Serious assault of a child in care by an adult in 2019, resulting in life-changing injuries. The perpetrator was the son of a member of the residential unit staff where PS lived. PS experienced many adverse childhood experiences (ACEs), including physical and emotional abuse. At 7-years-old he was removed from Mother's care and lived with his paternal grandparents under a Special Guardianship Order (SGO). PS was described as a troubled child, and in 2017 his grandparents felt unable to cope with his aggressive behaviour. Following several placements in foster care and in a residential care home, PS was placed in the residential unit where he stayed until the assault. Ethnicity or nationality not stated. Learning includes: it's critical that families involved in SGO placements receive information, advice and training on ACEs and the strategies they need to adopt to maintain the placement; agencies should have acted as responsible adults and asked for a previous assault of PS to be investigated. Victims of crime often are fearful of retribution. Recommendations include: ensure that the 'voice of the child' is routinely captured during assessments; ensure that measures used to determine suitability of residential settings for placing children are fit for purpose; ensure that newly-qualified social workers and practitioners working directly with children and families receive formal monthly supervision; staff working with children such as PS should be trained to spot and respond to early signs of exploitation, such as cash in hand work; staff and managers should know and be able to apply the principles of trauma-informed practice.
      
    Serious Case Review No:  2021/C8893  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.      Child Safeguarding Practice Review PS Lead Reviewer: Jan Pickles OBE Official LCSPR -PS FOR PUBLICATION - March 2021   1    Contents  1.Glossary ......................................................................................................................... 2 2. The LCSPR Process, Author and Review Panel ............................................................ 2 3.Terms of Reference. ....................................................................................................... 3 3.1 Aim of the Review .................................................................................................... 3     3.2 Time Period to be Considered by the Review and Rationale: .................................. 3 3.3 Key Issues to be Addressed by the Review:............................................................. 3 4. The Facts ...................................................................................................................... 3 5. The child and family views ............................................................................................. 8 6. Key Decisions .............................................................................................................. 10 7. Analysis of events ........................................................................................................ 14 8. Wider significance ....................................................................................................... 16 9. Learning from events ................................................................................................... 17 10. Good Practice ............................................................................................................ 19 11. Recommendations for change ................................................................................... 20                 Official LCSPR -PS FOR PUBLICATION - March 2021   2  1.Glossary ACEs Adverse Childhood Experiences: A Public Health model which identifies multiple negative experiences in childhood that impact on a person’s resilience to cope with life. A&E Accident and Emergency Unit  CAMHS Child and Adolescent Mental Health Services LCSPR Local Child Safeguarding Practice Review MST Multi Systemic Therapy CSC Children’s Social Care Services LSP  Local Safeguarding Partnership SGO  Special Guardianship Order came into being in 2005 following the Adoption and Children Act 2002 used to legally place children in the care of usually extended family   2. The LCSPR Process, Author and Review Panel This LCSPR was convened in 2019 and was due to report in 2020. The panel met, and the relevant agencies produced their Information Reports in a timely way. The family and PS were interviewed at length and a draft LCSPR was submitted. However, due to the Covid-19 pandemic the report was delayed and, due to lockdown restrictions, the family did not have sight of the report until early 2021 which was undertaken virtually. However, during these difficult periods, an easy read feedback letter was drafted to be shared with PS at the appropriate point by his key workers at the request of PS.  The lead reviewer is an experienced reviewer with a significant background in Safeguarding and Public Protection. She is a qualified and Registered Social Worker and has undertaken a range of roles in the public sector including as Assistant Police and Crime Commissioner for South Wales Police. She currently holds two Ministerial appointments in Wales as a member of the National Independent Safeguarding Board and as an Independent Member of an NHS Trust. She also Chairs the UK Advisory Board for the Centre for Expertise in Child Sexual Abuse.  The Review Team  Agency Role 1. Clinical Commissioning Group Designated Nurse  2 NHS Trust   Named Nurse Safeguarding Children 3 Children’s Social Care Services    Director  4 Police  Child Abuse Team  6  Local Safeguarding Partnership   Business Manager CSPR Officer 7 CAMHS  (Attended the first panel meeting in September 2019) Safeguarding Lead Official LCSPR -PS FOR PUBLICATION - March 2021   3  3.Terms of Reference 3.1 Aim of the Review  • The aim of this Review is to identify improvements that can be made to better safeguard children and to prevent, or reduce the risk, of recurrence of similar incidents. • The Review will undertake a rigorous and objective analysis of what happened and why. It will consider whether there are systematic issues, and whether and how policy and practice need to change. • It should be noted that the Review is not being conducted to hold individuals, organisations or agencies to account as there are separate processes for this.  3.2 Time Period to be Considered by the Review and Rationale:  Following discussions by the panel it was agreed to extend the period under review from late summer 2017 to 2019. The wider context in which paternal grandparents came to care for PS was significant and therefore this review has attempted to provide that context to aid an understanding of these tragic events.  3.3 Key Issues to be Addressed by the Review:  1.Were PS’s views identified and considered by services involved in the review period? 2.Were PS’s grandparents appropriately consulted and involved in care planning for PS? 3.Were correct procedures followed regarding the making of referrals following the first assault in 2019 on PS? 4.Was an up-to-date assessment of PS’s needs available to all agencies involved in his care and completed in line with agency policies and procedures?  5.Was an up-to-date assessment of the risks posed to and by PS available to all agencies involved in his care and decision making?  6.To what degree and to what effect did agencies work together to ensure the best outcomes for PS? 7.To what degree and effect was management oversight of assessments, contact with PS and significant others established or sought at key points? 8. As PS was placed in care in another area, to what degree did this effect the level of supervision, care and oversight of his case?  4. The Facts 4.1 PS was seriously assaulted in 2019 by an adult perpetrator. The assault was captured on CCTV and suggested premeditation by the perpetrator. The injuries PS sustained were life threatening and PS was taken to hospital for lifesaving surgery. PS has made a remarkable recovery due to the skills of the NHS staff and his own tenacity. PS has suffered life-changing injuries from this attack and is awaiting further surgery and ongoing treatment. The perpetrator was imprisoned with an additional term on license. The perpetrator was the son of a member of the Care Home staff where PS was a resident. That member of staff has been charged with offences within Section 53 of the Regulation of Investigatory Powers Act 2000 (c.23) (RIP or RIPA) as the staff member failed to provide the passcode to their phone as requested as part of the Police enquiry. The member of staff had their employment terminated with immediate effect and is currently awaiting trial. Official LCSPR -PS FOR PUBLICATION - March 2021   4  4.2 As a child PS experienced a high number of ‘Adverse Childhood Experiences’ (ACEs) in his life. His birth parents were both young and are believed to have lived together briefly before separating when PS was under 2 years old. During this time, it is recorded the Police attended the home due to reports of incidents of domestic abuse. The report from Children’s Social Care (CSC) records state that PS, although no older than 8 years himself, took responsibility for caring for the younger siblings in the family. 4.3 At 7 years old, following a disclosure made to the school that mother’s partner had kicked, punched and threatened to throw him into a canal, PS and another sibling were removed from mother’s care and placed temporarily with paternal grandparents. According to CSC, parents received custodial sentences in response to the abuse inflicted on their children and PS and sibling went to live with paternal grandparents on an interim basis. Eighteen months later this arrangement was formalised when PS was made subject to a Special Guardianship Order because of the physical and emotional abuse experienced at the hands of mother and her partner. Records indicate that mother had a significant substance misuse problem and that biological father, with whom there was no significant contact, died from cardiac problems. PS remained in the care of his paternal grandparents until he was in his mid-teens and over these years experienced a period of stability due to the support and love they provided.  4.4 Police records indicate that PS’s mother had several partners whilst PS and his brother were in her care. They show also that she had several pregnancies with various partners, was young and had significant substance misuse problems. Domestic abuse was noted as being a feature within these relationships.  4.5 The Special Guardianship Order to the care of paternal grandparents was made when PS was 8 years old and the case was closed three months later by Children’s Services. However, according to PS and the family he was a troubled child due to the neglect and abuse experienced from birth. PS was described as quick to anger, obsessive and defiant. As a result of a request for help in 2017, CSC became involved with PS as a Child in Need. The CSC report states that the last six months of PS’s time with grandparents under the SGO were particularly difficult for the family due to PS’s deteriorating behaviour and that they felt unsupported by the intervention of CSC. It is recorded that CSC were considering closing the case due to the non-engagement of the grandparents. 4.6 The grandparents coped until PS’s behaviour became threatening and aggressive to them and his younger brother, and he had to be restrained. There were also concerns about his relationship with a younger female. These allegations were investigated jointly by the Police and CSC as a Section 47 Enquiry. This led to a series of interventions by CSC coordinated by a multi systemic therapy (MST) team and the specialist family support team. In addition, a Child in Need meeting was convened in 2017 in which it was noted: “There was lot of tension between Grandad and Social Worker due to feeling that CSC had let them down during the period of the Guardianship.”  4.7 During his childhood PS experienced continuity in his education attending two mainstream schools (primary and secondary) despite multiple moves by the family. Both schools provided significant Special Educational Needs support for PS. However, as his home life began to unravel so did his behaviour in school. PS began having difficulties in the secondary school which came to a head when it is alleged that he attacked a staff member around the same time as the problems at home were escalating. Shortly afterwards he was placed in short-term respite care and had to manage a change in education; from then on PS did not return to his grandparents’ care. In 2017, with the oversight of the specialist virtual school provision, alternative education provision was sourced. PS initially had Official LCSPR -PS FOR PUBLICATION - March 2021   5  difficulties settling in as within two weeks PS was excluded for ‘throwing a chair’. In 2018, PS made an allegation that he was being bullied and in a few weeks was himself excluded. Despite these difficulties the specialist virtual school provision built a supportive and effective relationship with PS. It is also encouraging and significant to note that, despite being placed out of borough, PS continued to attend school, albeit less regularly. PS's continued engagement with the school is a significant testament to the strength of relationships, supervision, care and oversight provided by the school, especially given the level of disruption in his life. 4.8 As stated, PS’s behaviour at home had deteriorated in 2017 with aggression, threats, assaults of his grandparents and brother, self-harming and periods in which he was missing from home and damaging the home. The triggers for this deterioration can only be speculated upon but are not known to professionals at this point. It is known that PS was aware that his father had died of a heart condition a few years prior. Later he learned that an elder sibling had taken his own life in 2018. The impact of these events and the loss of his family could be assumed to have some significance, but they are not referred to within the records relating to PS and his treatment. 4.9 PS was referred to CAMHS following an attendance at A&E in 2017 due to further aggressive behaviour at home. He was assessed by CAMHS who felt that his behaviour was not the result of mental health issues and that the service the family were currently receiving (MST) was appropriate. It was also suggested that PS may be on the Autistic Spectrum. The grandparents describe the suggestion of possible Autism as particularly helpful as it helped them to understand PS’s behaviour and reframe it from his being ‘naughty’ to being a result of a known behavioural condition which could not be helped. At this appointment he was prescribed Risperidone for his impulsive behaviours. PS then attended five further appointments with CAMHS where his medication was increased and further medication prescribed to help him sleep. At this point psychotherapy was discussed because of his childhood trauma but no decision made. It is a concern that these contacts appear to have focussed on establishing a diagnosis and possible treatment plan solely. The Panel felt it would have served the interests of all concerned, but particularly the grandparents and PS, if alongside assessment, PS and his grandparents could also have been helped to manage his behaviour. Records suggests that Social Workers involved with PS spent too much time trying to meet the requirements laid down by CAMHS to access treatment. Time and attention focussed on this endeavour seems to have removed the focus and diluted the energy of the Social Workers to the point that no other type of intervention was considered or tried. It is significant that PS’s Social Worker had only just secured funding for him to be placed in a therapeutic placement and so able to receive the treatment CAMHS recommended when he was viciously assaulted. It is also ironic that due to his life-changing injuries from that assault, a further assessment will have to be made to secure CAMHS’ help in the future. 4.10 The crisis point came in the summer of 2017 when PS was taken to A&E due to his grandparents feeling unable to cope. It is said that the trigger for this decision was PS ‘barricading’ his sibling and cousin in a room following a row in the home. PS had not been taking his medication to control his impulsivity. CAMHS felt he was fit to be returned home as this behaviour was not thought to be due to mental health issues. On discharge from A&E, his grandparents refused to have him home with them. A two-week period of respite care was agreed with the grandparents and a temporary foster care placement was found for PS to allow time and space to develop a plan to enable PS’s return to his grandparents. However, at the end of this period, the grandparents did not feel able to cope with PS and did not allow him to return home. PS was found a foster placement – it was to be the first of Official LCSPR -PS FOR PUBLICATION - March 2021   6  four placements within a six-month period, three of them breaking down due to what were to become recurring issues – poor behaviour, aggression, self-harming, substance misuse and the influence of anti-social peers. 4.11 The foster care placement which began well broke down after less than four months due to concerns about PS’s behaviour which included assaults on staff in school and a resident at the placement, drug and alcohol misuse and increasing contact with anti-social peers. It was at this point, as the foster care placement was at the point of breaking down, that CAMHS began a psychotherapy assessment late in 2017. Six days after that appointment, PS was admitted to A&E after being found on the roadside unconscious due to alcohol misuse and was seen later the same day by CAMHS as part of the psychotherapy assessment with no reference to this incident. A further appointment took place a few days later in which “intensive assessments were undertaken” and he was warned that psychotherapy would be “a long and painful process”. This suggests that CAMHS were either unaware of the breakdown of the foster care placement and the admission into hospital, or that they continued their planned work despite these events. The CAMHS Information Report does not note these significant background events, only their appointments with PS. The Foster Carer gave notice to the LA of the placement end after the incident. 4.12 There was a LAC Review held late in 2017 in which it was agreed that the Care Plan now was not to return to the grandparents but to seek a long-term foster placement. It is not stated how this change was communicated to PS, nor how it was received. It is noted that throughout the first placement PS had stated his desire to return home and that he missed his grandparents. 4.13 Late in 2017, PS moved into a Residential Home where, after several serious incidents including him assaulting a member of staff in school resulting in another exclusion and a resident in the Residential Home, he was moved into an emergency foster placement early in 2018. Within two days of moving into this placement he was again admitted to A&E following a drugs overdose, and then ten days later was again admitted having self-harmed by drinking bleach and consuming washing powder tablets. He was seen by the hospital specialist support team who assessed him as having no mental health needs but did express concern for the safety of other children in the Residential Home. He remained in hospital for three days until a suitable alternative placement could be found. It is recorded that PS had self-harmed as he did not want to remain at his foster placement. PS was then accommodated in another Residential Unit in another area, stated to be “the only placement willing to take him”. He remained there until the assault. This was the fourth placement in six months.     4.14 PS’s behaviour remained challenging but able to be managed by the home, and CAMHS noted that PS was settling in and managing to focus on his exams. A professionals’ meeting was held at CAMHS in the summer of 2018 attended by a range of professionals. At that meeting there were concerns expressed by the Psychotherapy Team within CAMHS as to how psychotherapy would impact upon PS’s existing mental health and if he would be able to contain his emotions as the therapy intensified. The question of whether PS should be transferred to a more secure unit to enable this was considered but no decision taken. PS was admitted to A&E in late summer of 2018 following an incident of self-harming due to feeling low. It was noted that the carer from the Residential Home stayed with PS at the hospital overnight. 4.15 PS’s behaviour continued to be challenging, both at the home and at school, but records indicate there was positive partnership work between CAMHS and the Psychologist Official LCSPR -PS FOR PUBLICATION - March 2021   7  employed by the residential placement. PS was described as attending education, not thinking about self-harming and “managing better”. His medication was reported to have been reduced in consultation with CAMHS later in 2018 as a result. PS stated that he would like contact with his birth mother and a month later requested help with his mental health from his Social Worker. During the same period, CAMHS recommended that PS be moved to a placement that would offer enough support to enable the impact of psychotherapy sessions to be managed safely. This plan was reversed a month later – the decision was made instead for PS to remain at his current placement and for psychotherapy sessions to be carried out there, mainly due to PS’s positive engagement there. PS’s Social Worker reported him to be “happy, settled and secure” at the Residential Unit.  4.16 Late in 2018, PS’s funding arrangements for his education provider ended. At the end of 2018, PS was described as a child not in education, employment or training (NEET) and continued to be supported by specialist school provision with targeted employment support which enabled him to secure a number of GCSE passes despite the disruption caused by his frequent moves, exclusions and non-attendance. 4.17 The time of relative stability for PS that had existed in the new placement would begin to break down from the end of 2018 onwards. From 2019 there followed several significant incidents within a three-month period that were to have serious consequences for the plans being made for PS and his life. In 2019 PS deliberately ‘wound up’ another resident and caused damage to the home before storming out. The next day PS was assaulted by six men and hit with a crowbar outside a ‘car wash’ he was working in and he was robbed of £20. This assault was described as a ‘fight’ by the staff at the Residential Home, which seemed to underestimate the significance and likely impact on PS.   4.18 The report from the residential setting states that the assault on PS was discussed with a Police Officer but not recorded by them as a crime as PS did not wish to proceed. However, Police state that the matter was not reported to them and this is confirmed in the CSC Information Report. The residential setting report states further that in line with PS’s wishes, the staff at the Residential Unit and PS’s Social Worker agreed that they would not take any action. This decision was not in line with safeguarding practice. It is not known whether this was a random robbery or part of an ongoing dispute. A few days later due to having self-harmed, PS was admitted to A&E. He described having problems ‘where he was living’ and that he had been feeling suicidal but was now OK. A few days later PS disclosed to his Social Worker that he did not want to stay at the Residential Unit any longer. At his CAMHS Medication Review, the assault and robbery which occurred the month before was not addressed and the Social Worker from the Residential Home simply reported that “he had a good week; he had been out and about with staff. There was no further self-harm or thoughts of self-harming”.  4.19 There were further concerning incidents including cannabis being found in PS’s room and Police being called to an incident when PS repeatedly punched a male to the head as he left a McDonald’s site following an argument over a girlfriend, and in defiance of staff from the home insisting he return with them. This incident suggests both PS’s heightened anger and aggression but also the inability of external forces and sanctions to control him. A few weeks later a knife was found in PS’s room, and he stated he found it and kept it for protection. A week later PS assaulted a member of staff and was involved in a serious incident involving others from the home in which a car was damaged and staff threatened and assaulted, as a result of which PS was arrested. Shortly before PS was seriously assaulted (the incident which initiated this report) PS asked staff members if they would lend Official LCSPR -PS FOR PUBLICATION - March 2021   8  him money, returning later with new clothes. In a four-week period there were four incidents of PS either threatening or assaulting staff and residents at the home or damaging property. 4.20 The Special Guardianship arrangement remained in place for PS and his younger sibling and, following surgery, PS was cared for by his paternal grandparents at their home for seven weeks. PS then moved into a Residential Unit preparing him for independence.   5. The child and family views  5.1 In autumn 2019 the reviewer met with PS, his paternal grandfather, step grandmother and sibling at the family home, which was warm and welcoming. The reviewer’s view is that the family members communicated with each other in an open and supportive way. PS’s grandparents have provided stability and loving care for both grandchildren and, despite the trauma following PS’s removal into care and assault, still do so. The grandparents described to the reviewer the traumatic events that led to PS and his sibling being removed from their mother’s care and placed temporarily with them initially. At the time it was thought that the sibling was not their biological grandchild, but they could not bear to separate the two frightened and traumatised children. Together with his sibling, PS was eventually placed on a Special Guardianship Order (Adoption and Children Act 2002 came into operation in 2005). During the Special Guardianship Proceedings, the Judge ordered a paternity test which established they were full siblings. Grandparents believe that in order to help them care for the two children they should have received assistance both financially and to help them build resilience and coping strategies to help the traumatised siblings adjust to their new life. Instead of that, PS’s grandparents describe pawning jewellery to buy the children beds and clothes and feeling out of their depth and isolated with two such traumatised children to care for. They strongly believe that help at this point could have given them a greater understanding of the children’s individual needs and the strategies for meeting them and may have helped avoid the tragic events that they have all endured. 5.2 The grandparents believe PS was one of nine children born to his mother with one child being removed at birth. Prior to this crisis, his paternal grandparents had attempted to support PS’s mother and PS by taking them away on caravan holidays, buying toys and a computer and providing money for food to his mother. They believe these gifts were sold to fund her drug misuse. Nowadays PS has no face-to-face contact with his mother and only occasional Facebook Messenger contact. He has limited contact with a few of his half siblings, sadly the eldest of whom has taken his own life; PS’s grandparents understand that traumatic childhood experiences and their impact were the prime cause for the suicide. 5.3 Grandparents managed to cope with PS’s anger and distress and believe they needed but did not receive specialist professional help and guidance to manage. The exception to this was when PS was assessed by MST in 2017 as being on the ASD Spectrum. Grandparents describe this as a helpful service bringing them to understand at last that PS was not just being “naughty” but that the behaviour was related to physiological factors. This helped them to understand this behaviour and helped them to stop blaming PS and/or themselves when it happened. PS too benefitted from this insight and began to understand it was related to how his brain worked differently to others; this helped PS to recognise and sometimes prevent triggers that could lead him to lose control and also to stop seeing it as his fault for losing control. PS told the reviewer that he needed longer than others to process and understand instructions and that he can become obsessive over things and with people. During the interview he nodded confirmation constantly when spoken to, an example of a strategy learnt which others develop naturally to reassure that he understands what is being Official LCSPR -PS FOR PUBLICATION - March 2021   9  said. This was observed by the reviewer during conversations, when PS was nodding even when it was likely he did not truly understand. This was believed to be another learnt behaviour to avoid conflict, criticism and perhaps ridicule from others. It could be reasonable to surmise therefore that for PS, everyday engagement with others can be quite a taxing exercise. It is a measure of PS’s ability and determination and the support he received from family and education providers that, despite these difficulties, he was able to secure academic qualifications. 5.4 By early 2017 PS’s grandparents were feeling they could no longer cope with PS. The final trigger that led to this decision happened in the summer of 2017 when PS’s ‘barricaded’ his sibling and cousin in his room, following a row in the home. PS had not been taking his medication to control his impulsivity. The grandparents were particularly fearful of PS fire setting in his bedroom and the risks to him and the other children in his room. They told the reviewer that this decision was reached after much thought and they tried to pressurise services into providing a therapeutic environment for PS believing that the early experiences of neglect and abuse were the root cause of the current behaviour. PS has little memory of these earlier events but told the reviewer that he asked to be arrested by the Police as he did not want to cause any more upset to his family. At that time, he describes his behaviour being impulsive and destructive, fuelled by him feeling overwhelmed and angry. 5.5 These behaviours continued and caused the breakdown of the initial foster placement and then the first Residential Home where again he did not cope and continued to exhibit distress. From here he was placed in an emergency foster care placement where PS describes how his distressed behaviour caused an experienced Foster Carer to lock him in the garage as the only way to keep him safe. In spring 2018, PS moved to another Residential Unit where he remained a resident when assaulted. Initially PS described how he was one of two children placed in the unit with a small staff group. PS believed he settled in well and was receiving good support from his then Social Worker. The family believed they, with the Social Worker and CAMHS, were working towards obtaining the much-needed therapeutic support for PS. However, at this point, although CAMHS agreed that PS needed help, they were unwilling to undertake psychotherapy with him unless he was in a specialist residential placement that could ensure his and others’ safety during the therapeutic work. The grandparents believe funding was just being secured for this when PS was violently assaulted. 5.6 The final Residential Unit was described by PS as initially being a place where he felt safe but as the numbers of children and staff increased it became an unsafe environment where he could not manage his distress. PS described numerous incidents of internal door windows being broken, furniture damaged and rooms “trashed” by other distressed residents. PS felt staff had no control and that a member of staff was assaulted by a resident. PS believed staff did not like him, a view shared by PS’s grandmother, who described the staff member as being much less professional when making contact with her than other members of staff. On one occasion the staff member called in mid argument with PS and was unpleasant and derogatory about PS to her. It later emerged the staff member was the parent of the perpetrator who seriously assaulted PS. PS was told that he was known by the person who committed the assault, and PS later remembered a previous acquaintance with the perpetrator.  5.7 Following the assault in 2019 the staff member went to the hospital and stayed with PS’s grandmother at his bedside refusing to take a break. At the time PS’s Grandmother thought this was odd behaviour from a member of staff who she believed did not care for PS but was Official LCSPR -PS FOR PUBLICATION - March 2021   10  too upset to address this as she feared PS would die. At no point did the staff member reveal being related to the assailant. 5.8 Early in 2019, prior to the serious assault, PS was assaulted and robbed by a group of six males with a crowbar outside of the car wash where he was working on a ‘cash in hand’ basis. £20 from stolen from him, and PS stated that he was warned “not to speak to a staff member like that” by the boy with the crowbar but did not know who he was talking about. The same staff member had accompanied PS to work on a few occasions and knew where the car wash was. Following the sentencing of his assailant, his picture was printed in the local newspaper; PS recognised him immediately and rang his grandmother to tell her it was the boy who had threatened him in the earlier incident when he was robbed and threatened. PS had reported this robbery and the threats he received to staff at the Residential Unit, but they had not reported it to the Police nor supported him to do so. There is no evidence of the Regulator being informed. The family believe that had this been done and investigated then the later assault on PS could have been prevented. During the trial, CCTV was used to identify the assailant. As the robbery and attack occurred in the same place (just outside the car wash) his grandparents believe the same camera could have provided coverage of the earlier unreported attack and identified those responsible. It seems that both staff at the home and PS’s Social Worker were swayed by PS’s desire not to proceed nor contact the Police rather than follow safeguarding procedures. 5.9 The family believe that the Residential Unit was not fit for purpose, as following PS’s discharge from hospital after the attack various staff members visited PS at the grandparents’ home and behaved in an unprofessional manner. Some revealed they were not trained to manage the residents including the then Manager. It appears these concerns were shared by Ofsted who closed the Residential Unit after the assault. 5.10 At the time of writing PS is due to return to hospital for further surgery to insert a metal plate into his skull and he will require ongoing treatment and support following this terrible attack. His grandparents are fearful for PS’s future as they do not believe he will now be able to manage independently or is being equipped to do so given the impact of the injuries sustained.  6. Key Decisions 6.1The family feel they were not offered enough support or services when PS and his brother came to live with them. At no point did they feel they were given the knowledge, understanding and skills to enable them to support the children as part of the Special Guardianship Order. Foster Carers are given skills to foster, and other agencies supporting Foster Carers offer quick access to a Psychologist and a Social Worker for them as well as one for the child. There is little difference between the Foster Carer’s role and that of Special Guardianship other than the child and carers being related. The level of trauma experienced and being held by the children when they arrived to live at their grandparents’ home required a multi-faceted response containing practical, emotional and psychological support and advice over a period of years which the grandparents feel they did not receive. Given the level of trauma and the existence of a high number of Adverse Childhood Experiences (ACEs), which the Police report documents, breakdown of the SGO without additional support was likely. This is a national issue, particularly in relation to cases of a similar nature.  6.2 In late 2017 PS’s foster care placement was flagged by CSC as breaking down and it did so weeks later, prompting PS’s fourth care move to the Residential Home where he resided when the incidents occurred. During the same period, psychotherapy services became involved with PS and six days after an appointment PS was admitted to hospital having been Official LCSPR -PS FOR PUBLICATION - March 2021   11  found at the side of a road unconscious as result of drinking large amounts of alcohol. CAMHS appeared to continue this assessment and at a further appointment PS was warned that psychotherapy would be “a long and painful process”. This suggests that CAMHS were unaware of the breakdown of the foster care placement and potentially the admission into hospital or continued this intensive work despite that knowledge. The CAMHS Information Report does not note these significant events running alongside their interventions but refers to ‘good multi-agency working’. There is a note in the CAMHS report which indicates some knowledge of the unstable nature of PS’s accommodation status - “PS was also a little anxious as the placement was coming to an end and another was needed as stand bye (sic)”. This was a positive step from CAMHS in PS’s therapy journey. It is difficult to imagine a child, particularly one traumatised by past events and recently removed from their one known source of stability and security, being able to participate in such an intensive experience as a first session of psychotherapy. It would be disappointing if CAMHS were aware of the recent as well as the past traumatic events if they continued in their work with PS on these two occasions despite this. 6.3 During a scheduled psychotherapy appointment at CAMHS in which PS, a number of other professionals and PS’s grandparents attended (but not PS’s Social Worker, who had left the team, nor a representative from CSC) they discussed the risks of harm that PS could pose to others. According to CAMHS record, the psychotherapy team stated their concerns, along with PS’s grandparents, about the capacity of PS to harm others in the light of the information about the serious assault perpetrated by PS at a McDonald’s site where he banged a young person’s head against a wall. The representatives in the meeting appeared to agree (the notes are not explicit in this) that PS could be managed in the placement as advocated by the Residential Home’s representative at the meeting. It is of concern that such an assessment was made without the input of CSC who were the main agency responsible for PS and the only agency with access to all the information concerning PS’s behaviour and potential risks. There is no evidence of communication of this discussion to CSC. CSC were legally the Corporate Parents of PS and as such should have been involved in this meeting. The group were informed of the Social Worker having left the area and that a replacement was not available. Given the Corporate Parent role of CSC, good practice would have been to rearrange the meeting or at least defer the decision as to PS’s risk and suitability of placement to a date when a CSC representative could attend. As the Corporate Parent, CSC were carrying the responsibility for any such risks identified. 6.4 Early in 2019 PS was violently assaulted and robbed and days later contacted his Social Worker to say he was fearful about remaining in the area and that he did not feel safe. No record of any discussion with PS by the Social Worker, or any reassurance being offered to him concerning his fears, has been seen. Nor is there evidence of this being discussed in case supervision with the Social Worker’s Line Manager, which did occur and noted that: “The placement was settled.” PS’s concerns for his safety were not shared at his medication review at his CAMHS appointment which followed. If anything, a much more positive view was painted by the Residential Worker who described PS as “calmer”. The report from the Residential Unit refers to a “fight at work” and not a violent assault and robbery. This suggests the event was minimised by staff who may have become normalised and desensitised to such behaviours and their impact. Supervision, training, and management scrutiny are required to address the effects of these common dynamics or the dangers of unconscious bias in which such acts are seen as ‘the norm’ for such groups. This may also account for the fact that, despite the escalation in PS’s poor behaviour at the unit, residential staff did not flag these behaviours nor ask for a strategy meeting until months later. Other concerns are the lack of communication or possibly weight given to information provided by field workers to the CAMHS team concerning these events. It does not appear that they took Official LCSPR -PS FOR PUBLICATION - March 2021   12  any account of how the sessions with PS were to be managed. This could be a case recording issue in which such issues were addressed but not recorded. 6.5 The Residential Unit where PS lived prior to the assault was next door to an Unregulated Home for children of the same age, some of whom were placed from outside the area as well as an ex-resident of the Residential Unit. The Unregulated Home provided residents with greater freedom, had a much lower staff-to-resident ratio, gave residents a much higher living allowance (£57 compared to £10 per week where PS was placed) and a lower level of oversight cover. The co-location of two Residential Homes for disadvantaged and vulnerable young people in one local area caused both homes and the local neighbourhood significant problems in terms of anti-social behaviour and influence. The Panel were of the view, which was supported by practitioners and managers at the reflective learning events, that if possible, any ‘Change of Use’ Applications to the Local Authority for the establishment of an Unregulated Home near a Children’s Home should consider the likely effects and impact on the residents of the homes and the neighbourhood. The appropriate planning staff and councillors should receive appropriate safeguarding training with a focus on managing risks of this kind. As a result of learning from this event, it is a recommendation that current local planning regulations are explored to ensure that if the Local Authority has the power to restrict similar applications, it does so. The grounds of any restriction or refusal of a Change of Use application would be the impact it may have on environment, community and the welfare of the vulnerable children and young people residing in the units.  6.6 PS worked on a ‘cash in hand’ basis at a car wash – a fact which his Social Worker, Psychiatrist, employment advisor and residential staff (who sometimes dropped him off and picked him up from the car wash) were all aware of. Hand car washes are known ‘hot spots’ related to organised crime and exploitation. This placed a vulnerable Looked After Child in a potentially risky environment. PS was pleased to have found this work via a friend in the autumn of 2018 but became anxious about working there and left in early 2019. After that he began to express concerns about his safety in the area to his Social Worker and residential staff and was found with a knife in his room. In spring 2018 PS asked a staff member if he could borrow money then went missing and came back with new clothes, refusing to say where he had got them from. These are all recognised potential signs of exploitation. It would appear that at no point was Criminal or Sexual Exploitation considered by services despite him being in a high-risk group in terms of vulnerability. In addition to concerns regarding this, it was highly likely that his employment and renumeration were illegal in terms of revenue if not criminal law. This behaviour was being endorsed, at least implicitly, and is far removed from the example of leading a productive and law-abiding life that such services should be setting to its service users. 6.7 Early in 2019, PS was treated at A&E with bruising to the head and left hand following an alleged assault. PS stated he was "sitting in car with a friend after work" when he was approached by "six men in their 20s" who told him to get out "or they would attack him". PS told the A&E doctor that they "pulled the car door open" and then hit him on the left side of his head and left hand "with a crowbar”. The Doctor completed a MARF as this was seen as a safeguarding incident. However, the response by those with responsibility to care for PS following this assault is significant in its failure to protect PS and implicit acceptance of the harm that had been done to him. Records from the Residential Unit suggest that they informed PS’s Social Worker and spoke to the Police about the assault. They state it was agreed that no action would be taken regarding reporting this matter as a crime as PS did not wish to do so. However, the Police state they were not told of this assault and that it was described to them as a ‘fight at work’ – a significant minimisation. The Police state that had they been told of the assault they would have been required to record and treat it as a crime Official LCSPR -PS FOR PUBLICATION - March 2021   13  and proceed as such. It is likely that had the prosecution been pursued, evidence would have been available to have made a successful prosecution likely. We cannot predict the impact this would have had on PS, but it may have changed the escalating spiral of violent and anti-social events involving him and others known to him in the area. Clearly the issue of whether the Police were told and to what level they were consulted is important here in terms of an opportunity to intervene not being taken. It is accepted that both staff at the residential unit and PS’s Social Worker were aware of the assault and did agree to go along with PS’s wishes not to pursue the matter. This review has been unable to make a finding of fact related to these two versions of agency actions. Similarly, both staff at the Residential Unit and PS’s Social Worker knew that his behaviour had been deteriorating – he had been involved in acts of violence and damage to property and was known to carry a knife, and in view of this, the assault should have been seen as significant escalation in risk to him and possibly others. This acceptance suggests a tolerance of harm and risk for a Looked After Child and those around him that does not meet the standard expected.  6.8 The level of ACEs experienced by PS required a therapeutic response from the outset of Local Authority Services becoming involved with PS and his family. From the record it appears that the impact of such events on PS and his sibling were not considered, nor a plan made to ameliorate the impact when PS and sibling were removed from their mother’s care due to the abuse they had suffered. Indeed, the funding formed an important part of this plan: Psychotherapy by the CAMHS Team was not agreed until 2019 and even then could not be carried out as it was unclear whether such therapy required a different setting to the one in which PS resided at that time. On the contrary it seems that CSC did not consider these needs whilst all seemed well with the grandparents’ care of the children, despite all the known evidence concerning the impact of abuse on the emotional and physical wellbeing of children. It seems services only became involved in response to the grandparents’ request for help at crisis point in 2017. Had services been proactive and assumed that the family would need support taking on two vulnerable children at an earlier stage, the breakdown in 2017 may have been avoided and possibly the traumatic events that followed that breakdown also. It is a firmly held view of the Panel that CAMHS should have been more proactive at the time when PS was attending appointments, cooperating, relatively settled emotionally and engaging with services offered. The panel felt CAMHS could have worked with PS and his grandparents to address the difficulties they were all facing. The Psychotherapist had successfully established a working relationship with both PS and his grandparents. It is the Panel’s regret that this opportunity was not capitalised on during this period of active engagement by PS. 6.9 In the view of this reviewer, the failure by professionals not to override PS’s wishes and formally report the assault early in 2019 to the Police was misguided and ill judged. It breached safeguarding principles in every aspect alongside the impact on PS himself. It also prevented broader considerations, for instance whether the assault was part of a wider set of circumstances possibly involving organised crime, gangs or other elements of extortion for drugs or other debt. The CSC Information Report acknowledges a lack of information sharing with the Police by the Social Worker over this assault, all of which clearly indicates safeguarding concerns. What is evident is from that point on PS was fearful about remaining in the area and was found with a knife in his room. Ofsted reportable incidents in Schedule 5 include ‘a. Child involved in or subject to or is suspected of being involved in or subject to, sexual exploitation and b. Incident requiring police involvement has occurred in relation to a child which the registered person considers to be serious’. These events would have met these criteria and should have been reported irrespective of the wishes of the child. Official LCSPR -PS FOR PUBLICATION - March 2021   14  6.10 The key decision for a period of respite to determine what intervention was required for PS to return to the care of his grandparents in 2017 became a decision to obtain a long-term foster placement, possibly in response to the grandparents’ refusal for him to return to them. This is the pivotal decision that led to PS’s behaviour worsening and the inability of any placement to ‘hold’ him due to his anger, frustration and sadness at not being able to live with his family, which he knew to be due to his own behaviour. Such a decision may have been thought to be necessary on a pragmatic level. It does however raise two questions; i) Why weren’t the likely consequences of PS’s grandparents not feeling able to have him home discussed with them? Why was it not made it clear to the grandparents about the type of places and level of care he was likely to experience and the possible impact on him in terms of disruption? It is clear they did not know how the care system worked yet it seems their expectations were never checked out with them. ii) Assuming the grandparents would be willing to have PS home if they could manage him, why was a plan not formulated to provide the support they needed to enable this? There is no evidence in any of the documents of either actions being taken or considered to enable PS’s return. CSC recorded in 2017 that the grandparents felt PS’s return to be impossible unless they could move into a house with an additional bedroom to separate the siblings. I am aware that PS and his sibling sharing a bedroom was often the catalyst for arguments. Why was there no advocacy with the Housing provider to enable a move to a house with an additional bedroom? Or a discussion with the grandparents to plan to enable them physically, financially and emotionally to manage PS’s return? This may have helped the grandparents to feel they were being supported practically and to be more confident in taking the risk of PS returning to them. 6.11 The absence of supervision notes regarding these key issues suggests that supervision played little part in the decision making or guiding of the Social Worker concerned. I aware that PS had six different Social Workers allocated to him from the time of his becoming a ’Child in Need’ to his assault. I am assuming from turnover of staff that the allocated Social Workers involved would not have had much prior knowledge of PS or the case, and that case supervision would have been of help in terms of decision making and passing on knowledge and experience of the case.  7. Analysis of events  7.1 Before commenting on this it is important first to note that PS had six Social Workers working with him and his family over 18 months from 2017 to 2018. Given this degree of turnover of staff it is difficult to expect that they would be able to identify, connect with and engage with other agencies immediately. Equally the other agencies experiencing this degree of turnover in staff were likely to become a little disillusioned in working with personnel who were again starting from a low knowledge base of their role in PS’s care. 7.2 There is little evidence of CSC working with the grandparents once PS and sibling were removed from their mother and placed in their care. On a practical and emotional level, it appears the grandparents were entirely dependent on their own resources to accommodate the two children. The grandparents describe having to pawn goods in order to buy beds and continued to live in a house too small for two additional children. Implicit in these observations is the message that they were left to it by CSC. In the defence of CSC, there is no evidence that grandparents ever explicitly asked for help before early 2017. It is clear from the Child in Need meeting in the summer of 2017, which makes reference to the ‘tension’ between PS’s grandfather and the Social Worker, that working relations were poor and unlikely to be able to secure positive outcomes as things stood. Crucially there was no Official LCSPR -PS FOR PUBLICATION - March 2021   15  evidence that CSC engaged with PS’s grandparents in order to establish what they needed to be able to have PS return to their care and did not seem to discuss their decision and the implications of PS being made subject to a Care Order with the plan changing to long-term foster care. 7.3 Similarly the relationship between CSC and CAMHS was not effective. PS’s Social Worker spent a lot of time and energy trying to access help and support from CAMHS who then would stall any commitment on their part by requiring further assessments, reviews of PS’s emotional state or suitability of the accommodation to sustain the work planned. To the Social Worker’s credit, they persistently tried to access help, but this was at the cost of considering other more immediately accessible support. Information exchanges did not seem good either with significant events not seeming to be on CAMHS’s radar when working with PS. The Psychotherapist from CAMHS was a consistent professional who did engage and was an available point of contact with PS. However, there are no references to liaison with workers in the community or vice versa with CAMHS in relation to PS. 7.4 CSC met with other key professionals in PS’s care at the Looked After Children’s meeting to which Education Services generally sent a representative. From the notes shared of those meetings it seems that the various education providers generally managed PS on their own and used their own means of rewards and sanctions to manage his behaviour. There was not much evidence of worker to worker contact nor of the Social Worker maintaining oversight of his progress and behaviour. It would seem that the Social Worker was taken up with the task of keeping PS accommodated safely and responding to crises and did not have the space to consider educational matters. Clearly in the long-term this was unfortunate. Records available make little mention of supervision and none of reflective supervision in which the worker is helped to review how they responded to current situations as a tool for further learning. There are no entries in the records detailing advice being sought or given in terms of how to manage PS and whether his supervision was effective in reducing risks both to and from him, despite his known history both before and after his removal from his mother’s care. Management oversight is invisible in this case other than in terms of funding matters, responding to crises or other legal or practical matters. 7.5 It is noted that it does not seem that the Advocacy Service were ever engaged to help PS present his views in any of the many forums that were meeting to discuss his future, nor of any strategy meetings being called in response to the assault in early 2019 nor any of the other matters that PS was involved in. All such episodes appear to have been dealt with as individual incidents by the professionals involved, rather than being identified as a pattern of behaviour that required co-ordinated responses involving Police, Education, Substance Misuse, Youth and Diversion Services etc. 7.6 From the outset of PS being removed from his grandparents’ care all foster care placements were out of area. Although this was probably not by choice, the family have not identified this as an added barrier to their continuity of involvement. A Panel member from Health believed these frequent moves outside of the originating Local Authority meant that professionals did not get to know PS well and take ownership of his care. Moving GP surgeries meant he did not build up a therapeutic relationship with any one doctor. The Residential Unit is overseen by the Local Authority in which it is located, but they would not be privy to PS’s issues and needs, therefore they did not appreciate how inadequate the placement was. This may also have had an impact on the continuity of care and the ability of the Social Worker to obtain and co-ordinate services in an unfamiliar area. There are no documentary references to substantiate this. The placing authority (CSC) continued to provide the Social Work resource, however all other services (educational, fostering and Official LCSPR -PS FOR PUBLICATION - March 2021   16  residential) were and had to be provided from the area in which PS was resident. This may have caused communication and difficulties in succession planning on top of the disruption already experienced by PS. It is to PS’s credit and a testimony to him and the education providers that, despite the trauma and dislocation in his life at a critical time in his education, provision continued and he did secure GCSE qualifications – an amazing feat.  8. Wider significance  8.1. The Local Authority should be required to recognise the possible significance when considering a planning application for ‘Change of Use’ of the impact of the proposed change on existing facilities in close proximity, such as Children’s Homes or other establishments which accommodate vulnerable children or adults. Such co-locating could lead to increased risk both to the residents of the co-located units and the local community. This issue may be beyond the powers of the Local Authority to address. This in itself needs to be clarified and if it is the case then the possible impact of such ‘Change of Use’ applications should be taken to the appropriate national forum so that the issue of restricting risk near Children’s Homes in the future can be raised there. 8.2. Following the assault early in 2019 a Section 47 Enquiry should have been triggered and the Residential Unit should have reported the matter to Ofsted. The practice identified in this case suggests that neither the Social Worker nor Residential Staff worked in line with safeguarding principles in their failure to report PS’s assault by a group of males using a crowbar to the Police. At this point we do not know whether or to what degree Police were aware of the assault, as Police state they were not informed of it, which is confirmed by CSC. However, the report from the Residential Unit states that the matter was discussed with the Police. This failure meant that the Police, who may have used this information as intelligence in terms of issues such as organised crime or Child Criminal or Sexual Exploitation, could not do so. It also meant that the wider issue in terms of PS’s safety were not able to be explored. Was he targeted? If so why? Was there a continuing risk to his safety? Did he need to be moved for his own safety? These were all questions that did not appear to have been considered by the responsible professionals.  8.3 It is striking throughout the Information Report from CSC how few references were made to decisions or significant issues being discussed with managers, either in formal or informal supervision. This is concerning as PS had six changes of Social Worker in the 18 months leading to his assault in 2019. Changes of Social Workers are known times of heightened risk for the service user and the organisation. It is reasonable to surmise that maintaining grip and continuity with a case in which change and escalation could occur so quickly would be difficult for a new worker unless they were supported purposefully by a manager with some background knowledge of the case. The issue of the frequency, quality and nature of supervision and management oversight in general of such cases, particularly but not exclusively of new staff, should be reviewed with a view to identifying whether the current approach is adequate to support staff and keep children safe. 8.4 Inter-agency communication did not seem to work very well in this case, particularly concerning CAMHS, the CSC Social Workers and the residential workers. Significant events that involved PS – arrests, assaults, fights and A&E admissions – did not appear to figure in the sessions or meetings conducted by CAMHS and significant decisions, such as whether PS posed a risk to other residents, were made without the input of the Social Worker or CSC representatives. It is not clear from the evidence whether such failings were isolated or representative of a wider issue nor whether they were systemic or cultural in origin. However, failure to communicate could have a devastating impact on the lives of the children Official LCSPR -PS FOR PUBLICATION - March 2021   17  and their families being supervised by CSC and of the potential victims of those children. It is likely that these issues have existed for some time. The author is aware that there were significant changes in the provision of CSC services in the local authority area responsible for PS’s care following Ofsted inspections that found the Local Authority Children’s Services to have been ‘inadequate’ in performance for several years.  8.5 The ability of the Social Worker to access resources to respond to PS’s risk and needs and the deterioration in his circumstances after becoming a Looked After Child in 2017 is concerning on a wider level. Accessing the identified resource appeared complicated. Although CAMHS were readily available to offer support when needed – the Psychotherapist was particularly accessible in this regard – it was difficult for the case worker to access help on a more planned basis to enable PS to receive the psychotherapy sessions it was felt he needed. Referrals to secure access to psychotherapy sessions appear to have taken up much of the Social Worker’s time and from 2017 until PS’s assault in 2019 had still not secured the intervention, requiring the approval of the Resources Panel on two occasions. This was due to changes in PS’s circumstances and delays caused by the need for a ‘Forensic Examination’ which did not include PS or grandparents and for which a further funding application had to be made. It seems that once the CAMHS option had been identified, no other plans or strategies were considered. This had two effects, firstly, directing the Social Worker’s time, attention and resources to securing that resource, and secondly preventing any other more accessible options being considered.   9. Learning from events  9.1 SGOs on the whole offer positive and cost-effective placements for children keeping them close to extended family and safe. PS’s case was closed by CSC three months after the making of the SGO. For SGOs to work, family members are expected to deal with extraordinary presenting behaviours, stress and often financial outlay. Guardians need training, advice and support to be able to do this. Research has identified the factors that impact on the stability of SGO placements include the presence of emotional and behavioural difficulties of the child/ren placed, and the level of support the Special Guardians receive (Boyer et al, 2015)1, (Harwin et al. 2019)2, and (Wade et al, 2014)3. Therefore, it is critical that families involved in SGO placements receive information, advice and training at the start on ACEs and the strategies they need to adopt to maintain the placement and so provide stability for the child. Providing ongoing support for Special Guardians would reduce breakdowns and help to manage risk in a cost-effective way. PS and his grandparents believe that had they, as a family, been supported throughout, the placement may not have broken down, preventing the trauma and lifelong impact PS has experienced and will continue to have to live with. His grandfather stated that it was only when PS received his diagnosis in 2017 did any professional explain to him that PS’s behaviour was not ‘naughty’ i.e. within his control but a response to previous trauma. This is basic knowledge obvious to those in the social care system but not necessarily so to others. Additionally, the grandparents had only a rudimentary knowledge of how the care system worked and of how decisions were made within it. This lack of knowledge meant that their own decision not to allow PS to return to them was based on inadequate information. This was unfair to both                                                            1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/450252/RR478B_-_Family_justice_review_special_guardianship_orders.pdf.pdf 2 https://www.cfj-lancaster.org.uk/app/nuffield/files-module/local/documents/HARWIN%20summary%20report%20SO%20and%20SGOs%20_%204Mar2019.pdf 3 http://eprints.whiterose.ac.uk/82322/1/SpecialG2014.pdf Official LCSPR -PS FOR PUBLICATION - March 2021   18  them and PS, and tragic given the consequences of his move into the care system. There is no evidence of any conversation, information or advice being offered to the grandparents within the time from PS’s temporary ‘respite care’ to the assault. 9.2 The Residential Unit was not fit for purpose or equipped to care for a child such as PS, who as a vulnerable child was allowed to work for ‘cash in hand’ in a car wash, places that are known to be potentially risky environments related to Child Exploitation and Organised Crime. The Residential Unit Values as stated on their website were not translated into everyday practice. It would appear poorly trained and inexperienced staff were not supported or effectively supervised by management. Following the assault on PS in 2019 Ofsted closed the home; prior to closure the management would have been alerted to Ofsted’s concerns but failed to respond appropriately i.e. failure to provide evidence of key worker sessions. The Residential Unit’s Information report provided for this review was of poor quality and offered a generic response to specific concerns. In order to create a positive and safe environment in a children’s home the safeguarding culture must be completely embedded across all processes – recruitment, supervision, case management, training, key worker plans, external communication with other agencies and management oversight. The organisation which owns the Residential Unit should provide assurance to the commissioner evidencing that its services now meet the required standards. 9.3 Psychotherapy services commenced PS’s assessment for psychotherapy late in 2017 as the foster care placement was breaking down. Previously they had liaised with the Foster Carer and should have checked prior to commencing what they described to PS as “a long and painful process” to ensure his circumstances would allow such work to be carried out safely. At the appointment he was described as presenting as “a little anxious as his placement was coming to an end and another needed to be found as a stand bye(sic)”. He was found six days later drunk and unconscious at a roadside. This suggests that PS was going through something of a crisis in his life and yet it appears that both sessions continued without reference to these personal and environmental factors, other than acknowledging his ‘anxiety’ as to his accommodation. 9.4 Although PS did not wish to proceed with a complaint following his assault early in 2019 the agencies involved should have acted as responsible adults and asked for the assault to be investigated. Victims of crime often are fearful of retribution. PS had disclosed there was a witness who could have been interviewed. In their response Police stated they were not informed. If this was the case, then the culpability of both the Residential Unit and the Social Worker in this omission could be seen as greater. If, however the Police were informed in some capacity as described by the Unit and it was not recorded, this is a significant error. This was a key incident where information in terms of intelligence gathering could have informed a risk assessment. It is of note that there was no evidence of any strategy discussions by CSC with the Police in respect of PS’s missing episodes, the assault on PS and PS’s fears for his own safety. 9.5 The focus of all agencies’ attention from the temporary move into respite care onwards was on practical and necessary tasks – finding stable accommodation, continuing in education and responding to the numerous crises PS presented. The source of much of these difficulties – PS’s trauma, anger and frustration at his rejection by his family, his behaviour and moods that seemed to him beyond his control – were effectively outsourced to CAMHS. This meant that for months PS had to live with the effects of such thoughts and feelings in large part on his own. It is not a tenable strategy to leave the management of such discomfort and distress in a vulnerable person solely in the hands of a scarce resource with a stringent assessment policy that would require funding before it could be accessed. Official LCSPR -PS FOR PUBLICATION - March 2021   19  An interim plan should have been made that would have enabled some opportunity for PS to be able to express his feelings, hopes and fears with someone he could trust at the earliest opportunity after his expression of such feelings. Such an intervention would not have to be ‘therapeutic,’ just a listening response would have been supportive and valid good practice. 9.6 The Social Workers involved in PS’s case failed to respond and try to fix one of the key barriers to his grandparents being able to take PS back, which was the lack of a bedroom in their existing property to enable both PS and his sibling to have their own space. This practical solution does not appear to have been considered by any of the Social Workers, nor raised with a Manager, although PS’s grandparents had raised it with the LA. It raises the wider question of to what degree is co-operation and consultation is accepted practice and to what degree does becoming involved in environmental factors such as housing be recognised as a valid and essential part of casework.  9.7 It is difficult to judge the impact of PS being placed out of area as one cannot prove cause and effect; did the lack of consistency lead to PS being at increased risk? It is recognised that consistency of care in terms of health needs is key to a positive outcome and because of this the Psychotherapist from CAMHS made concerted efforts to remain a SPOC for PS and his family. I would also assume that the Social Worker’s task of identifying and coordinating services to support PS and trying to maintain continuity with his life prior to removal into foster care would be more difficult due to lack of familiarity with the area. For PS it would have added another level to the discomfort and disruption already experienced and with few internal or external resources to call on to help.  10. Good Practice  10.1 Although out of scope of this review, the endurance and commitment to the well-being of PS and his sibling by their grandparents throughout should be recognised as good practice. 10.2 The commitment and effort made by the Psychotherapist to become and remain a consistent figure within PS’s life from 2017 is considered good practice. He understood and acted on the importance of continuity of care for PS, to the point in which he changed role in CAMHS so he could remain a single point of contact for PS. The Psychotherapist was able to see PS at short notice at clinic when requested late in 2017. 10.3 The tenacity and flexibility of PS’s providers of Education in trying to manage and respond to PS’s difficulties in ways in which allowed his education to continue. In particular the secondary school provided continuity as well as the specialist virtual school provision and employment advisor who continued to support and prepare PS for GCSE exams even after he had been permanently removed from the school due to his violence and aggression. 10.4 The consultant on duty at A&E Unit early in 2019 recognised a safeguarding concern and made a referral (MARF) following his attendance due to his serious assault. It is unfortunate this referral did not trigger an appropriate response.  10.5 The Community Health Team flagged to the dedicated Safeguarding Nurse their concerns over a high number of A&E visits by PS. 10.6 The Social Worker’s persistence with CAMHS in relation to PS was recognised by his grandparents and is acknowledged by this Review. However, this is tempered by the limited impact this had due to the lack of management oversight.  Official LCSPR -PS FOR PUBLICATION - March 2021   20  11. Recommendations for change  11.1 The Local Safeguarding Partnership (LSP) should undertake an audit within six months to gain assurance that the ‘voice of the child’ is routinely captured and taken into account during assessments, including Child in Need and Child Protection plans. That there is a mechanism in place to evidence how well agencies are incorporating the voice of a child during interventions. This should be a key performance measure within the LSP performance dataset.  11.2 The LSP request a review of the availability and role of Advocacy for the Looked After Children of the LA including the provider, the effectiveness of the service, and information of the accessibility to all children in care, to identify whether improvements can be made.   11.3 The LSP to seek assurance from Corporate Parenting of the measures used to determine suitability of residential settings used for placing children. This relates to children’s homes such as that in this case and must include the practices which are required, i.e. adequate maintenance of building, adequate staffing levels, appropriate selection and training of staff and that supervision of staff and day-to-day recording systems are fit for purpose. This level of detail to be then built into the commissioning framework used by CSC with all suppliers of residential homes for children and young people. 11.4 That LSP to share this report with the local authority area where the Residential Unit was located and to also share the report with the organisation responsible for the Residential Unit and seek assurance that the concerns raised in this review have been addressed. Confirmation to include that all residential staff receive face-to-face interactive training which includes awareness and understanding of the stages of child development, the impact of ACEs on development and behaviour and the issue of safeguarding young people with vulnerabilities, learning and other disabilities, in relation to both Child Criminal and Sexual Exploitation. This training reminds staff that all offences should be reported and that the young people they work with are more likely to be victims of crime and require support to report matters to the Police. Completion of training for all staff to be a condition of continuing employment and of this organisation’s continuing contract with CSC.  11.5 That the LSP seeks assurance from Health and CSC that the channels of communication between Social Workers and CAMHS are underpinned by a joint working protocol which emphasises the importance for information sharing and collaborative working. To help, a joint learning event with CAMHS and CSC be undertaken to improve understanding and communication between the two bodies, along with referral procedures and requirements to streamline the process.   11.6 That the LSP seeks assurance from each partner that cases are scrutinised in a formal process. This may be through formal case supervision. Specifically, that newly-qualified Social Workers and other practitioners working directly with children and families receive formal supervision on a monthly basis, irrespective of any ‘informal’ supervision that may have happened in the interim. That in the absence of any Manager through illness etc, supervision be explicitly made available by a stand-in Manager as an interim measure, particularly in the case of newly-qualified or Agency Social Workers. 11.7 That LSP establish an independent working group to review how effective the current support given to Special Guardians is and how it can be improved. This group to include at least one lay person and a special guardian. A report with recommendations to improve effectiveness to be submitted by April 2021. Official LCSPR -PS FOR PUBLICATION - March 2021   21  11.8 That all staff working with children such as PS including Social Workers and Managers be resourced and trained to spot the early signs of and apply swift response to exploitation and be able to provide Mental Health ‘First Aid’ to the children and young people they are supervising that are known to be vulnerable. That all staff working face-to-face with children including all Managers are aware of and can apply the principles of the ‘Trauma Informed Practice’. That the ongoing training to deliver this to all staff be completed as part of CSC’s   training plan. 11.9 That LSP seek assurance that the Referral Pathway with CAMHS is effective and provides a therapeutic consultation with the referrer if it is known that CAMHS will be unable to offer any interventions themselves in the short term (i.e. within 3 months). Such interventions to be recognised as a ‘stop gap’ and not a replacement to CAMHS involvement. This to be an expectation that will be agreed by respective managers on a case-by-case basis. CAMHS then to signpost appropriate work and resources to enable the responsible worker to engage meaningfully and to prepare the child for their work with CAMHS both practically (e.g. housing) and emotionally. 11.10 That LSP are assured that all staff working with children and young people have an understanding of Child Criminal Exploitation and are able to identify the early indicators such as cash in hand work. 