exposed.  7.4. The analysis is structured around five areas of significant practice, which highlight key findings or learning points. Recommendations for LSCB are grouped under thematic issues. The ASPs are listed below and further details follow:    Pippa SCR/LR/03.02.2022/updated Final Report  12 ASP 1: How well professionals understood Pippa’s vulnerabilities  ASP 2: The quality and timeliness of Assessments  ASP 3: Professional Judgment and decision-making  ASP 4: The extent to which agencies worked effectively together ASP 5: Pippa’s lived experience    7.5. ASP 1: How well professionals understood Pippa’s vulnerabilities.  Impact of Adverse Childhood Experiences   7.5.1. Various agency records suggest that growing up, Pippa was subject to number of adverse childhood experiences (ACES); parental mental ill health, family conflict, feelings of rejection by  her mother, emotional abuse  and very probably sexual abuse by P3. Research shows that the impact of these early experiences on children can lead to trauma which is linked to a long list of cognitive, behavioural and mental health disorders in children.5. There is little to suggest that these factors, which may have offered some insights into why Pippa behaved as she did, were considered in any significant depth either when she was a young child or when she grew older and risks around CSE began to emerge.   7.5.2. The possibility, that Pippa’s behaviours could be attributable to a diagnosis of Autism Spectrum Disorder6 (ASD) was a reoccurring theme evident in agency records from when she was a young child.  Young people who have experienced adverse childhood experiences and early trauma can present with signs and symptoms similar to those present for ASD, such as difficulty in establishing and maintaining relationships, avoiding eye contact and being overly obsessive about certain rituals, and it may be that, at least initially, this distracted professionals from thinking more deeply about Pippa’s early life.  However, in October 2016, CAMHS concluded that Pippa’s behaviours were linked not to ASD, but to an Attachment Disorder.7  Whilst the exact cause of attachment disorders is not known, inadequate or compromised parenting are widely thought to be directly linked to children with behavioural problems and attachment issues.   7.5.3. The topic of a child's vulnerability is a long-standing and well-recognised subject in work with children about whom there are concerns. It is, however, such a common concept that it is easy to underestimate its significance and allow presenting behaviours to be the focus of work. This appears to have been the case with Pippa. Most of the work described in assessments and plans both prior to and during the period under review, describe work which was focused on supporting MP ‘learn’ how to manage her daughter’s behaviour and helping Pippa ‘gain insight’ into her emotions so she could ‘develop strategies to control her behaviour’. This was undoubtedly important work but what appears to be missing was any intervention, which sought to directly address the impact of Pippa’s early life experiences, her feelings of rejection and belief that her mother did not want her. The impact on Pippa, learning during a family argument at the age of 12 that P2 was not her birth father must have come as a shock, yet there is little to evidence the impact of this was analysed in any detail                                                              5 The impact and long-term effects of childhood trauma  Heather Dye. Journal of Human Behaviour in the Social Environment Volume 28, 2018 6 Autism is short for autism spectrum disorder (ASD). It's a group of neurodevelopment (or brain pathway) disorders that cause behaviour and communication problems. 7 Attachment disorders’ are diagnoses, which are sometimes applied to children who have experienced significant patterns of insufficient care.     Pippa SCR/LR/03.02.2022/updated Final Report  13 within the context of her displayed behavior. According to school records, it was soon after this that Pippa’s behaviour began to deteriorate even further.   7.5.4. There is a wealth of research, which suggests that children who have been traumatised have had experiences that have overwhelmed their sense of safety. For Pippa, her early childhood experiences, despite the care offered by her grandparents, are likely to have threatened her sense of security and feelings of control, yet there is no evidence to suggest any one to one work was undertaken with Pippa until July 2018, when she was moved to CH2.  A deeper understanding of childhood trauma may have helped professionals determine that work with Pippa needed to include, as a priority, a focus on instilling feelings of belonging, control and security, especially at times of crisis when she had to be moved from one place to another.   7.5.5. Although conversations with CH2 staff indicate that Pippa ‘declined’ the offer of therapy, there is some evidence to suggest that Pippa may well have responded to sensitive outreach by a skilled practitioner had there been earlier opportunities in place for her to do so.  Sadly, it was not until July 2018, that Pippa’s need for one to one therapeutic work was recognised.  In discussions with some practitioners, it appears that the ‘involvement; of CAMHS in Pippa’s life led to an assumption that this ‘type’ of work was being or had been undertaken by that agency.   7.5.6. Research around ACES and trauma is not new but it has come to the fore in recent years.   Whilst some agencies have delivered training around ACES and trauma to staff, there has to date, been no multi-agency training on ACES commissioned by the LSCB.   Learning Point 1:  It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours.  Child Sexual Abuse and Child Sexual Exploitation  7.5.7. In 2014, the Office of the Children’s Commissioner published the results of an inquiry into child sexual exploitation.  The inquiry found that.’… many young people told…of their early histories of being sexually abused within the family home and of their experiences never being acknowledged.’ 8 Research from the inquiry, highlights that children and young people are often identified as victims of sexual abuse following the provision of support for other presenting problems, such as challenging behaviour, substance or alcohol abuse or missing from health, care or education. Yet, many of the factors, which bring the child or young person to the attention of professionals, can also result from, or be exacerbated by, the impact of the sexual abuse.  7.5.8. The inquiry also concluded that while society now better recognises the existence of the sexual abuse of children by family members or people close to their family and child protection practice has improved over the last two decades, the outcomes for children do not appear to have improved.                                                              8 The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation In Gangs and Groups 2014    Pippa SCR/LR/03.02.2022/updated Final Report  14 Nationally, the numbers of children made the subject of a Child Protection Plan for sexual abuse has fallen steadily over the last decade. It is suggested that this decline, which was still evident in 2018, is not commensurate with what is known about the overall prevalence of CSA9, and has resulted in, or has been the result of, declining levels of professional understanding and awareness in relation to the issue of CSA.   7.5.9. Prior to Pippa’s disclosure to a care worker in 2018, there are no references in case files, (other than those relating to the initial investigation) which suggest there was any ongoing consideration that Pippa may have been a victim of sexual abuse by P3 and that her behaviour was a response to what happened to her when P3 was living in the home. There are references to Pippa running away around this time and not wanting to undress for PE but despite concerns about her challenging outbursts, professionals did not appear to be overly curious as to whether sexual abuse could account for some of her behaviours.   7.5.10. Certainly, there were some concerns about Pippa’s behaviour at school and in the family evident before P3 joined the family and this may have deterred professionals from looking more closely into any link between P3 living in the family and Pippa’s behaviour. However, the fact that P3 lived with the family for almost two years before he was convicted of downloading indecent images of children, should have prompted professionals to consider that Pippa and HSP had been victims of sexual abuse by him. It is not known whether Pippa ever told MP about P3 at the time. Records from CH2 in July 2018 do refer to Pippa asking staff why her mother did not want her and why she did not believe what Pippa had told her. Pippa did not, it would appear, expand on these thoughts.      7.5.11. Agency records refer to Pippa withdrawing the various allegations she made at different times and some records seem to accept this as being ‘typical of Pippa’. It is vitally important that professionals do not take retractions that children make at face value but understand the pressure on children to take back what they have said in the face of overwhelming family pressures. In the chaotic aftermath of ‘telling’ children can be blamed for destroying the family, can face hostility from family members and may even feel professionals do not believe what they have disclosed.   At times like these, children are known to want things ‘just back to normal’ and are more likely to retract what has been said. In these circumstances, the message to the child is often that the child’s ‘lie’ is more believable to adults than the claim of abuse.   7.5.12. In June 2018, Pippa did tell a member of staff at CH1 that she had been sexually abused by P3. At this point, there should have been an immediate strategy discussion but Pippa’s disclosure was not discussed until two weeks later at a strategy meeting convened to discuss concerns about her drug use and her claim to have had unprotected sex with an unknown male and with a resident of CH1.  At that meeting, the local authority was given 7 days to move Pippa to another placement due to her being a safeguarding risk.  It is, perhaps, not difficult to imagine what ‘message’ Pippa received following these proceedings.                                                                9 How Safe are our Children. NSPCC 2018    Pippa SCR/LR/03.02.2022/updated Final Report  15 7.5.13. According to the chronology, officers from Police Force B, spoke with Pippa, two months later when she was living in CH2.  From records, this visit seems to be in relation to her alleged sexual behaviors in CH1. Records suggest  a conversation was held at the same time with Pippa about her allegation of abuse by P3 but Pippa told police officers just to ignore what she had said and it   would appear they did exactly that and no further enquiries were undertaken.  Police records are confusing - the police entry in the integrated chronology states that ‘officers updated the suspect’, and advised the matter ‘would be closed’. It is not exactly clear however, to whom this entry refers, it is assumed to be P3. Expected practice would have been for P3 to have been interviewed about Pippa’s allegation.   7.5.14. In seeking to understand why this did not happen, the review team was unable to establish with any confidence the reasons why Pippa’s allegations were not followed through as would be expected. Although the Police Force A would normally have investigated the alleged offence by P3, it was Police Force B who spoke with Pippa in line with the other enquiries they were making at the time. It seems that once Pippa said she had no wish to pursue the matter, no further action was taken. Whilst pursuing historic allegations without the cooperation of the alleged victim is difficult, the circumstances under which Pippa refused to engage with police were not as well considered as the might have been and her response to police enquiries were too readily accepted at face value. There was no challenge by officers from Police Force A to this decision nor from any other professional working with Pippa at the time.  MP told the lead reviewer that she was unaware that Pippa had disclosed this information about P3.   7.5.15. It is well known that disclosing abuse is difficult under any circumstances but the response to Pippa’s disclosure by the police from Area2 fell short of expected standards. Pippa was given a clear message that what happened to her was not important. It is possible, she may also have concluded, given the circumstances of her move from CH1, that if she spoke about what happened she could be moved again. It is, perhaps, not surprising that Pippa decided not to co-operate with what the police described in their records as her ‘complaint’ against P3.   7.5.16. As with many types of abuse, there can be an overreliance on children to come to statutory services to disclose abuse happening to them, but the responsibility lies with professionals being attuned to, and curious about changes in behaviour of children, their emotional responses and other indicators that things are not going well in their lives. Professionals need to consider a number of hypotheses to explain a child’s behaviour and abuse, including sexual abuse, should always be considered as one possibility amongst others, even though it may be discounted then or later. The review team was told by practitioners that it would not be usual practice to consider the possibility of sexual abuse for all concerns that came to their attention and were hesitant about ‘thinking sexual abuse’ inappropriately in some situations. The fact that Pippa may have been a victim of CSA does not appear to have been explored in any depth even when concerns were raised about CSE several years later.   7.5.17. Discussing Child in Need statistics for Area1 with practitioners, the review team was informed that neglect of children is the biggest challenge for professionals in the area as opposed to child sexual abuse and although it is recognised when there is clear evidence of it occurring, it is less frequently identified as the main category under child protection plans.        Pippa SCR/LR/03.02.2022/updated Final Report  16   Learning Point 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies because of a secondary presenting factor, which then becomes the focus of intervention. It is worth considering, especially in light of the findings from the Children’s Commissioner whether more work is needed in the area to increase professional understanding and awareness of familial child sexual abuse. This might be particularly helpful given the range of ways the impacts of physical and emotional neglect can mediate or set the scene for a child’s increased vulnerability to this form of abuse.    7.5.18. Protecting children and young people from sexual exploitation is a challenging area of practice across all sectors including social care but also health, education, the police and third sector organisations. The indicators for child sexual exploitation can be mistaken for ‘normal risk-taking adolescent behaviours’ but CSE is a complex form of abuse and can be difficult for those working with children to identify and assess. It is important that professionals recognise how adverse childhood experiences can increase a child’s vulnerability to exploitation and take these factors into account when determining risk. The review team was of the view that Pippa’s vulnerabilities associated with child sexual abuse and child sexual exploitation were not as well understood as they could have been either by social workers or by the MDSP process which viewed the risk to Pippa only in terms of a one off episodic incident. Her childhood experiences including what may well have happened with P3, her low esteem are factors known to  contribute to children being pushed towards situations where their vulnerabilities and ‘need to belong’ are exploited by others.    7.5.19. The review team was informed that arrangements in the MDSP process and the CSE risk assessment tool are now based around the Signs of Safety approach and this will better support practitioners to consider the cumulative impact of childhood experiences when identifying risk and vulnerabilities.    ASP 2: Quality and timeliness of assessments   7.5.20. During the period under review, Pippa was subject to various assessments by key agencies.   7.5.21. The Single Assessments10 undertaken by CSC in May 2016 and September 2017 contain a good deal of information but they do fall short in a number of areas. Whilst there are detailed narratives, which demonstrate some understanding of the issues facing Pippa and HSP, the analysis which explores the impact of these issues on the development and well-being of both Pippa and HSP, was not as robust as it should have been. There is no exploration for example, of family relationships, past partners, the role of P4 or MP’s lack of awareness about Pippa’s emotional needs. There is a sense that at times the assessments are written only from MP’s perspective rather than with Pippa and HSP being the main focus.                                                                10 The Single Assessment is a detailed assessment to determine whether a child is need, requires a protection plan, or requires immediate protection. These assessments are conducted in line with statutory guidance and are used to identify which services may be required to meet a child’s needs    Pippa SCR/LR/03.02.2022/updated Final Report  17 7.5.22. Much of the information provided by MP appears to have been taken at face value without any evidence of, what is described, as ‘respectful uncertainty’, an approach that requires professionals to critically evaluate the information they are given. It is possible that there was, initially, an over-reliance on an expected diagnosis of ASD to account for Pippa’s behaviour and therefore the more complex issues around family relationships were not challenged but this inevitably left the possibility and sustainability of any future work with MP, and P4, far less likely to happen.   7.5.23. The review team queried to what extent the assessment template and a requirement to use the same template for each assessment rather than adding to a previous version made a ‘cut and paste’ approach more likely. Compared to the volume of information presented in both assessments, the analysis sections are very brief and do not address the ‘so what’ implications of the descriptive content. There was certainly a view that the document template does not help or encourage practitioners to ‘think analytically’ and perhaps more could be done to support them in this task. Certainly, when talking through the assessments with practitioners there was far more evidence of analytical thinking and critical reflection than appeared in the actual document itself.    Learning Point 3: Whilst social workers and other professionals are skilled at communicating and gathering information, there is evidence that they need greater support to analyse and evaluate the data they collect so a multi-agency analysis can support and be seen to support professional judgments and decision-making.  Engaging with significant males in a family  7.5.24. Both assessments completed over a 16-month period make little reference to P4, despite him clearly being a key figure in the family. It is possible that MP explained to social workers that P4 had his own accommodation in Area2 and did not always stay with the family, but, as a partner of MP with access to the children, his relationships, his views and his background should have been included in the assessments undertaken, especially, according to agency records, Pippa stated a dislike of the man and his involvement in family decisions which affected her.  7.5.25. Men play a very important role in children’s lives and have a great influence on the children they care for or with whom they are in regular contact. Prior to and throughout the period under review, there was a strong emphasis on supporting MP to develop her parenting skills and build a more nurturing relationship with her daughter, but there is no evidence to suggest that any of this work involved the male who was living with the family at that time. What became evident during the review process from records and conversions with professionals and other family members, was that P4 was a significant and very influential person in MP’s life. The relationship was relatively new in December 2015 and Pippa struggled to accept him as part of her family, which was another important reason for him to have been included in both assessments undertaken by CSC.     7.5.26. A repeated finding in case reviews and audit work nationally is how often fathers and male figures are absent in recordings, assessments and care plans. Recurrent shortcomings highlighted in serious case reviews have pointed towards the failure of many social workers and health professionals to engage with men whose involvement with mothers is clearly evident even though they may appear on the periphery of family life. The review team noted that because P4’s role within the family was not explored at all as part of the assessment, it actually compromised any support work with MP to help positively engage with her daughter.     Pippa SCR/LR/03.02.2022/updated Final Report  18 7.5.27. Conversations with practitioners highlighted the wider and varying challenges in trying to identify and then engage with significant males in a child’s life. It is clear that some practitioners would welcome more support and guidance in this complex area of work.  Learning Point 4: When working with children, practitioners need to proactively assess and engage with all significant men in a child’s life, recognising that some may pose risks, some may be assets to the family and some may incorporate aspects of both.  Where concerns exist and there is evidence of conflict between a child/young person and significant none birth related males in a family, this should always be explored in assessments and be incorporated into ongoing work.  Assessing capacity, motivation and willingness to change  7.5.28. Where there are significant concerns about a child’s safety or welfare, well-informed social work assessments concerning the ability of parents or family members to keep their children safe and meet their developmental needs are essential to making appropriate decisions about a child’s future. However, the assessments undertaken in respect of Pippa’s needs did not consider whether, given past concerns, MP was actually willing or had the capacity or motivation to change her lifestyle or her own behaviours to meet the emotional and developmental needs of Pippa.  Whilst MGM and to some extent MGF had the motivation to care for Pippa realistically, their capacity to do so was limited and it was always highly unlikely they would be able to care for Pippa in the longer term.   7.5.29. Assessment models, which assess parent or family member’s ‘capacity to change’, are less concerned with the adult’s report of their intentions but are more concerned with the direct assessment of actual change. Such an approach considers only the attainment of goals as evidence of a parents’ capacity to change, and it is this that allows for a better prediction of future parental functioning.  In reality, this process is no different to the effective monitoring of a good child protection or child in need plan, but the emphasis on this aspect of the assessment process is finding out whether a parent is willing and able, regardless of whether they are motivated, to change their behaviour for the benefit of their child.  7.5.30. Parenting capacity can be compromised for a variety of reasons and the ability of parents to sustain change in the long term depends on a number of factors. MP had her own struggles growing up, and had experienced abusive relationships and in this respect, she was herself, vulnerable and may well have struggled as a parent. Agency records comment on MP’s negativity towards Pippa even as a young child, including requests for her to be taken into care when Pippa was as young as 6 or 7 years old.  7.5.31. It would have been helpful for these issues to be explored in some depth as it remains unclear given the various services and interventions that had been put in place over the years whether MP had in fact, the capacity or motivation to change how she parented or cared for Pippa. There was evidence from agency records that suggested that whilst MP stressed that she wanted what was best for Pippa and HSP, she was not always able to prioritise the needs of her children over her relationships and work with early help services was rarely sustained.   7.5.32. Although both grandparents independently wanted to care for and look after Pippa, the practicalities and implications of them doing so were never realistically assessed. MGF lived with a partner who was concerned about Pippa making allegations, which could place her job in jeopardy.  MGM was frail and had recently suffered a stroke, whilst Pippa was a lively and boisterous 13 year old whose behaviours had, for several years proved problematic to the adults around her. None of the    Pippa SCR/LR/03.02.2022/updated Final Report  19 assessments seen by the review team addressed these issues in sufficient depth, had they done so it is possible that, despite residential care often being perceived as a placement of last resort, Pippa’s deep rooted need for stability and security may have been met much earlier through the care system.  7.5.33. Agency records clearly indicate that both MGF and MGM were seen as protective factors in Pippa’s life. It was also clear from records that MP was not willing or able to provide the care and security that Pippa needed. The direction by a judge to return Pippa to live with MGM went against the views of the local authority but they were compelled to act as directed.  Even so, as Pippa grew older, it became apparent that much as MGM wanted to keep Pippa safe and living with her, it was becoming increasingly difficult for her to do so and this situation was not likely to change. The LAC reviews did not pick up that MGM’s age, and poor health significantly reduced the capacity of MGM to exert influence over Pippa and apply boundaries. These factors, including the fact that Pippa had no personal space of her own when at home, were effectively creating ‘push’ factors which actually increased Pippa’s vulnerabilities and susceptibility to influences outside the home.    Learning Point 5: Professionals need to be able to make informed decisions not only about which parents/family members are able/unable to meet their children’s needs and why, but also what aspects of a parent’s behaviour needs to change. Consideration also needs to be given whether parents/family members have the motivation and capability to make such changes in line with their child’s needs and timeframe.  The CAMHS Assessment. 7.5.34. There are references in various records, to the fact that CAMHS was ‘working’ with Pippa, implicit in which is an assumption that Pippa was receiving ‘help’ from that agency. According to records made available to the review team, CAMHS was assessing Pippa for a mental health disorder rather than undertaking any therapeutic work with her. CSC records indicate that following a Section 47 investigation in May 2016, CAMHS were approached to provide information, which could support the CSC assessment, but it appears that no report could be forwarded, as the assessment was still ongoing.  The CAMHS worker (CMS1) did however attend various multi-agency meetings, which took place throughout 2016.    7.5.35. Records do suggest that MP often contacted the crisis team at CAMHS during 2015/2016 to report Pippa’s behaviour. The assessment to determine if Pippa met the criteria for an ASD diagnosis took almost a year to complete; the review team was unable to determine exactly why it took so long, although they were informed that such assessments can take several months to complete. It was not until CAMHS were directed by a judge in September 2016 to conclude their assessment that they were able to confirm four weeks later, that Pippa did not meet the criteria for a diagnosis of ASD but there was evidence of an attachment disorder.  A review of CAMHS case notes from meetings and phone calls with the family seem purely descriptive and there does not appear to be any assessment of Pippa’s mental health needs or any attempt to place her behaviours in any context. The review team was reminded however that the involvement of CAMHS at that time, was to just to undertake an assessment, not to undertake any therapeutic work.   7.5.36. CAMHS concluded that Pippa’s needs at the time did not meet the threshold for any ongoing work and the case was closed. This was a missed opportunity for Pippa to receive specialist help even indirectly, as the review team was informed that in some circumstances CAMHS can offer support to    Pippa SCR/LR/03.02.2022/updated Final Report  20 professionals who remain involved with the family. It may have been helpful  if such a working relationship had been established  but such an arrangement  was neither offered nor sought by any professional working with Pippa, neither was the detailed CAMHS assessment shared with CSC to inform their work with Pippa and her family going forward.   Looked after Child (LAC) Health Assessments   7.5.37. The review team had sight of a LAC Assessment dated September 2017 which indicated that Pippa was generally fit and healthy. Pippa answered No to the question about self harm. The review team was curious about the many references to Pippa’s ‘self-harm’  in agency records but it would seem  there was no evidence of this other than what was reported by MP - that Pippa cut or scratched herself ‘until she bled’.  Although school nurse records (SN1) indicate that Pippa told SN1 that she self-harmed, this does not appear to have been explored and no additional details are provided.  There is no information in GP records, which indicate evidence of self-harm. There are references in the records of two agencies that Pippa took an overdose in May 2014, but again there are no records, which can confirm this.   7.5.38. Research recently published in the Lancet Psychiatry Journal and published in the Guardian newspaper 11(4.6.19) suggest that self-harm is almost becoming normalised as new figures from the NHS show that there has been a huge increase in self-harm amongst children, more prominently in young girls. Whilst self-harm was recognised by practitioners as being a worrying concern, it was acknowledged that in Pippa’s case, there was a lack of professional curiosity about Pippa’s reported self-harm,  how or if it was manifest and what it entailed. This was almost a form of professional bias in that it was perhaps expected behavior so it was not challenged but accepted as given.    Risk assessments undertaken in residential homes 7.5.39. Good risk management demonstrates that staff understand each child, recognise the triggers for unsafe behaviour and know what steps to take in order to reduce to reduce harm. Above all, risk assessments have to be dynamic if they are to be an effective part of the overall plan to care for children and keep them safe.  7.5.40. The review team was advised by CH1 that in line with their usual practice, they undertook a risk and pre-admission assessment based on information provided by the social worker and the commissioning team from the local authority.   The review team was informed by the manager of CH1 that although the information made available to them was ‘inaccurate and inadequate’, Pippa’s placement was nevertheless confirmed. The review team have not had sight of any risk assessment undertaken by CH1 on her arrival in early May but have access to a copy of a risk assessment which was completed one week before Pippa left the placement in late June 2018.   7.5.41. In that document, the risks posed by Pippa to other residents from Pippa’s sexualised behaviours are assessed as being ‘very high’. There were no concerns noted relating to self-harm. The review team was told there was however a discrepancy in the initial documents provided by the social worker in                                                              11 https://www.theguardian.com/society/2019/jun/04/one-in-five-young-women-have-self-harmed-study-reveals     Pippa SCR/LR/03.02.2022/updated Final Report  21 that the placement request form indicated no concerns around self-harm yet the risk assessment rated the risk of self-harm as medium.  The review team was of the view that given this was not initially explored at the outset of the placement, its significance has only become apparent with hindsight.  Best practice would be that risk assessments are regularly reviewed and updated in light of significant daily occurrences and reported incidents. This does not appear to have happened in CH1.   7.5.42. The review team had sight of a risk assessment completed by CH2 in the first few days of Pippa’s arrival at the placement. The identified risks by CSC on their placement request form were considered and appropriate control measures were identified. However, the risk of self-harm/suicide, assessed by CSC as being low/medium, was included only in a sub section under Substance Misuse and Exploitation rather than as a section in its own right.  The risks, triggers and control measures associated with self harm/suicide are however quite distinct and despite CSC indicating there ‘was no evidence of self harm’, this specific risk and possible measures to mitigate harm could have been better considered.   The review team were of the view however, that even had this risk been more carefully explored in relation to Pippa, there was very little to suggest self harm or suicide ideation.    7.5.43. The risk assessment in CH2 was not reviewed between July and September as would be expected and although all staff indicated they had read the assessment not all staff had signed the document to this effect.  According to agency records, these issues have now been appropriately addressed by CH2.   7.5.44. There were it would seem, and in stark contrast to her time at CH1, no reported incidents of any significance whilst Pippa was at CH2 and the review team was keen to explore why this might be. However, neither the manager nor any staff from CH1 attended review team meetings or the practitioners group and neither did they respond to overtures by the lead reviewer to meet as the SCR process unfolded.  Assessments of Risk  7.5.45. A risk assessment for Pippa was undertaken in September 2017 by SW2 and discussed at a MDSP practitioners meeting the following month. The risk assessment identified the presence of 8 High Risk indicators of CSE, 17 Medium Risk indicators and 1 Low Risk indicator. The MDSP practitioners discussed the ongoing risk of CSE for Pippa in November 2017 and again in January 2018 where it was noted that the level of risk for Pippa, emerged from only one reported episode several months earlier and had not changed. A decision was taken that Pippa should  be removed from the MDSP process on the basis that she no longer had a phone, she was attending school, had a CSE worker allocated to her and she was subject to a LAC plan. The review team was of the view that further exploration of these issues would have highlighted Pippa’s continuing vulnerabilities; she did in fact have access to a mobile phone and was not engaging with the CSE worker.  Furthermore, it was becoming increasingly evident that MGM was struggling to exert any influence over Pippa and her whereabouts.   7.5.46. Pippa went missing on four occasions after she was ‘closed’ to MDSP in January 2018; on two occasions, she was missing overnight. The review team queried why this did not lead, as they should have done, to further referrals to MDSP so risk to Pippa could be reassessed. The review team was    Pippa SCR/LR/03.02.2022/updated Final Report  22 advised that police assessed two of these missing episodes as medium risk, and as MDSP only dealt with high risk cases, these were not referred back into the MDSP process.   7.5.47. The risk to Pippa was clearly viewed as a one off episode rather than an early indication of sexual exploitation. Understanding how different factors interact to increase vulnerability is particularly relevant when exploring risks in relation to children and young people especially those who go missing from home, education or care, because being ‘missing’ increases vulnerability. There are no reports which indicate where Pippa was or who she was with when she went missing, perhaps it would seem, because she always returned to MGM’s home rather than anywhere else. There were missed opportunities to use local intelligence and to explore in more detail Pippa’s contacts in the community and the influences they had or may have had on her behaviours.  One of Pippa’s known contacts (KTP) was well known to MDSP but the extent of his involvement with Pippa was not explored nor was any risk he may have posed to her.    7.5.48. A lack of analysis and critical thinking has consistently been highlighted in a number of serious case reviews, inquiries into child deaths and inspection reports. Assessment practice has been criticised for adopting a procedural, checklist approach when in fact assessing risk of sexual exploitation is complex and messy and certainly not straightforward. Risk-taking is a normal part of adolescent development and most young people experiment with the increased opportunities for risk that their growing independence allows. Deciding what is risk taking behaviour, what is ‘normal’ adolescent behaviour and what behaviours may be considered adaptive responses to adverse experiences is not easy.    7.5.49. It is not known whether Pippa was initially testing out her independence when she was first found missing from MGM’s home or whether she was seeking to spend less time with MGM - perhaps a combination of both – but what is known is that there were a number of pre-disposing factors which were not as well considered in the MDSP assessment as they might have been and which, coupled with Pippa’s living arrangements, meant that Pippa was particularly vulnerable to CSE. Whilst these indicators should have influenced to a far greater extent subsequent decision making and planning, it is not possible to determine that any other course of action may have prevented the actions which led to her death.  However, the continuing focus on Pippa’s behaviour obscured and hid the effects of cumulative adversity and this left Pippa vulnerable.   Learning Point 6:  Where CSE is suspected, it is essential that risk assessments take into account not only the presenting risk factors but also those risks, which emerge from vulnerabilities arising from past experiences such as abuse, loss and trauma.  Adolescents, self-harm and suicide   7.5.50. Suicide is the act of intentionally causing one's own death. It is not known whether Pippa intended to end her life and it is outside the remit of this SCR to consider whether the outcome of Pippa’s actions were deliberate or accidental.   7.5.51. Pippa’s death has however highlighted the importance of professionals understanding the factors that can lead to adolescent deaths by suicide. Suicide in young people is rarely caused by one thing; it usually follows a combination of previous vulnerabilities and recent events. Although Pippa was the subject of a risk assessment for CSE, the review team was not aware of any specific assessment to determine whether she was at risk of suicide.  Research suggests that the circumstances that lead    Pippa SCR/LR/03.02.2022/updated Final Report  23 to suicide in young people often seem to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversities, high risk behaviours in adolescence and early adulthood, and often, but not always, ‘a final straw’ event. It is not possible to determine whether something ‘flipped’ for Pippa, but even knowing the combination of her history and her existing struggles, the possibility of Pippa taking her own life was never considered as a risk factor by any of the professionals who knew her. 7.5.52. In discussions with the review team, practitioners described their shock upon learning of Pippa’s death and the way in which she died. Comments such as ‘I would never have thought it of Pippa’ and  ‘it never crossed my mind that she, of all young people would take her own life’ are testament to how little is known about  what goes on in the minds of young people who take actions, deliberate or otherwise, which end their life.   7.5.53. Whilst referrals into CSC during the period under review were made and accepted appropriately, they were too often viewed as individual episodic events and focused on the content of the referral, Pippa’s aggressive and violent behaviours’ while failing to consider in sufficient detail not only her history, but also what she may have been subjected to during her missing periods. Incidents need to be considered in context; concerns need to be connected in order to build up a fuller picture of a child’s life. Whilst some practitioners felt that there is not always enough time to read through a child’s file, without a careful sifting of case history and a realistic understanding of the impact of new and recent experiences, work with children may not be as effective as it could be.  Learning Point 7: Given the vulnerability of children coming into the care system, it would be helpful  to ensure that all assessments for adolescents thought to be at risk contain a standalone section which requires professionals, including health colleagues,  to consider and carefully comment upon self-harm or suicide ideation. The triggers and control measures associated with these harms are distinct and require careful consideration of what steps can be taken in all circumstances to minimise opportunities for a young person to harm themselves.    7.6. Professional Judgment and Decision-making  Terminology and the use of language 7.6.1. The language used by professionals provides a medium for describing perceptions and therefore has an extraordinary capacity to influence the way professionals think.12   Pippa’s behaviours were described by MP as ‘violent and aggressive’, a phrase frequently repeated in case files but without any clear analysis of the what, when and why aspects of this behaviour. The references to ‘self-harm’ littered through agency records are accepted as given, even though there is no description as to how these harms were manifest, or whether they actually existed. The way professionals describe what they hear and what they observe is hugely significant.   7.6.2. The description in CH1 records, that Pippa was seen coming out of a male resident’s room ‘giggling’ is, within the context of the recording, meant to infer, without any specifics, that ‘something was                                                              12 This is sometimes called the Sapir-Whorf hypothesis. ‘Language may indeed influence thought’ Jordan  Slatev and Johann Blomberg. Phil Papers October 2015    Pippa SCR/LR/03.02.2022/updated Final Report  24 going on’. Records also state that she was seen to ‘entice and pester’ another resident, a clear example of language being an indicator of a biased and less than objective judgment.   7.6.3. The 2017 Single Assessment has entries copied from a previous assessment but there is also additional and more up to date information included. Pippa’s behaviours continue to be conceptualised as a problem within herself, rather than being a symptom of any underlying issues. Evidence for this, is found in comments in the assessment such as   ‘there were several violent incidents in the home… caused by Pippa reacting badly when she can’t get her own away’ and ‘Pippa needs to learn to deal with emotions appropriately’. Professionals can compound misconceptions through their attitudes and inappropriate language and euphemisms, and the words professionals use to describe a child or their behaviours clearly indicate a particular perspective which is not always helpful. The review team found the contrast between how CH1 and CH2 described Pippa and her behaviours particularly noticeable.  Bias and Professional Curiosity 7.6.4. There is a substantial body of research evidence13 that has identified the tendency for ‘early evidence bias’ in human decision-making that a first summing up of a situation strongly influences the analysis of subsequent or new information. Given the need to record judgments at an early point, there is a very real danger that practitioners who are not mindful of this potential bias in human reasoning will simply search for and accept evidence that confirms their first hypothesis.  7.6.5. The review team found numerous examples during the review of professionals and to some extent MP, simply not being curious enough about Pippa’s behaviours or even what she said; MP described at a network meeting how Pippa, then aged 13 became physically aggressive one evening when MP prevented her from phoning her ‘grandfather’ after midnight and Pippa’s comments that she had a 17 year old boyfriend were dismissed as Pippa ‘telling lies’. There does not appear to have been any curiosity of follow up to Pippa expressing her discomfort about being around a male foster carer.   7.6.6. As part of an English assignment in early 2018,  Pippa produced a piece of writing in her English lesson,  explicitly written in the first person, the text  describes an abusive sexual relationship involving what might be described as a form of ‘strangulation’. There is also a reference to ‘my sexual abusive past’. According to education records, Pippa was excluded for three days for submitting this piece of work and although SW1 was informed and it was recorded in the LAC review meeting which took place the following month, there was no significance attached to this incident. Even acknowledging the possibility of hindsight bias, such explicit writing submitted by a young adolescent with Pippa’s history should have led to sensitive outreach by SW1 and further exploration of CSE risks.   7.6.7. There were at times assumptions made by professionals and by MP that Pippa’s outbursts, her aggression, and certainly her prose, as in the example above, were just ‘typical’ of Pippa. What would have been more helpful was for professionals to have explored in much greater depth, what had                                                              13 Munro, 2011, 1999; Burton, 2009.    Pippa SCR/LR/03.02.2022/updated Final Report  25 happened to Pippa in the past, and importantly, exactly what was still happening to her in the present and with whom.   7.6.8. Young people rarely disclose abuse or neglect directly with practitioners, if they do, it is most often through unusual or testing behaviour or comments. Equally, young people are unlikely to comfortably disclose risky sexual behaviours they may encounter or which they find themselves in. This is where professional inquisitiveness or curiosity is so important. Professional curiosity is the capacity and communication skill to explore and understand what is happening to a child rather than making assumptions or accepting things at face value. The review team considered that professionals could have been more curious and inquisitive about what Pippa’s was experiencing as a young adolescent and how or if she was making sense of these experiences, some of which were clearly abusive.    Learning Point 8: Curiosity and inquisitiveness should be part and parcel of professional practice. Unless professionals maintain a questioning and curious response to what they are told or what they see, opportunities for exploring the unthinkable or opening up conversations with young people will be limited and they may be left vulnerable.  Lack of challenge 7.6.9. For much of the time during the period under review, Pippa lived with MGM and did not have a room of her own. It is puzzling how this situation was accepted for so long, without challenge either from professionals, their managers or the IRO. The decision by the judge, supported by CAFCASS, to remove Pippa from a foster home where she had lived for 6 months to be placed with MGM conflicted with the views of the local authority. The judge also directed that the local authority should support MGM secure appropriate accommodation and although two housing association homes were viewed, neither was found to be suitable and Pippa remained sleeping on a sofa bed from February 2017 until May 2018.    7.6.10. The absence of any sense of urgency by CSC led to Pippa’s placement drifting without evidence of any long term planning.  Managerial oversight was not robust and case supervision records lacked reflection and focus. The review team was advised that the number of management changes compounded oversight even further and this was reflected in the supervisory arrangements not being as effective as they should have been. More recently, there has been a move to address these issues through a series of practice skill sessions aimed at improving supervisory practice within children’s services. Whilst managerial oversight in CSC was not good, neither did any other agency check or challenge the appropriateness of Pippa’s placement, or the drift and delay in addressing the escalating risk to Pippa of living with a grandparent who found it increasingly difficult to exert any boundaries or manage her behaviours. The review team thought it highly unlikely that agencies would have been content to leave a younger child for so long without a proper bed or robust adult supervision.   7.6.11. The range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience and research. The review considered that the response of practitioners and the lack of challenge might    Pippa SCR/LR/03.02.2022/updated Final Report  26 have reflected a faulty assumptions that Pippa was perhaps more resilient by virtue of her age despite the evidence that she had experience of more cumulative harms.  7.6.12. Research in Practice14 states that ‘all too often services do not recognise or respond to underlying causes of crises, do not adequately ‘work with the grain’ of adolescent development, do not draw on the strengths of young people, their families and peers, and do not support practitioners sufficiently to manage the complexity involved with adolescent risk.’ The Review Team found evidence of significant amounts of professional activity and some good practice but little to suggest the activity was in response to well thought out plans or clearly defined expected outcomes. This aspect of work with Pippa should have been challenged at so many levels but a lack of direction and urgency was evident despite the efforts of those involved.  Learning Point 9: Without robust managerial oversight to ensure that work plans are in place and are regularly reviewed, the effectiveness of interventions cannot be easily determined, and work with families can drift leaving children vulnerable.  7.7. ASP 4: The extent to which agencies worked collaboratively.  7.7.1. Agencies have a collective responsibility to safeguard and protect children and this demands effective communication and co-ordination of services at both strategic and operational levels. Although there was good information sharing between agencies, multi-agency working was not as effective as it might have been. Around 10 multi-agency meetings, appear to have taken place in 2016, some were referred to as CIN meetings, whilst others were described as Network meetings. The review team was told these were different names for the same meeting.  In 2017, according to the integrated chronology, only 4 multi-agency meetings were recorded and in 2018, only one LAC review was recorded. Not all agencies recorded the same dates for meetings and some meetings were recorded in agency records but not included in the integrated chronology.  Use of Chronologies to share significant events  7.7.2. As in many other SCRs, it was only when the integrated chronology was shared with all agencies that the gradual and steady risks to Pippa became apparent. Chronologies have been identified as invaluable tools to record a child’s development throughout ongoing work and to track a child’s pathways, especially when a child’s journey takes them into areas of risk such as CSE. However, single agency and multi-agency chronologies are too often completed retrospectively after harm and adverse outcomes have been identified.   7.7.3. In reviewing agency records and examining Pippa’s assessments, there is much information provided but so much is repeated and reworded that it was not easy to gain a true sense of Pippa’s journey. Without a multi-agency chronology, it is almost impossible to ‘see’ any emerging patterns or understand how the work of individual agencies does or does not, contribute to a child’s overall plan. Despite, this and it is a key learning point in many SCRs, the process of creating a shared and multi-agency chronology from the outset of work with families, where there are concerns is not common or expected  practice.                                                               14Research in Practice Developing a more effective response to adolescent risk (2014)     Pippa SCR/LR/03.02.2022/updated Final Report  27  7.7.4. Reading through the integrated chronology, even from December 2015, Pippa’s fractured relationship with MP, her lack of stability and security and what must have been the inevitable frustration as an adolescent of not having any personal space whatsoever, other than her phone, reveal a number of ‘push’ factors which made Pippa particularly vulnerable to exploitation by others. These patterns and pathways are not so easily observed through reports, assessments, and minutes of meetings but they do become crystal clear through the lens of an integrated chronology.  7.7.5. Whilst chronologies are invaluable tools to systematically monitor patterns and significant incidents, the practicalities of creating and maintaining them are numerous and complex. Yet, these tools can greatly aid case analysis, and encourage practitioners to contextualise presenting issues in the wider family history. Health colleagues describe how they use every fourth entry in a significant incident chronology as a trigger to discuss concerns in supervision. There does not appear to be similar systems in other agencies and there is no current system or agreed process in place in the locality to support the production of shared chronologies within a multi-agency framework. This is a key area which if developed could have significant impact on multi-agency analyses and decision-making.   Learning Point 10:  When concerns are raised about a child, a clear chronology of significant events can show agencies where risks lie, but unless practitioners are supported to identify and share significant events or incidents in a child’s life, and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making will not happen. Multi-agency collaboration.  7.7.6. There were many examples of professionals communicating with each other, sharing information via emails and phone calls; the school nurses kept social workers up to date after health assessments, social workers regularly liaised with school staff and police usually ensured that reports were submitted following Pippa’s missing from home episodes. In this respect multi-agency working was as expected. However, these communications, important as they are, are not the same as multi-agency collaboration. When important and relevant information related to a child is shared or communicated to colleagues, it is important that professionals take the next step of exploring within a multi-agency context what this means and why significance is attached to certain issues and not others.   7.7.7. Multi-agency meetings remain the key mechanism for implementing and progressing plans to promote a child’s well-being, safety, and welfare. When these meetings work well, they ensure that everyone works collaboratively towards agreed goals so the very best outcomes for a child can be secured. Where they existed, the review team obtained copies of minutes from the various multi-agency meetings, which took place during the period under review, including minutes from LAC reviews. These documents record feedback from practitioners and note what should happen next, they are not particularly helpful in determining who should do what and why and how progress of that work would be monitored and measured.   7.7.8. Health services, and especially school nurses, make a significant contribution to supporting children and young people and especially those at risk of or harmed through sexual exploitation. Pippa was    Pippa SCR/LR/03.02.2022/updated Final Report  28 under the Universal Partnership Plus for school nursing services, which provided targeted packages of support. School Nurse 2 (SN2) had several contacts with Pippa and MGM during the period under review and records indicate she was concerned about the viability of Pippa’s placement with MGM. There is evidence that the school nurse liaised with the LAC nurse when Pippa became a looked after child, but the review team were curious as to why the there was no involvement from school nursing service in multi-agency meetings and whether this is a capacity issue and/or a policy decision. School Nurse 1 (SN1) was not informed, when Pippa became looked after for the first time and SN2 was not kept informed about Pippa being the subject of the MDSP process. The School Nursing service is, the review team was told, now represented on the MDSP practitioner group.  7.7.9. The LAC reviews simply listed a number of tasks, which had to be achieved, or which had not been completed. None of the minutes seen by the review team indicated close collaboration between agencies and it was difficult to understand what goals had been agreed and what progress had been made towards their achievement. The format and style of these documents are clearly designed to meet the needs of an IT system rather than the individuals who have to make use of them. What emerged from the review of minutes from a number of multi –agency meetings was the absence of any robust multi-agency plan to inform and guide work undertaken with Pippa throughout the 2 year period under review.  Learning Point 11: Unless multi-agency meetings are well chaired, structured, and purposeful, work with families can drift but because the meetings take place, they give the impression of progress.    Quality of Plans 7.7.10. Children’s plans, built and designed for children who need care or protection, represent the framework in which professionals help children develop and be safe. It is well researched that they are best developed and implemented through the functioning of multi-agency groups. The issue of how plans - are produced and utilised is a vexed one, but families and practitioners - need to be clear about what needs to change, by when and what the expected outcome will be and, importantly, how and where the intervention of professionals will make a difference. Such plans are crucial to multi-agency working in that they provide the agenda and direction of work to be undertaken with families.  7.7.11. Given how central these plans are in improving outcomes the review team was concerned to note that the CIN plan and the subsequent Care Plan for Pippa were vague, unrealistic and without the means by which progress could be easily measured, making them largely ineffective. One example extracted from a CIN plan in June 2016 was for ‘parents to support Pippa to develop strategies to help her manage her emotions and behaviour in a positive manner ‘as if by stating this, changes in the family would simply happen. The language, too, is careless, Pippa had only one parent involved in her life, and P4 was not her parent.  7.7.12. Neither MP nor MGM could recall seeing any copies of plans for Pippa or receiving any minutes of key meetings. Whilst this issue is one, which should be addressed, the review team also concluded that the format of plans and minutes are not produced in ways which are helpful and especially not for the children to whom they refer.      Pippa SCR/LR/03.02.2022/updated Final Report  29 7.7.13. The objective of the Pippa’s LAC plan in August 2016 was to ‘ensure that Pippa is in a stable and safe environment in which her physical and emotional well-being will be promoted.’ In effect, between July 2016 and August 2018, plans to provide a stable environment for Pippa did not materialise and there was considerable scope for the IRO to challenge how realistic the plans were for Pippa and how well they were being executed. On the occasions when placements broke down, plans for Pippa should have been subject to greater scrutiny by the IRO. It would have been helpful if upon learning that Pippa’s placement had broken down in CH1 that the due date for her LAC review in October was brought forward to July/August so plans could be reviewed. There was certainly a sense of drift and little challenge to a precarious family placement where professionals were repeatedly told by MGM that she could not manage or control Pippa’s behaviour. Neither is there evidence that Pippa’s Care Plan was updated or changed once risks of CSE became known.   Learning Point 12: Unless all children’s plans have SMART15 objectives and are regularly scrutinised, work with families will lack focus and will be ineffective, leaving some child vulnerable.   A shared responsibility  7.7.14. MP informed the lead reviewer and the LSCB Business Manager that she had received no communications from CSC inviting her to meetings about Pippa, neither had she received any information about what was happening in her daughter’s life. The review team have however had sight of letters and minutes that were sent to MP at her address in Area1 in 2016 and later to her address in Area2. Agency records suggest that MP sent her apologies to some meetings through contact with SW1. Pippa was made subject to a full Care Order in February 2017 and the local authority supported contact between Pippa and MP initially, it seems, through occasional supervised contact sessions. Pippa’s views are later recorded several times as saying she did not want contact with MP and her wishes in this respect were respected. MP told the lead reviewer she would have attended meetings if she had been able to attend and had been invited.   7.7.15. During the period under review, Pippa had four out- of- home placements. Two of these were with foster families, one of whom Pippa lived with for 6 months before she was returned to the care of her MGM. Pippa then stayed with MGM for 15 months before moving into CH1. After 7 weeks, Pippa was moved again to CH2. The review team could find no evidence that disruption or end of placement meetings took place when any of the previous placements ended. Such meetings are known to be best practice as they provide the means by which the child and the placement provider can be supported to understand why the placement has ended and what support might be needed to ensure the stability of any future placements.    7.7.16. Practice experience and key research findings support the critical importance of placement stability for children and young people who need looking after. Children who experience multiple caregivers undergo repeated and stressful transitions to and from different living arrangements. Research and practice wisdom attest to the negative impact of multiple placement changes not only on children’s development, confidence and well-being but also on their internal working model and self-beliefs. Even prior to coming into the care system Pippa had experienced multiple moves back and forth                                                              15 Specific, Measurable, Achievable, Realistic and Time bound (SMART)     Pippa SCR/LR/03.02.2022/updated Final Report  30 between her mother and her grandmother’s home and the issue of her lack of stability was a significant aspect of her vulnerabilities.   7.7.17. Once it became evident that Pippa could no longer live with MGM, a decision was taken that Pippa’s needs would best met through the provision of a therapeutic residential environment. At a national level, the situation regarding the lack of suitable adolescent mental health beds remains a concern and even with early intervention, the right assessment, and good planning, finding the most appropriate resource remains a challenge for local authorities in relation to children with complex needs. Professionals face particular challenges when seeking placements, which can meet all the needs of the young person. Placement providers are, understandably, selective in terms of who they will accept, clearly wanting to offer placements, but equally not wanting to take excessive risk in agreeing a placement, which would prove disruptive of their regime or prove to be a risk to other residents. This places an immense burden on responsible professionals in securing a suitable placement for children whose needs are complex and significant and especially so where there is an urgent need for accommodation as there was with Pippa in May 2018.   7.7.18. Negotiations took place with CH1 some 20 miles in Area3. At this time SW1 had left and SW2, an agency worker, had recently been allocated to Pippa. From records it seems that SW2 was not as familiar with Pippa’s background history as she might have been which, given the circumstances was clearly of some concern to CH1. Pippa stayed at CH1 for around 7 weeks before CSC was given 7days notice that the placement was to be terminated. Regulations stipulate that the local authority must be given 28days notice but the manager of CH1 insisted that Pippa, because of her sexualised behaviour, posed a risk to other residents. According to records, this manager demanded that the social worker remove Pippa from the placement and with nowhere to go, Pippa spent two nights in a hotel with her social worker before accommodation was found in CH2, a newly established local placement offering therapy.   7.7.19. The review team was concerned not about the placement ending but the way in which it was managed, causing extreme stress to a child who had already experienced repeated and stressful transitions to and from different living arrangements. The issue of Pippa’s behaviour in CH1 is not in question; the placement might not have been right for either party, but the conflict which emerged between the local authority who asked for a longer period to find an alternative placement and the refusal of the manager of CH1 to accede to this request was of some concern to the review team, especially as the request to move was made soon after Pippa’s disclosure about historical sexual abuse.   7.7.20. The manager of CH1 completed an Agency Learning Report and the review team was disappointed to note that the only learning identified was the need for CH1 to revise their pre-admission format and risk assessments when in fact there was much learning to be gained in terms of how CH1 manage placements in future if young people begin to display sexualised behaviour. The tone and language of some recordings related to Pippa’s behaviour is not what would be expected of staff working in a caring environment with young people.      Pippa SCR/LR/03.02.2022/updated Final Report  31 7.7.21. It is important that professionals in all services utilise knowledge about child development, attachment and trauma and acknowledge that children, especially those coming into care, are more likely than not to be struggling with feelings of loss, bereavement, fearfulness and mistrust. Behaviour difficulties and challenging behaviours in this respect are perhaps to be expected and responded to in ways which do not further damage the child’s well-being and mental health. The needs of one individual of course need to be considered in line with the need of other residents, but the review team was of the view that if sexualised behaviour cannot be sensitively and safely managed in a care home, this should be made explicit on websites, literature and at initial meetings with Commissioners.   7.7.22. Pippa was placed in CH2 for an initial six week placement and the review team was told that Pippa was aware that her time at CH2 would be for a limited period.  CH2 was also a mixed therapeutic environment, where Pippa was described as ‘challenging but lovely’. There were no significant incidents relating to her behaviour. She was reported to be frequently baking cakes for staff and residents or performing a song or drama for their entertainment. Agency records suggest she was settled in the placement but what emerged from records was that Pippa needed to be reassured by staff that they cared about her and her anxieties noticeably increased as the date for another move was approaching.   7.7.23. It is unclear to what extent Pippa was involved in key decisions about what was happening, she certainly gave the impression to staff in CH2 that she believed the move was based on financial considerations by the local authority and this undoubtedly would have made it hard to accept her move even if this was not the case. The review team was unable to determine why Pippa believed her future was based solely on financial considerations and which professional, if any, had spoken to her about this. Despite previously refusing support, Pippa asked staff in CH2 only a few days before her death, to find her an advocate so she could be supported to stay in CH2.   7.7.24. Clear communication about the reasons why moves are necessary, and frequent reassurance for children and young people, is essential to manage the process of changing placement.  Not long after her arrival at CH2, Pippa was allocated her third social worker since SW1 had left earlier that year and there would have been very little time to establish any meaningful relationship, coupled with the fact that the ‘new’ social worker was male and Pippa had  previously indicated she felt ‘uncomfortable’ around males she did not know. The impact of changes in social workers at important times of transition and the detrimental impact of a lack of a trusted adult for some children at these times should never be underestimated.   7.7.25. Asked about the time it took for staff in CH2 to find Pippa, the review team was told by  the manager of CH2 that Pippa would often sleep late when she was not school, sometimes staying in bed until noon. Staff were aware that Pippa would not be going into school that day and despite a knock on her bedroom door around 9.00pm, staff did not return to her room until around midday. CH2 have since changed their procedures to ensure that all residents are seen or spoken to by 9.00 am every morning.      Pippa SCR/LR/03.02.2022/updated Final Report  32 7.7.26. Managers at both residential establishments raised concerns about the difficulties they encountered in trying to contact someone in the local authority to clarify or obtain key details relating to Pippa. Examples were given of calls not being returned, confusion about which social workers were involved and important paperwork not being completed. Both establishments indicated these issues happen often and even managers, did not always call back when messages were left. Neither establishment indicated they were aware of the LSCB escalation procedures. Whilst CH2 participated in the SCR process, conversations with the commissioners identified that there was no contract requirement for them to do so and this issue should be addressed in future contracts.   7.7.27. There would be value in the commissioning team in children’s services reviewing all contracts with providers of residential services to ensure they include references to LSCB’s safeguarding procedures for escalating concerns about professional practice and/or decision-making. Information should also be provided about the requirement for all providers to cooperate with any national or local safeguarding practice reviews, which may be established.   7.8. Pippa’s lived experience   7.8.1. It perhaps would be fair to say that from a very young age, Pippa received messages that she was a problem to her family and as she grew older, this version of herself was reinforced through the involvement of a range of professionals who tried to help with her behaviour. Reading through records and talking with practitioners it is clear that practitioners from all agencies wanted to do the very best for Pippa yet there are relatively few records, which give voice to Pippa’s wishes and feelings.   7.8.2. For adolescents who have strained or fragmented relationships with their family, and particularly for those who have experienced abuse or neglect, engagement with professionals can be difficult yet these relationships can be key for some children. Due to staffing issues, Pippa had at least 4 different social workers in contact with her between May and September 2018, the very time when she perhaps most needed to draw on support that was familiar, friendly, and, most importantly, trustworthy.   7.8.3. Research16 provides evidence of the powerful and central role that relationships play in adolescent’s well-being. SW1 had remained her social worker for almost two years before she moved to another post. Records do not comment on how Pippa handled this but undoubtedly, the timing of her move just prior to Pippa’s first residential placement would not have been without impact. SW1 no longer works for the authority so the review team has been unable to benefit from her perspective and what would undoubtedly have been some very useful insights. According to records, SW1 prepared Pippa well for her departure and wrote a warm letter to her outlining the work they had done together and expressing encouragement for Pippa’s future. Between May and August 2018, Pippa had 2 other social workers in contact with her and was allocated a fourth social worker a few weeks before she died.                                                                 16 World Health Organisation (2014) Health and  Well-being of young people    Pippa SCR/LR/03.02.2022/updated Final Report  33 7.8.4. Practitioners describe how Pippa would usually not want to talk to professionals if she could avoid it. There are records, which refer to Pippa saying that meetings were ‘boring’ and would often retort she did not want to spend  ‘three hours’ just talking. The use of non-engagement, as a coping strategy, is a common feature in adolescents but perhaps professionals could have been more persistent and creative about helping Pippa explore what must have been some very difficult issues. References in agency records to Pippa’s ‘quirkiness’, her apparent confidence and carefree approach together with her flippant remarks when professionals tried to encourage her to talk about herself, may well have unwittingly led practitioners to feel reassured about her ability to keep herself safe.  7.8.5. Listening to the ‘voice of the child’ does not only refer to what children say directly, but to many other aspects of their presentation, how they look, how they behave and with whom; it essentially means seeing a child’s experiences from their point of view. Professionals talked warmly about Pippa describing her as funny and engaging, stroppy and challenging, kind and abusive but with a personality that could not be ignored. The review team have also had sight of various records, reports, and assessments, but within those documents there is a scarcity of records, which describe in any depth Pippa’s thoughts about her lived experiences. 7.8.6. Whilst it is recognised that adversity in childhood is not in itself deterministic of a poor outcomes in later life, there is substantial evidence that it does make it more likely that, without the right sort of support, things can go wrong for the child and for the adult they will become. The fact that Pippa didn’t ‘seem’ like a young person to take her own life highlights that perhaps more needs to be done to equip professionals to better understand issues for young people whose actions, deliberate or otherwise, can lead to their death.  Learning Point 13: A lack of knowledge among professionals about the evidence base related to risk indicators for adolescents who die as a result of their own actions, could leave them ill equipped to discuss and/ or recognise signs and respond accordingly.  7.8.7. According to agency records, it appears that Pippa spent time in the company of other young people known to CSC and police. Whilst it is not known to what extent social media impacted on her life, MGM and MGF told the review team that Pippa was always on her phone, tablet or laptop. Access to these devices was however limited when she was living in CH2 but they were removed by police after her death.  7.8.8.  After Pippa’s death, police removed a laptop and tablet from CH2 but the review team was told information could not be accessed as both devices remain password protected. When a child or young person takes their life and the police have ascertained that a crime has not been committed, the review team learnt that police have no power to examine these devices to determine if the death was as a result of harm or incitement by someone else or was a result of access to websites about suicide. Investigating a child’s digital footprint as soon as possible after their unexplained death should be an immediate task, led by police, to determine any factors which may have led to the death of the young person and/or which could safeguard other young people.  7.8.9. In 2018, the Department for Education circulated a new draft of Working Together to Safeguard Children guidance, which includes attention to adolescents who are “vulnerable to abuse or exploitation from outside their families”. Inquiries into serious failures in other authorities have led to a national focus on improving understanding of and response to the complex risks faced by adolescents.    Pippa SCR/LR/03.02.2022/updated Final Report  34  7.8.10. It is impossible to say whether the sad death of Pippa was preventable. Pippa’s family and those professionals who knew and worked with Pippa have searched and continue to search for reasons, which help them understand what triggered the actions, which led to her death. Just as it was not possible to predict the death of Pippa, neither is it possible to attribute the cause of her death to any failings on the part of professionals who knew her or her family.  This review nevertheless reminds all professionals working with young people to be aware that the pathways leading to harms that adolescents face are complex, not least because they often involve what appear to be adolescent choices and behaviours which can mask, rather than expose, hidden vulnerabilities.   8. Summary of Learning Points  8.1.1. The learning points identified by the  lead reviewer and the review team were shared,, discussed and agreed with practitioners as being relevant to current  practice in Middlesbrough.   Learning Point 1:  It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours. (REC 1 and REC 2)  Learning Point 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies because of a secondary presenting factor, which then becomes the focus of intervention.  It is worth considering, especially in light of the findings from the Children’s Commissioner whether more work is needed in the locality to increase professional understanding and awareness of familial child sexual abuse. This might be particularly helpful given the range of ways the impacts of physical and emotional neglect can mediate or set the scene for a child’s increased vulnerability to Child Sexual Exploitation. (REC 1)  Learning Point 3: Whilst social workers and other professionals are skilled at communicating and gathering information, there is evidence that they need greater support to analyse and evaluate the data they collect, so the multi-agency analysis can support and be seen to support professional judgments and decision-making. (REC 3)  Learning Point 4: When working with children, practitioners need to proactively assess and engage with all significant men in a child’s life, recognising that some may pose risks, some may be assets to the family and some may incorporate aspects of both.  Where concerns exist and there is evidence of conflict between a child/young person and significant none birth related males in a family, this should always be explored in assessments and be incorporated into ongoing work (REC 3)  Learning Point 5: Professionals need to be able to make informed decisions not only about which parents/family members are able/unable to meet their children’s needs and why, but also what aspects of a parent’s behaviour needs to change. Consideration also needs to be given whether parents/family members have the motivation and capability to make such changes in line with their child’s needs and timeframe. (REC 3)    Pippa SCR/LR/03.02.2022/updated Final Report  35 Learning Point 6:  Where CSE is suspected, it is essential that risk assessments take into account not only the presenting risk factors but also those risks, which emerge from vulnerabilities arising from past experiences such as abuse, loss and trauma. (REC 1)  Learning Point 7: Given the vulnerability of children coming into the care system, it would be helpful to ensure that all assessments for adolescent thought  to be at risk contain a stand-alone section which requires professionals, including health colleagues, to consider and carefully comment upon self-harm or suicide ideation. The triggers and control measures associated with these harms are distinct and require careful consideration of what steps should  be taken to minimise opportunities for a young person to harm themselves. (REC 1)  Learning Point 8: Curiosity and inquisitiveness should be part and parcel of professional practice. Unless professionals maintain a questioning and curious response to what they are told or what they see, opportunities for exploring the unthinkable or opening up conversations with young people will be limited and they may be left vulnerable. (REC 1)  Learning Point 9: Without robust managerial oversight to ensure that work plans are in place and are regularly reviewed, the effectiveness of interventions cannot be easily determined, and work with families can drift leaving children vulnerable. (Rec 2)  Learning Point 10:  When concerns are raised about a child, a clear chronology of significant events can show agencies where risks lie but unless practitioners are supported to identify and share significant events or incidents in a child’s life, and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making will not happen. (REC 3) Learning Point 11: Unless multi-agency meetings are well chaired, structured, and purposeful, work with families can drift but because the meetings take place, they can give the impression of progress.  (REC 3) Learning Point 12: Unless all children’s plans have SMART17 objectives and are regularly scrutinised, work with families will lack focus and will likely be ineffective, leaving some child vulnerable (REC 3)  Learning Point 13: A lack of knowledge among professionals about the evidence base related to risk indicators for adolescents who die as a result of their own actions, could leave them ill equipped to discuss and/ or recognise signs and respond accordingly. (REC 1)                                                               17 Specific, Measurable, Achievable, Realistic and Time bound (SMART)   9. Recommendations for the Safeguarding  Children Partnership18 (SCP) 9.1.1. The recommendations have been discussed and agreed with the review team.  Recommendation 1: SCP should support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents.19  Learning Point 1:  It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours.  Learning Point 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies because of a secondary presenting factor, which then becomes the focus of intervention. It is worth considering, especially in light of the findings from the Children’s Commissioner whether more work is needed in the locality to increase professional understanding and awareness of familial child sexual abuse. This might be particularly helpful given the range of ways the impacts of physical and emotional neglect can mediate or set the scene for a young person’s  increased vulnerability to risk, including Child Sexual Exploitation  Learning Point 6:  Where CSE is suspected, it is essential that risk assessments take into account not only the presenting risk factors but also those risks, which emerge from vulnerabilities arising from past experiences such as abuse, loss and trauma.   Learning Point 7: Given the vulnerability of children coming into the care system, it would be helpful to ensure that all assessments for adolescent thought  to be at risk contain a standalone section which requires professionals, including health colleagues, to consider and carefully comment upon self-harm or suicide ideation. The triggers and control measures associated with these harms are distinct and require careful consideration of what steps should be taken to minimise opportunities for a young person to harm themselves.   Learning Point 8: Curiosity and inquisitiveness should be part and parcel of professional practice. Unless professionals maintain a questioning and curious response to what they are told or what they see, opportunities for exploring the unthinkable or opening up sensitive conversations with young people will be limited and they may be left vulnerable.   Learning Point 13: A lack of knowledge among professionals about the evidence base related to risk indicators for adolescents who die as a result of their own actions, could leave them ill equipped to discuss and/ or recognise signs and respond accordingly.                                                               18 From September 2019, the Local Safeguarding  Children Board was replaced by the Safeguarding  Children Partnership (SCP) 19 See ‘That Difficult Age: Developing effective response to risks in adolescence’ Research in Practice 2016t     Pippa SCR/LR/03.02.2022/updated Final Report  37   Recommendation 2:   STSCP should seek assurance that all agencies a)  have systems which can evidence robust  managerial  oversight of  actions, decisions  and plans relating  to work with adolescents b)  have systems to ensure practitioners  have regular  supervision from a senior manager, safeguarding lead or an appropriate external source c)  provide practitioners  with access to  learning and development opportunities about ACES, Trauma and familial Child Sexual Abuse  Learning Point 1:  It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours.   Learning Point 9: Without robust managerial oversight to ensure that work plans are in place and are regularly reviewed, the effectiveness of interventions cannot be easily determined, and work with families can drift leaving children vulnerable. (REC 2)    Recommendation 3: SCP should audit the effectiveness of VEMT meetings, LAC reviews and all Child Protection meetings and take steps to ensure these multi-agency meetings are robust and lead to improved and timely outcomes for children and young people. Learning Point 3: Whilst social workers and other professionals are skilled at communicating and gathering information, there is evidence that they need greater support to analyse and evaluate the data they collect so multi-agency analysis can support and be seen to support professional judgments and decision-making.  Learning Point 4: When working with children, practitioners need to proactively assess and engage with significant men in a child’s life, recognising that some may pose risks, some may be assets to the family and some may incorporate aspects of both.  Where concerns exist and there is evidence of conflict between a child/young person  and significant  none-  birth related males  in a family,  this should always be explored in  multi-agency assessments and be incorporated into  ongoing work  Learning Point 5: Professionals need to be able to make informed decisions not only about which parents/family members are able/unable to meet their children’s needs and why, but also what aspects of a parent’s behaviour needs to change. Consideration also needs to be given whether parents/family    Pippa SCR/LR/03.02.2022/updated Final Report  38 members have the motivation and capability to make such changes in line with their child’s needs and timeframe.  Learning Point 10:  When concerns are raised about a child, a clear chronology of significant events can show agencies where risks lie but unless practitioners are supported to identify and share significant events or incidents in a child’s life, and without clear systems to gather, record and share this information in multi-agency settings, the use of chronologies to inform good assessments and decision making will not happen.  Learning Point 11: Unless multi-agency meetings are well chaired, structured, and purposeful, work with families can drift but because the meetings take place, they can give the impression of progress.    Learning Point 12: Unless all children’s plans have SMART20 objectives and are regularly scrutinised, work with families will lack focus and will  be ineffective, leaving some child vulnerable                                                               20 Specific, Measurable, Achievable, Realistic and Time bound (SMART)   