Fatal stabbing of a 17-year-old in 2021. At the time of his death, Lilo was a Child in Need who had a diagnosis of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), as well as limited mobility because of a moped accident. Learning themes include: access to education and delays in assessments for Education Health and Care Plans (EHCPs) and the experiences of neurodiverse Black boys in education; recognising and responding to risk in the context of extra-familial harm; understanding the impact of trauma in the context of extra-familial harm and wider trauma; and understanding the impact of trauma on the workforce. Recommendations include: education must undertake a review of the EHCP process; the local safeguarding children's partnership should commission further learning to improve professional understanding across all agencies to ensure a better understanding of trauma, intersectionality, adultification bias and neurodiverse children in the context of extra-familial harm, always considering language and framing of children; ensure that the voice of the child is heard and integrated into planning; ensure that all social workers and managers can recognise and respond to extrafamilial harm, especially for children with additional needs; improve the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner; improve the quality of record keeping and assessments; child and adolescent mental health services should introduce multi-disciplinary review meetings when a child is referred more than three times and does not meet threshold for intervention as well as monitor and improve access and support for Black and ethnic minoritised children.
      
 Title:  Child safeguarding practice review: Lilo. LSCB: Lewisham Safeguarding Children Partnership Author: Jahnine Davis Date of publication: 2023  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                  Child Safeguarding Practice Review:   Lilo    June 2023                    Independent Reviewing Author: Jahnine Davis  2   My Son   My son was a caring, loving, cheeky and sensitive child who wore his heart on his sleeve. He had alopecia from an early age which was a sign of his sensitivity. He was a good listener who wanted to help others but often kept his own feelings to himself.  He was very close to me and when we were alone together going to hospital appointments in the car, he would talk deeply about life and the future for himself. I knew him well to know what he liked and disliked. Because of my son’s ASD and his ADHD, he was sometimes misunderstood, and he could get frustrated if he didn’t quite get the grasp of what was being asked of him. My son had multiple sports activities after school to help him to use it to manage his ADHD, as an alternative to giving him medication from CAMHS, which neither myself nor my son wanted to do. He was sometimes very innocent about how the world works and struggled to grasp some concepts.  This made him very vulnerable. He would always need one instruction at a time and struggled to process two things at once.  He was a very family orientated child who loved his siblings and enjoyed playing with them, plaiting his little sister’s hair etc. He had many interests including sports and he loved to travel and had been to Egypt, Spain and the Caribbean. He loved nature and the freedom of being outdoors. He was studying a multi-trades course and wanted to build houses. He had a clear plan to build his own house, wanting a family business in housing, marrying his girlfriend and starting his own family.  His girlfriend was important to him. They met at college. She was Bengali and he was learning the Koran. He was accepted by her family and her community, who felt that he had really helped to calm their daughter and helped her on her journey. She is now studying Criminal Law. Her family feel that my son was instrumental in that for her.  My son was a very positive child that impacted many lives. His death has had a real impact on our family, his friends, and his local community, and he is greatly missed.               3  Contents  1. Introduction  2. Family and Case Context 3. Parent views: Professional Network 4. Thematic Analysis 5. Emerging positive practice 6. Conclusion  7. Recommendations    1. Introduction  1.1 This Local Child Safeguarding Practice Review was commissioned by Lewisham Safeguarding Children Partnership1. The review is in respect of a Black British Caribbean male, who died at the age of 17 in 2021. He died as a result of being stabbed, in the context of extra-familial harm 2(harm outside of the home). At the time of his death, Lilo was a Child in Need who had diagnosis of Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactive Disorder (ADHD). A few years prior to his death he sustained a life changing injury which affected the way that he walked and limited his mobility. This became significant at the time of this death, as he was unable to flee from the those that fatally stabbed him.  The combination of Lilo’s needs arising from his neurodiversity3 and limited mobility, left him extremely vulnerable to extra-familial harm.   1.2 This review will show thematic learning across four overarching themes, which are listed in section 4. All themes of learning relate to the key lines of enquiry which were created by members of the review panel and signed off by the Lewisham Safeguarding Children Partnership Executive.   1.3 The four themes identified include:   o Access to education and delays in assessments for Education Health and Care Plans and the experiences of neurodiverse Black boys in education o Recognising and responding to risk in the context of extra-familial harm o Understanding the impact of trauma in the context of extra-familial harm and wider trauma o Understanding the impact of trauma on the workforce   1 Jahnine Davis is the lead reviewing independent author, she has extensive experience in child protection and Black and minoritsed children and is the leading UK subject matter expert in adultification bias and the impact on child protection. Siobhan Burns provided specialist advice in her expertise of children’s services and children with complex needs and disabilities   2 Extra-familial harm is defined as risks to the welfare of children that arise within the community or peer group, including sexual and criminal exploitation. See www.contextualsafeguarding.org.uk  3 Neurodiversity is a concept where neurological differences are seen as natural variations of the brain. These neurological differences are recognised and respected, celebrated and allow people to be themselves. These differences can include those diagnosed with Autism Spectrum Disorder, Dyspraxia, Dyslexia, Attention Deficit Hyperactivity Disorder, Dyscalculia, Tourette Syndrome and others. See https://childrenandfamilyhealthdevon.nhs.uk/wp-content/uploads/2020/04/1-minute-guide-neurodiversity.pdf    4 1.4. The review then concludes with a summary of the most significant learning and   recommendations to improve practice.    Key learning includes the following:   ▪ Professionals must consider how services support neuro-diverse children that do not always have the capacity to comprehend risk, potentially increasing vulnerability and exposure to extra-familial harm. When a child is known to several agencies, it is important that any offer of support is joined up and co-ordinated, reducing siloed responses rather than a holistic and collaborative approach. This includes considering how agencies understand extra-familial harm and their role as statutory safeguarding partners.  ▪ Individual professionals, agencies and the wider partnership must demonstrate how they consider a child’s intersecting identity4 , always remaining curious in exploring how and to what extent does the race/ethnicity/gender and neurodiversity of a child impact decision making, assumptions and attitudes. This is important because this group of children may experience more punitive informed approaches when they present with behaviours which may be symptomatic of their unique educational needs5.  ▪ Black boys (and girls) are also at a greater risk of adultification bias, this must be understood as a manifestation of racism6. This means that professionals are more likely to overlook the vulnerability and impact of traumatic experiences of Black children, due to racist assumptions that Black children are either complicit in the harm they experience or somehow able to safeguard themselves, more than other children. Thus, reducing a child protection response whilst increasing the chances of interventions to control behaviours or especially for Black boys to become known to Youth Justice services rather than providing trauma informed and a needs led approach7.   ▪ It is critical to understand the impact of trauma on children, who have experienced both direct and indirect harm. This includes physical injury (whether caused by extra-familial harm or by any other means), life changing injuries, emotional impact of living in fearful circumstances and experiencing bereavement. Trauma can present through both physical change and behaviour. Due to negative stereotypes about Black boys being perceived as more ‘aggressive’, ‘mature’ and ‘difficult’8,  it is important to consider how trauma is interpreted by professionals when the child is Black, male and neuro-diverse.  ▪ All children deserve the opportunity to thrive and be the best they can, regardless of their race/ethnicity/gender and neurodiversity.  Research shows us that children who  4 The interconnected nature of social categorizations such as race, class, and gender, regarded as creating overlapping and interdependent systems of discrimination or disadvantage; a theoretical approach based on such a premise – Oxford English Dictionary 5 Davis, J, (2022). Adultification bias within child protection and safeguarding. His Majesty’s Inspectorate of Probation (See https://www.justiceinspectorates.gov.uk/hmiprobation/wp-content/uploads/sites/5/2022/06/Academic-Insights-Adultification-bias-within-child-protection-and-safeguarding.pdf ) 6 Davis, J. and Marsh, N. (2020). ‘Boys to men: the cost of ‘adultification’ in safeguarding responses to Black boys’, Critical and Radical Social Work, 8(2), pp. 255-259  7 Davis, J, (2022). Adultification bias within child protection and safeguarding. His Majesty’s Inspectorate of Probation 8 ibid  5 receive consistent and high-quality education, where their special educational needs are identified and responded to in a timely manner, can meet their full potential9.  ▪ Education and safeguarding systems are complex and co-ordination between these services must be improved. It is good practice for professionals to come together to problem solve, particularly for children with a combination of needs, that cannot be met by any one service. Child in need meetings and strategy meetings are key opportunities for this to happen in a multi-agency way.  ▪ It is important that all professionals working with children understand their responsibilities in respect of safeguarding and are aware of their duties to work in partnership and share information.   ▪ There is important learning from this review for CAMHS around the accessibility of services for young Black boys that require therapeutic interventions, particularly, how trauma is acknowledge and understood when extra-familial harm is a feature.    1.5. Scope and methodology:  1.5.1. This Child Safeguarding Practice Review has considered multi-agency practice between December 2018- April 2021. Although, to provide further context some learning falls outside of the above dates, to support future learning and practice improvement.  Professionals were asked to contribute to practitioner meetings and 1:1 sessions. Family members (mother, stepfather and father) were also offered the opportunity to speak with the independent author. Lilo’s father was unable to participate in this review. However, his mother and stepfather’s voices have been included in section 3.   2. Family and Case Context  2.1. Lilo and his family are of Black British Caribbean heritage. He lived at home with his mother, stepfather, siblings and resided in the London Borough of Lewisham. He also had a relationship with his biological father, which was at times inconsistent, but nonetheless they had a relationship. Lilo had a girlfriend who he loved deeply. Lilo was immensely loved and cherished by all his family members and his death has had a deep and profound impact. During the review, it was evident that the death of Lilo also deeply saddened the professional network.  2.2. From a young age Lilo started to present with behaviours that reflected a child who did not have the capacity to always understand risk. Lilo was a child who was easily led and wanted to ‘fit in’. His diagnoses of ASD and ADHD impacted his capacity to identify harmful and risky situations. His wish to ‘fit in’ left him especially vulnerable to grooming and exploitation outside of the family, despite his mother’s attempts to keep him safe. Lilo was sensitive to his mother’s feelings and felt sad that his injuries and at times his behaviour left her worried. The voice of Lilo was rarely documented in case notes, most of his experience was verbalised through the voice of this mother and some professionals in the system.    9 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2022/11/cc-beyond-the-labels-a-send-system-which-works-for-every-child-every-time.pdf  6 2.3.  Lilo’s mother was a significant protective factor throughout his life. She recognised from an early age that her son needed further support to address some of the difficulties he started experiencing. Lilo’s mother dogmatically sought support and reached out to agencies, particularly during his adolescence.  At times it seems that the mother was expected be the Lilo’s parent, his advocate and the conduit for sharing information between agencies.   These included:  ▪ Three requests for an education health and care plan needs assessment. ▪ Requests for support from services for Lilo in relation to his neurodiversity.  ▪ Requests for help from children’s services (children’s social care and children with complex needs and disabilities). ▪ Offering elective home education to safeguard her child and to provide a safer education provision. ▪ Sharing information with the professional network, for example communicating concerns about extra-familial risk and harm, both in respect of Lilo and his younger siblings.  3. Parents views about professional network   3.1. I wish to personally thank Lilo’s mother and stepfather for holding space with me and having the courage to contribute to this review. Lilo’s mother and stepfather shared their perspectives and experiences of the professional network. The following excerpts are verbatim.   3.2. Mother and Stepfathers view                     4. Thematic Analysis   4.1 The learning from this review was produced by the information and perspectives in agency reports, practitioner events and parent involvement. The review includes an intersectional analysis throughout.  All themes align to the key lines of enquiry as per the Terms of Reference:  Services, they need to listen, they don’t listen, we were crying out for help.  My son would always say, my mum is my role model, support and professional. That’s because I literally did everything. I felt like I was on my own. There were so many professionals in his life, it was so overwhelming. They did not understand my son, they did not understand his needs. Professionals should intervene where it matters, give young people the resources for them to be able to move on. Stay guiding them, as adults we seem to forget that even when a child is 14,15, 16 or 17, they still need guidance    We set up a provision in his name, which is a preventative programme for children who need support in their community. Parents know what needs to be done, not the institutions, they just focus on problems and solutions rather than having the understanding that you need to preserve first and foremost   7 o Access to education and delays in assessments for Education Health and Care Plans and the experiences of neurodiverse Black boys in education o Recognising and responding to risk in the context of extra-familial harm o Understanding the impact of trauma in the context of extra-familial harm and wider trauma o Understanding the impact of trauma on the workforce   4.2 Access to education and delays in assessments for Education Health and Care Plans and the experiences of neurodiverse Black boys in education.  4.2.1. Inconsistent and Fragmented Access to Education   4.2.2. Education was an unpredictable experience for Lilo, and he was not provided the opportunity to reach his full potential. The impact of Lilo’s ASD and ADHD coupled with the multiple school moves (including primary settings), made his secondary education an even more challenging experience. It is evidenced that children with ASD struggle more than their counterparts to manage change and form strong peer relationships.   4.2.3. Between the ages 13-16 years, Lilo had moved across four education provisions. In addition, one period of elective home education (placement two) was due to his mother’s concerns regarding his first school. She was concerned that they were not meeting his needs and providing a safe and nurturing environment. He had become involved in fights in the school, and he had begun to get drawn into low level criminal activity10.     School  Placement dates  Length  Secondary School 1 September 2016 – March 2017 6 months  Elective Home Education April 2017– October 2017 6 months  Alternative Provision 1 (this included two sites for different key stages movement from 3-4)  October 2017 – December 2018 1 year and 2 months Not accessing or being provided education due to ill health January 2019 – June 2019 6 months  Alternative Provision 2 June 2019 – December 2019 Less than 6 months  College 1 February 2020 Leading to lockdown in March 2020  EHCP finalised  August 2020     4.2.4. Lilo’s father reported that he had been ‘beaten up badly’11 by a student from School 1 in October 2017. Given Lilo was harmed by a pupil from his previous school, a managed move was agreed for a temporary placement in an alternative learning provision.    4.2.5. The purpose of the temporary placement to Alternative Provision 1 (third placement) was for the school to undertake a six-week assessment to establish whether Lilo could function  10 Taking and driving away, in possession of a stolen motorbike 11 Account of LILO ’s father  8 in mainstream education12 following a period of elective home education and experiencing two fixed term exclusions in School 1.  This placement exceeded the initial assessment duration and was the longest period Lilo experienced in education, a total of a one year and two months. It is unclear why he did not return to a mainstream school following his assessment period or, if his needs were such that he could not return to a mainstream school and why an education health and care plan needs assessment was not triggered.    4.2.6. There is a lack of evidence that Lilo’s wishes, and feelings were sought about being in this provision and what aspirations he had for the future.   4.2.7. Lilo’s fragmented access to education impacted on his educational achievements, the continuity of SEN provision and his capacity to build a trusted, positive peer network.   4.2.8. Significant traumatic experiences and the impact on education    4.2.9. Lilo experienced significant trauma during ages 14-16 years, which happened in tandem with changes in his education placements. Whilst a student at Alternative Provision 1, Lilo experienced two significant traumatic events.   ▪ The murder of a close friend who was also a child impacted by extra-familial harm. ▪ A month following the death of his friend, Lilo was stabbed by another pupil from his alternative learning provision. This student lived on the same road as Lilo, and he had regarded him as a friend.   4.2.10. Lilo left Alternative Provision 1 due to experiencing extra-familial harm from a school peer. He missed learning and was not provided access to education between January 2019 and June 2019 due to poor health, arising from the incident in December 2018.  The receiving schools request for a full assessment of his needs further contributed to the delay in him starting.   4.2.11. There is no evidence to suggest that Lilo was offered any professional support following the death of his friend.  Concerningly, the education provision was aware of the death13 of his friend and yet without professional support, it remains unclear how Lilo’s mental health, wellbeing and sense of safety were acknowledged.  Furthermore, there was a lack of understanding and professional curiosity regarding the impact of Lilo’s ASD and ADHD and the way in which this increased his risk of extra-familial harm. The stabbing and the occasion when he was ‘badly beaten’ both occurred when either at school, or by peers from his same educational setting.   4.2.12. Lilo struggled with peer relationships in both his first secondary school and first alternative provision. The difficulty to navigate and understand peer relationships was exacerbated due to his ASD and ADHD diagnosis, which increased his vulnerability to extra-familial harm 14. However, this was not understood across the safeguarding system due to a lack of exploration and co-ordinated understanding of contextual risk. Professionals in the children’s social care practitioner event shared that contextual risk was a new and emerging issue at the time of these critical incidents in 2018, which may have impacted how risk to Lilo was understood in the professional network. This will be discussed further in the section ‘Understanding risk in context of extra-familial harm’.  12 Information taken from Education IMR and practitioner learning events 13 Account of LILO ’s mother and Stepfather – shared verbally with independent author Dec 2022 14 Notes from ADHD and ASD diagnosis 2012   9  4.2.13. Unfortunately, Lilo did not get the opportunity to settle into his fourth education placement; Alternative Provision 2 in June 2019, as he was involved in a serious moped incident a few weeks later, which resulted in life changing injuries and a long and difficult recovery. Lilo was not able to continue with his education until later in the year. This was provided using a combination of online and some face-to-face support. This was challenging for Lilo as it was a new provision for him, and he had to travel across boroughs to access learning. During the practitioner events, professionals shared that they did not fully understand Lilo ’s needs and his vulnerability, due to a lack of information sharing between agencies.  An example of this was the last college he attended. They were not aware that he had a social worker and their exclusion from the child in need processes resulted in missed opportunities for information sharing and interagency communication.   4.2.14. Evidence provided in the review suggests that Lilo was struggling to come to terms with the life changing injuries he had sustained and was showing signs of trauma. For children who experience significant trauma, compounded with neurodiversity, Lilo would have likely had trouble in comprehending the harm caused to him.   4.2.15. The way in which Lilo processed and experienced trauma will have had an impact on his recovery, both physical and emotional.   4.2.16. Impact of Covid and Education   4.2.17. In February 2020, Lilo started his fifth education provision, whilst awaiting his Education Health and Care Plans (EHCP) assessment outcome. However, in March 2020, the Covid Pandemic resulted in a national lockdown. Lilo was left without consistent support and finding it difficult to respond to online education. During the practitioner event, professionals shared that they understood his learning needs. However, given that education was offered online and without minimal support it is unclear if and how his new provision fully grasped his needs.    4.2.18. Impact of unassessed special educational needs   4.2.19. Due to inconsistent and fragmented education, professionals did not get to know Lilo or fully understand his needs to support the development of a coherent SEN plan to either meet his needs or evidence the need for an ECHP needs assessment.  There was a lack of effective information sharing between schools which meant that the early recognition in 2015 that he had sufficient additional needs to require him to be placed on the school’s SEN register, was not passed on. This created a ‘start again syndrome’ in each of his new schools each time he moved.   4.2.20. Due to this lack of information sharing, his additional educational needs were not assessed, and he was not offered education tailored to his specific needs across any of the provisions he attended between 2017 to January 2020. This includes Primary education, as Lilo was 9 years old when he diagnosed with ASD and ADHD, as such there should have been a transfer of his plan from primary to secondary education. There were multiple missed opportunities to establish a coherent plan.  Secondary School 1 Lilo was on SEN the register, however it is unclear if and how his plan was implemented.   10 2018 – mother’s request for EHCP declined. (aged 12) Alternative Provision 1 SEN plan was not shared from Secondary School 1 – Lilo had no SEN plan in place, and this was longest placement in education.  Alternative Provision 2 In Autumn of 2019 a request for EHCP is made and declined on the same day.  Lilo’s mother follows up the request for ECHP to be fast tracked two days later due to changes in his health – (Lilo aged, 16).  College 1 February 2020 (a month before the Covid Pandemic lock down – Lilo’s EHC needs assessment is agreed.  4.2.21. Lilo’s EHCP was eventually finalised in August 2020 a month before his 17th birthday.  4.2.22. Lilo’s mother advocated strongly for him and made numerous attempts to get an EHCP needs assessment, so that his additional needs could be recognised, and a tailored package of support could be devised addressing his needs arising from his neurodiversity, health and social care needs. Despite these requests for an EHCP needs assessment by his mother, the threshold for an assessment was not met until January 2020. During this period Lilo’s mental health and overall wellbeing had declined following his moped incident and subsequent life-changing injury. When the decision to undertake an assessment was made in 2020, it appears that his additional health needs were a factor in the decision that the threshold was met to trigger this statutory assessment. Prior to this, his needs relating to ASD and ADHD were never perceived to be enough to meet the threshold.  4.2.23. Whilst an EHCP may not always be required for children with a diagnosis of ASD and ADHD, Lilo still should have received a high-quality SEN plan15 to ensure that he had the best opportunity to achieve. When it became evident that Lilo required an EHCP, there had already been multiple missed opportunities to provide Lilo with the specialist educational, health and social care support he required.   4.2.24. Black, male and neurodiverse in school education   4.2.25. Some professionals considered Lilo as being a ‘danger to others’ and having ‘irrational angry outbursts’16. This language denotes the image of the ‘angry Black boy’. During his education Lilo experienced both fixed term exclusions and periods of being excluded from the classroom17.   4.2.26. In the Ofsted Inspection (2016) of School 1 where Lilo experienced the most fixed term exclusions, the school was found to be inadequate. The key issues highlighted included: inadequate safeguarding, inability to manage behaviour and over-use of school exclusions and a lack of pastoral care and welfare support.    15https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.pdf 16 Documented in EHCP needs assessment review case notes, 2020 and GP notes 2011 17 Based on the information provided it is unclear if these periods outside of the classroom were categorised as internal exclusions   11 4.2.27. As a Black neuro-diverse male, in the context of a school that was found to over-use exclusions and struggling to manage behaviour, it is probable that Lilo was perceived as the issue, rather than a consideration that he might have been responding to the conditions created within the school environment.  It is not clear how these perceptions of Lilo impacted on how he perceived himself as a Black neuro-diverse child when excluded from lessons and activities. However, Autism UK (2019) found that exclusions can leave autistic children feeling sad, angry and let down18.   4.2.28. When the focus shifts to responding to a child’s behaviour, without the consideration of critically reflecting what might be the cause of behaviour, professionals are at risk of overlooking the vulnerabilities and difficulties neuro-diverse children experience in education settings19.   4.2.29. Given that Lilo was a Black British Caribbean male, who are more likely to experience punitive responses and expulsion from education20 and where autistic pupils are three times more likely to be excluded from schools than their neurotypical peers21, it is likely that his behaviours were not always considered to be symptomatic of his neurodiversity.   4.2.30. Lilo’s lack of educational progress and negative perceptions about his behaviour could be suggestive that Lilo had started to experience the hallmarks of the school to prison pipeline. This is the movement of Black working-class boys from mainstream education to alternative learning provisions and/or pupil referral units (PRUs) to the criminal justice system, due to lower aspirations for Black boys in education22.This is an important consideration because ‘the proportion of PRU’s and Alternative learning provisions in the capital is almost double the national rate, with young boys from Black Caribbean heritage overrepresented in the sector’23.  4.2.31. The movement of education provisions, significant traumatic experiences, the deterioration of Lilo’s mental health and the limited understanding of his vulnerabilities and learning needs in the professional network, leaves questions about how Lilo experienced his final years before his death.  From reviewing Lilo’s experience of secondary education, in tandem with his trauma, it can be best described as an unsafe and unstable period.      4.2.32. Learning Points:   ▪ Moving children between multiple education settings can result in feelings of instability in relationships, in both peer and professional spaces. It is incumbent on schools to understand and be responsive to the needs of neurodiverse children. This requires information seeking, sharing and clarifying information and providing high quality special educational needs plans to ascertain if and what support a child requires.   18 Autistic pupils and exclusions (autism.org.uk) 19 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2022/11/cc-beyond-the-labels-a-send-system-which-works-for-every-child-every-time.pdf 20 https://thecommissiononyounglives.co.uk/commission-on-young-lives-calls-for-an-end-to-exclusions-culture-as-part-of-a-new-era-of-inclusive-education-to-tackle-the-scourge-of-teenage-violence-and-exploitation-and-help-all-children-to-succe/ 21 https://www.autismeducationtrust.org.uk/exclusions. 22 https://irr.org.uk/article/beyond-the-pru-to-prison-pipeline/ 23 ibid  12 ▪ Negative stereotypes about Black children can reduce professional curiosity to explore the extent to which presenting behaviours are symptomatic of neurodiversity. Professionals must always consider how bias and assumptions about Black boyhood can impact children receiving the best opportunity to thrive in education.  ▪ Risks of extra-familial harm increases for children who experience fragmented education. This risk is heightened when children are placed in alternative provisions and pupil referral units. Children who are neuro-diverse and not always able to comprehend risk and healthy relationships and require education settings which provide nurture, understanding and boundaries.    Recommendation 1: Education must undertake a review of the EHCP process  o Education must gain assurance that when a child has an SEN plan it always follows the child throughout each educational setting.   o It must be expected that SEN plans are updated and where they are not meeting the needs of children, an EHCP needs assessment is progressed.  o Education must gain assurance that SEN plans are robust, effective and provide a clear understanding of the needs of the child in order to ascertain if and what further support is required, such as an EHCP.    Recommendation 2: Identifying, acknowledging and challenging bias within the education system  Lewisham Safeguarding Children Partnership to commission learning and development for Adultification bias and review its current training offer on trauma, neurodiversity and extra-familial harm.    5.3.  Understanding risk in context of extra-familial harm   5.3.1.  Children’s Social Care Services:   5.3.2. Lilo was assessed twice in February and August 2017 by the referral and assessment team.  Notifications had been made to the service following his arrest in August 2016 when he was stopped and searched by the police who found Lilo with a screwdriver, balaclava and pair of gloves24. Another notification was made to children’s social care later that year when Lilo had been involved in a fight which involved groups of boys from two schools. No further action was taken by children’s services following these notifications.   5.3.3. Children social care became involved with Lilo again in 2018 after he had been stabbed. An assessment was triggered, and it was later decided that Lilo’s case would close in June 2019. At the time of the stabbing there was important knowledge held in the professional network showing signs of significant risk to the family. This included:   24 In total Lilo was stop and searched 5 times by the police all resulting in no further action   13  ▪ Lilo’s close friend had been murdered and Lilo was wearing his friend’s coat at the time of the death ▪ Lilo’s mother told the YOS worker that Lilo had said he did not feel safe ▪ Lilo’s mother told a Redthread25 worker that Lilo had been approached on a few occasions to sell drugs ▪ A group of males were reported to have been seen outside the home address and school  There were several agencies in contact with the family at this time, which included:   ▪ The school, who had requested CAMHS support for Lilo  ▪ Redthread, who had been informed of signs of extra-familial harm by the mother ▪ Family Functional Therapy, offering support for Lilo and his mother to develop their communication ▪ The police, who had responded to the stabbing and report of the threat to the home ▪ YOS due to the offences involving motorbikes.  ▪ The GP, who held the family’s history and diagnosis of ASD and ADHD and stress related Alopecia ▪ CAMHS who were offering remote medication provision    5.3.4. The risk to Lilo in December 2018 was recognised to be significant and a strategy meeting26 was held. However, this meeting was not recorded and the planning from this meeting was unclear. This was a critical missed opportunity to bring together all the information known about Lilo, to set out his vulnerability and lived experience and to take steps to secure the immediate safety of Lilo and his siblings.   5.3.5. A further incident happened at the end of December 2018, where a ‘blue light’ had been shone through the letterbox of the family home and this made the family fearful about further violence or harm. There is no evidence that a strategy discussion took place and the only response to this incident was to advise the mother to move out of the family home. To note, if his mother had moved out of the local authority permanent home, her secure tenancy and the rights attached to this would have been compromised, leaving the family ‘intentionally homeless’.   5.3.6. Since this review Lewisham Housing have updated their housing needs assessments and this now includes the impact of extra-familial harm. It is important that housing associations are updated with any changes or new information regarding this assessment.   5.3.7. Notes from a multi-agency meeting in February 2019 show that there was some recognition of the risk to Lilo from extra-familial harm. However, Lilo had multiple changes of social worker and in June 2019 the decision was made for his case to close as there were:   Practitioner case notes:   25 Redthread provide youth violence intervention programmes in identified hospitals in London, including one where Lilo was an inpatient in 2018. See (https://www.redthread.org.uk ) 26 A strategy meeting is a multi-agency meeting, hosted by children’s services to identify levels of risk and plan for the immediate safety of the children involved.   14  ‘No parenting concerns, Lilo had a school placement, and he was working with the Youth Offending Service and health27’    5.3.8. This decision implies that extra-familial harm was not well understood at the time, a view that has been reflected by practitioners that took part in this review.   5.3.9. A month later Lilo was involved in a moped accident which triggered a fresh referral to children’s social care and a new assessment of need in August 2019. The outcome of the assessment was that Lilo should be offered services from the Safe Space Team. This was a new team designed to meet the needs of children at risk of extra familial harm. A decision was later made that Lilo should be held by the team who cater for children with complex needs and disabilities. This was a perplexing decision given that children with complex needs and disabilities teams usually have high thresholds and do not usually serve children with needs arising from neurodiversity - unless acute, such as non-verbal.    5.3.10. Feedback from practitioners was conflicting when this decision making was explored. One explanation was that the Safe Space team did not have capacity to take Lilo at the time as the criteria for services from this new team were not clear and it had been flooded with referrals. Another explanation was that the decision was made from a service manager level whereby the Local Authority felt the complex needs and disabilities team was most suitable.   5.3.11. Lilo transferred between social work teams until November 2019 where a request had been made for support in meeting Lilo’s needs arising from the injuries, he sustained in the motorbike accident. He was allocated for a child and family assessment by a social worker in the children with complex needs and disabilities team to see if he met the threshold for services from this team. The supervision notes at this time indicate that Lilo blamed himself for some of the issues he was experiencing due to ‘hanging around the wrong peer group’28. Although it is unclear how professionals supported Lilo in exploring these feelings.  5.3.12. The child in need planning following this assessment did not highlight the risk Lilo was experiencing due to extra-familial harm. This planning was focussed on his physical needs and his mother’s need for breaks from providing care to him. Lilo’s voice was not present in case planning. If he had attended his reviews in person or his voice represented by his mentor29 or mother, it is highly likely that his sense of feeling unsafe would have helped to focus the attention of the other professionals contributing to the planning. As a result of this important gap the planning was not linked to his need for protection.   5.3.13. It is expected practice that a boy of Lilo’s age would contribute to planning and be given the opportunity and support to express his wishes and feelings about his life. It is also expected that all professionals working with children are either invited to attend reviews or consulted on their views.  5.3.14. It is also expected that where significant harm has been identified that basic child protection processes are followed: e.g., strategy discussions and safety planning.    5.3.15. Child and Adolescent Mental Health Services (CAMHS)   27 This note is taken from the children service’s record.  28 Supervision notes dated 22.11.2019 29 A mentor from Young People Relate Mentoring Service was commissioned by the children with complex needs and disabilities service to additional support to LILO   15  5.3.16. Lilo disclosed concerns about his safety a few months after he was stabbed in December 2018, in his initial medication assessment appointment in March 2019.  5.3.17. Lilo told the professional undertaking the assessment that he had carried weapons as means to protect himself from harm, indicating concerns regarding safety. This information was not shared with children’s social care or any other professional, at the time Lilo was subject to a Child in Need plan.  Upon reviewing the assessment notes, the focus was on Lilo needing to understand the risk of carrying weapons, rather than the underlying issue – his fear and lack of safety. The assessment concluded that there were no known safeguarding issues, although his risk of external harm was recorded as ‘moderate30. This is despite his disclosures of not feeling safe and the evident extra-familial harm that Lilo and his family were exposed to in December 2018.   5.3.18. It is important to note that CAMHS were not informed about the stabbing incident in December 2018 by children’s social care but were informed at the medication review meeting by his mother. This illustrates there was a lack of effective information sharing across the partnership which was exacerbated by the fact that Lilo did not have a care co-ordinator in place until March 2021. It is the role of the care co-ordinator to ensure that planning is holistic and co-ordinated across agencies.   5.3.19. As part of the review, information in the SLaM IMR into CAMHS suggested that professionals did not have an understanding Lilo’s risk of harm. The assessment of his needs endorses the view of the IMR author. There were, however, contradictory views about this as SLaM’s serious incident report31 does not share the same perspective as recorded - ‘the risk assessment forms…. were not detailed. However, the team consultant who also provided care coordination demonstrated a detailed understanding of the issues...’ It is difficult to understand this view based on the limited information on the medical assessment form and poor practice seen in this review.   5.3.20. Records of the medication assessment show that records were copied and pasted from previous assessments which indicates a lack of vigour and exploration of his changing needs.   5.3.21. Since Lilo’s death further concerns have been raised about how CAMHS understand their role in child protection. During a CAMHS practitioner 1:1 meeting a senior professional stated that they were not assured that issues like those identified with Lilo, including poor assessment and understanding of risk had improved following the death of Lilo.   Practitioner comments:  ‘I still do not feel assured that SLaM have an understanding of child protection and our role within that...’  ‘There was no risk management plan and no sharing of information’   5.3.22. Race, racism and other biases and Extra-familial Harm   30 Medication assessment notes 27th March 2019 31 SLaM  undertook an investigation in line with the NHS Serious Incident Framework: NHS England » Serious Incident framework  the investigation was a joint investigation with Oxleas NHS Foundation Trust.   16  5.3.23. Black children are at an increased risk of extra-familial harm32as such, services must feel able to critically reflect how assumptions about Black boys can impact safeguarding responses and decision making.   5.3.24. To better understand if and how Lilo’s identity impacted safeguarding responses and decision making, during the review, professionals were asked to complete an online anonymous questionnaire which included questions about if and to what extent racism and bias potentially influenced safeguarding decisions. A total of 17 responses were received with over 90% from one service, overwhelming practitioners felt that racism was not an influencing factor.   Practitioner comments:  ‘I feel confident that racism did not impact services responses to Lilo ’  ‘Our services are open and inclusive and the LSCP has a good understanding of racism and discrimination’  5.3.25. However, during a 1:1 meeting with the lead reviewing author and LSCP interim strategic safeguarding lead some practitioners felt that racism had impacted on safeguarding responses to Lilo.  Practitioner comments:  ‘He was a Black boy at the bottom of the well, adultification bias impacted how Lilo was responded to as child’  ‘Racism was a compounding factor he was just another Black boy’  ‘Talking about racism is not easy for our services which is frustrating as it constantly shapes how Black children are safeguarded’   5.3.26. In addition, during practitioner events there appeared to be some discomfort in talking about racism.  Periods of long silence occurred. Talking about racism can be challenging for several reasons; this includes, practitioners not feeling confident or safe, including concerns of causing offence. As such, services need to create the conditions so that conversations about race and inequality are normalised and part of everyday practice. The National Panel’s report into extra-familial harm; It was Hard to Escape33 identified that Black boys are at a heightened risk of being victim to this form of harm. Therefore, it is imperative that individuals and agencies feel able to talk about identity, in particular race and ethnicity. In addition, findings from a recent review into extra-familial harm and Black boys in a London Borough, identified naming racism as one of the difficulties in service provision34.   32 Hard to Escape (2020). National Children Safeguarding Practice Review Panel 33 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/870035/Safeguarding_children_at_risk_from_criminal_exploitation_review.pdf  34 https://www.contextualsafeguarding.org.uk/resources/toolkit-overview/building-safety-safeguarding-black-young-men-and-boys-in-lambeth/   17  5.3.27. Learning points:   ▪ It is important that children who are at risk of or experiencing extra-familial harm are provided with timely and effective support. This requires professionals to recognise risk and refer children to the services which can best meet their needs. This includes, reflecting on bias and being able to talk about racism in child protection when considering the experiences of Black boys in the context of extra-familial harm.  ▪ It is important that all practitioners and managers across all agencies, including specialist service areas (CAMHS and Children with Complex Needs and Disabilities) are alert and responsive to extra-familial safeguarding risk and harm. This includes understanding the increased vulnerabilities for children who are neuro-diverse and/or with physical disabilities  ▪ CAMHS practitioners must understand their role as a statutory safeguarding partner and their duty to share information as well as recognise safeguarding concerns.   ▪ Strategy meetings are important vehicles in identifying risks, developing plans and sharing and analysing multi – agency information. It is critical that these meetings take place, involve the relevant partners and are recorded.   ▪ Where a child has complex needs and is being served by a range of agencies it is important that a care co-ordinator is allocated in a timely manner.   ▪ Children’s voices are important to help us understand their lived experience and to inform planning.    Recommendation 3: The importance of the voice of the child that is heard and integrated into plans. Lewisham Children’s services to ensure that staff are aware of expected practice across children’s services regarding child in need planning and reviewing processes. Namely,  o it is expected that children (where possible) are involved in planning and reviews  o It is expected that all professionals working with children are invited to attend or contribute to child in need planning meetings and reviews. o It is expected that all professionals working with children receive the outcome of CIN planning meetings and reviews.    Recommendation 4: Recognising and responding to extrafamilial harm.  For Lewisham children’s services to take steps to ensure that all social workers and managers working with children can recognise and respond to extra-familial harm, especially for children with additional needs that increase their vulnerability to grooming and exploitation.   Recommendation 5: Improving the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner  o The Lewisham Safeguarding Children Partnership must gain assurance that there is regular management oversight of children who are open to CAMHS service but do not have an allocated care co-ordinator and performance around this expectation is  18 reviewed in the Lewisham Safeguarding Children Partnership Monitoring Evaluation and Service Improvement subgroup  o To gain assurance that CAMHS (South London and Maudsley) understands their role as statutory safeguarding partner and provide assurance of their capacity to recognise and respond to children at risk of and experiencing harm.  Recommendation 6: Improving the quality of record keeping and assessments   Lewisham Safeguarding Children Partnership must gain assurance that CAMHS assessments of extra-familial risk meet expected standards.   Lewisham Safeguarding Children Partnership must gain assurance that:  o Strategy meetings are happening when risk or potential risk is identified o These meetings are attended by all relevant partners o These meetings are recorded, and a copy of the plans are shared with all agencies working with child    5.4. Understanding the impact of trauma and mental health in the context of extra-familial risk, harm and life changing injuries  Children who are worried about potential risk of harm from others, or those who have already experienced harm, may not always feel able or safe to share how they are feeling, which can result in poor mental health and wellbeing.35 It is important that individual professionals and agencies understand trauma in the context of extrafamilial harm, considering children impacted by this harm may be perceived as being complicit or having increased agency to manage their own risk.36 When considering Lilo’s identity as a Black neuro-diverse male, it is likely that assumptions about increased capacity and agency impacted professional curiosity. During the undertaking of this LCSPR some professionals used language which could be considered as Lilo being complicit in the harm/risk he was experiencing, without due consideration of his lack of capacity to comprehend risk, due to his ASD and ADHD diagnosis. Some language used included ‘he put himself at risk’. This is an unhelpful narrative and erases the innate vulnerability of a child and not one which considers how Lilo’ s neurodiversity presented when grappling with potential risk or trauma.   5.4.1. There were notable episodes during Lilo’s adolescence where is started to present with trauma and poor mental health, some of which were related to extra-familial harm and other with reference to the impact of life changing injuries experienced outside of the home.  5.4.2. Child and Adolescent Mental Health Services (CAMHS)  5.4.3. Between 2018 -2021, Lilo was referred to CAMHS on seven occasions, this included both external and internal referrals. The rejection of internal referrals within and across CAMHS services, did not trigger follow ups or professional queries.  Lilo, his mother and agencies reported concerns regarding his mental health over a two-year period to CAMHS. However, none of these met the threshold for CAMHS intervention. Although Lilo was receiving  35 https://chscp.org.uk/portfolio/child-c/ 36 Mapping the policy and practice landscape of safeguarding young people from extra-familial risks and harms (EFRH),  19 support from the family functional therapy service37; CAMHS missed opportunities to be responsive to Lilo’s trauma and declining mental health.   5.4.4.  A brief timeline below provides some insight to Lilo ’s experience over a 12-month period:           2018  ▪ Lilo experienced an unexpected bereavement following the death of his friend  ▪ When Lilo was stabbed, he experienced alopecia, difficulty in sleeping, reported low mood and struggled hygiene  2019  ▪ March 2019, 3 months after Lilo was stabbed, he discloses at his medication review meeting that he feels unsafe and has carried weapons as means to protect himself38. During this period, Lilo has a ‘mild to moderate depressive episode’39. Although, this is not recorded on the assessment form. ‘Trauma’ as so far as it relates to PTSD or medical diagnosis was not present according to the assessment’40.  ▪ May 2019, YOS shares concerns regarding Lilo’s mental health with CAMHS, following an episode in custody. IMR indicates that following this concern, a meeting between Lilo, his mother and a CAMHS Consultant Psychiatrist took place where outcome of both Lilo and his mother’s mental health questions and signifies major depression. However, this has since been disputed.41 ▪ June 2019, Moped incident resulting in life changing injuries ▪ July 2019, Lilo ’s mother and Redthread Youth workers visiting Lilo in hospital raise concerns regarding his mental health and trauma, however CAMHS do not accept referral ‘he was not acute of high-risk enough in his presentation’42   5.4.5. In addition, Lilo experienced auditory hallucinations whilst in police custody in 2020.  5.4.6. It is deeply troubling and difficult to understand how a child who was a victim of stabbing, involved in serious vehicle incident and consequently left with a life changing injury within a period of six months did not meet the threshold for CAMHS and his mental health was deemed moderate.   5.4.7. Referral, acceptance and waiting times for Black and minoritised children requiring CAMHS support  5.4.8. During the undertaking of this review, third party disclosures were shared with the lead independent reviewing author, regarding concerns that Black boys referred into the Local Authority CAMHS service experience longer waiting times for support and intervention than their white counterparts.  5.4.9. At request of the independent reviewing author, CAMHS were asked to provide their most recent referral, acceptance and waiting time data. The data highlighted that in 2021, Black  37 Lilo was referred to the family functional therapy service  38 Medication Assessment 27.03.2019 39 Record from CAMHS Chronology submission to review 40 The Consultant Psychiatrist record on review template December 2022 41 The Consultant Psychiatrist emailed the independent reviewing author -stating Lilo was not diagnosed with major depression. It is unclear if and what case notes this alleged diagnosis was recorded.  42 Recorded on Redthread Lamplight record 17.07.19 – information provided by Clinical Nurse Specialist Children’s Safeguarding  20 boys waited 114 days for initial contact from CAMHS upon acceptance of referral, in comparison to 76 days for their white counterparts. Meaning Black boys had to wait one and half times longer for support. This was similar for Asian boys (115 waiting days).  5.4.10. In that same year, Black children had proportionally fewer referrals accepted than white children estimate of 72% vs 78% for girls, and 71% vs 78% for boys. The proportion of accepted referrals for children of mixed heritage is even lower estimate of 63% for boys and 62% for girls. There was no waiting list data provided for mixed heritage children. Whereas Asian children had the highest acceptance rate estimate of 83% males and 86% females43.  5.4.11. Given the disparity presented in the data, CAMHS must explore and reflect on why this disproportionality exists within its service provision and how it is assured that bias and discriminatory practice is not influencing which children are more likely to receive therapeutic support in a timely manner.    5.4.12. Key professionals from CAMHS who were involved in the decision-making regarding Lilo’s needs, were invited to participate in the review and share their perspectives. However, after more than several requests to meet, none of the invited practitioners were able to participate in the practitioner learning events or attend 1:1 meeting with the independent reviewing author. However, the independent reviewing author met with two members of the Senior Management Team within CAMHS who provided some level of insight following a review of Lilo’s case file.  5.4.13. There were missed opportunities to undertake a multi-disciplinary review of Lilo’s needs, as he had multiple referrals into the service. This was exacerbated by absence of a co-ordinated approach and fragmented information sharing across agencies within and external to CAMHS.  5.4.14. Referrals for Lilo tended to focus on his behaviour as the core issue, rather than trauma and his mental health. This raises questions about the lens in which professionals viewed and understood Lilo’s trauma and vulnerability.  5.4.15. Research suggests that traditional therapeutic services do not always consider the experiences of racialised communities44, and that the very foundation of mental health provision in the United Kingdom is underpinned by Eurocentric45 and neurotypical ideas and assumptions about the presentation of trauma and mental health46. Therefore, being a Black neurodiverse male likely resulted in a misinterpretation of Lilo’s behaviour and without consideration of how interpretations might be steeped in professional bias and negative racial gendered stereotypes.         43 CAMHS provided a graph with no actual percentages or numbers. Therefore, referral and acceptance information are estimates based on the interpretation of the independent reviewing authors analysis. However, the waiting time information is factually correct as CAMHS provided actual numbers for this data. 44 Therapeutic Intervention for Peace Report: Culturally Competent Responses to Serious Youth Violence in London. See www.powerthefight.org.uk  45 Oxford dictionary defines Eurocentric as’ an attitude that focuses on European culture or history and regards it as more important than the culture or history of other regions’ 46 https://doi.org/10.1080/13648470.2021.1949892    21 5.4.16. Learning Points:   ▪ Where there is a history of more than three referrals into CAMHS, which are not accepted, this should trigger a multi-disciplinary meeting to evaluate why the referral does not meet the threshold for services and to agree an alternative provision where the referral can be better redirected.   ▪ Children who experience, or who are at risk of extra-familial harm can experience trauma. There is a risk that children impacted by this kind of risk, may be overlooked due to assumptions that they are complicit in the harm experienced or have increased agency and capacity to safeguard themselves.  Language such as ‘children putting themselves at risks’ denotes a lack of understanding of the innate vulnerability all children possess and can lead to adultification bias.  ▪ Children who have social communication difficulties are at a greater risk of exploitation and extra-familial harm, whereby presentations of trauma are not always identified. Leaving children who already have limited capacity to navigate complex issues. Consequently, services are at risk of exacerbating the poor mental health and wellbeing of children, instead of providing the appropriate therapeutic support required.  Racial biases also contribute to misinterpretations of behaviour and risk.   ▪ CAMHS must demonstrate how they provide an inclusive service which considers the intersectional needs of children whose experiences of trauma span across various contexts, including extra-familial harm.   Recommendation 7: Reviewing repeated referrals into CAMHS not meeting the threshold for intervention  The learning from this review must be considered in how South London and Maudsley CAMHS service supports and responds to children impacted by extra-familial harm. CAMHS must ensure that a multidisciplinary review is triggered when a child is referred into more than 3 times within a 12-month period and does meet the threshold for intervention.    Recommendation 8: Improving understanding trauma in the context of intersectionality   Further learning and development is required for all agencies – with a particular focus on CAMHS and Children with Complex Needs and Disabilities. All learning and development must be underpinned by intersectional thinking. This requires high quality facilitation, to ensure that professionals better consider how they understand and offer their curiosity to children trauma related to experiencing, or at risk of extra-familial harm and who fall within intersecting categories e.g., race, ethnicity, neurodiversity, gender etc An evaluation of all learning must be revisited within three months of the initial training/development, evidencing next steps, improvement and areas for development.    Recommendation 9: Improving access and support to CAMHS   The learning from this review has highlighted that there is a disparity in which children are referred into CAMHS, including the waiting times for first contact. CAMHS must monitor and improve the inclusivity and accessibility of its services for Black and minority ethnic children.  22 This includes improving the quality of data and ensuring data is used to improve service design and provision   5.5. Understanding the Impact of trauma on the workforce  5.5.1. The impact of trauma on practitioners working with children impacted by harm can be significant. During this review practitioners shared how the death of Lilo had impacted their mental health and ability to remain hopeful and positive that youth violence can and will get better47. Professionals working closely with children who experience extra-familial risk and those who die as a result of this form of harm struggle with burn out, fatigue and require support to acknowledge the impact of loss48.  It is important that professionals have access to supportive spaces where they can share, reflect and be provided with support during difficult times, when a child they may know directly or indirectly is harmed.     5.5.2. Fatigue, hopelessness and trauma  5.5.3. During this review it became apparent that the professionals across the safeguarding system, including those from the youth offending service, were becoming somewhat used to receiving traumatic news about the children and families they work with or have supported in the past.   5.5.4. Practitioners also shared that at times, it is the same professionals called upon to participate in joint agency review meetings (JAR)49 and other multi-agency meetings about the death or serious injury of a child. It was evident by the emotion displayed during this review, that practitioners felt a sense of hopelessness, pain and exhaustion. Sadly, some practitioners blamed themselves for Lilo’s death.    5.5.5. Some practitioners shared that they were not provided any wellbeing support following Lilo’s death and were left to manage the impact of the bereavement in isolation, further impacting their mental health, with other sharing similar examples. All practitioners across the safeguarding partnership, including other external agencies must have access to and, or be informed of support services available to them, particularly when experiencing trauma.   5.5.6. In 2021, the year Lilo tragically lost his life, London documented the highest number of deaths related to youth violence on record, 30 teenagers between 14-19 years of age50. Most of these victims died as a result of knife crime.   5.5.7. Some of these themes in this review have been identified in other incidents involving Black boys such as, ‘Chris’: London Borough of Newham,51 ‘Child C’: London Borough of Waltham Forest,52 Child C: London Borough of Hackney.53 As such, it is important to recognise the re-occurring themes of Black boys impacted by violence. This is crucial to understanding why and how practitioners might feel overwhelmed.  47 Accounts taken from practitioner learning events held in June 2022 48 https://www.contextualsafeguarding.org.uk/resources/toolkit-overview/building-safety-safeguarding-black-young-men-and-boys-in-lambeth/  49 A JAR meeting occurs following the unexpected death of a child as per Chapter 5 in Working Together to Safeguard Children 2018 50 https://data.london.gov.uk/dataset/serious-youth-violence?_gl=1%2adyethe%2a_ga%2aMTA4Mzk1MjE4OC4xNjcwNTA4NTMw  51 https://www.newhamscp.org.uk/wp-content/uploads/2018/10/Serious-Case-Review-Chris-.pdf  52 https://www.walthamforest.gov.uk/sites/default/files/2021-11/WFSCB%20-%20SCR%20Child%20C%20May%20final_.pdf  53 https://chscp.org.uk/wp-content/uploads/2022/07/CHSCP-SCR-Tashaun-Aird-Child-C-Report-PUBLISHED-FINAL2.pdf    23  5.5.8. Examples of positive practice    5.5.9. Throughout the review, the Youth Justice Service (YJS) (previously known as the Youth Offending Service), demonstrated an in-depth understanding of the impact of trauma on the workforce. This is reflected in their Therapy Hub provision. The aim of the Therapy hub is to provide (consultation) to professionals when in need of support. This is a multidisciplinary service is delivered by YJS practitioners, (Family Therapists, Speech and Language Therapists and the co-located Forensic CAMHS team).  This is small and unique service where capacity is limited, as such it is important that leadership consider how to sustain it, without unintentionally absolving the responsibilities of other inter-agencies to provide a similar provision.   5.5.10. Learning points:    ▪ The impact of trauma following the serious injury or death of a child known to the safeguarding system can be profound. It is important that front facing practitioners are safeguarded and supported to manage the impact of trauma.  ▪ The impact of youth violence in London is profound. Professionals working within the context of extra-familial harm may experience burn out, fatigue and vicarious trauma. Access to effective wellbeing services must be standard practice.   Recommendation 10:  Understanding Trauma for Practitioners working within the context of Extra-familial harm   o Lewisham Safeguarding Children Partnership must provide wellbeing support to all practitioners working front face with children and families impacted by extra-familial harm. This should include reflective practice and high-quality supervision to ensure practitioners feel supported and able to share concerns regarding their mental health and wellbeing   o Lewisham Safeguarding Children Partnership must gain assurance the need wellbeing and mental health needs of professionals are being met. It must undertake review to explore what current wellbeing provision is available to practitioners, with a plan improve provision where needed. Including utilising learning from the YJS Therapy Hub.      6. Emerging Positive Practice  6.1. Whilst the review has highlighted challenges within the safeguarding system and individual agency practice. There were some examples of positive and improving practice.   6.2. Increased awareness of contextual risk and extra-familial harm    24 6.3. There is evidence in this review that there is now better understanding of the purpose and referral pathway for the adolescent safeguarding service (Safe Space). In addition, the development of consultation surgeries focused on contextual safeguarding. The purpose is for professionals to increase understanding about extra-familial risks and discuss potential concerns with experienced practitioners.  6.4. The development of the Safeguarding Partnership Multi-Agency Child Exploitation (MACE) panel provides an opportunity for a more focused consideration of extra-familial harm, enabling for a more improved and collaborative partnership approach.  6.5. Relational Practice  6.6. The Youth Justice Service and Lilo’s allocated mentor had a good and consistent relationship with both Lilo and his mother. Relationships are not mandated and therefore when practitioners nurture positive relationships with children and families, it should be recognised and celebrated. Hard to Escape (2020) highlighted the importance of relationship-based practice for children at risk of or experiencing exploitation.   6.7. Out of all the agencies who met the family, it seems that YJS had most in-depth understanding of the family needs and functioning, including the lived experience of Lilo.   6.8. YJS and the GP both demonstrated the importance of agencies having a good and communicative relationship with parents. Lilo’s mother shared that she felt able to reach out to individual practitioners in YJS, where a relationship remains.   6.9. Redthread 54acknowledged the challenging dynamics Lilo’s mother experienced when trying to safeguard her child but also managing with multiple difficulties which required wider support outside of the Redthread offer. Therefore, having a better understanding of a whole family approach rather just focusing on the individual child.  6.10. A trusted adult who builds aspiration - Lilo ’s mentor    Practitioner account:   ‘I seen and treated Lilo like my son, I would’ve done anything for him, he was one of the most caring and beautiful young men I ever had the privilege to know’ (Mentor)     6.11. A mentor from Young People Relate Mentoring Service was commissioned by the Children      with Complex Needs and Disabilities service to provide additional support to Lilo.  6.12. Having a trusted adult, such as a mentor, who role modelled consistency, boundaries and care, provided Lilo with a space he could access if and feeling unsafe, worried and overwhelmed by the realities of the difficulties he experienced in his external surroundings.    54 Combined Agency Chronology V5  25 6.13. Lilo’s mentor was allocated 5 hours of mentoring support per week55.  During the period Lilo received mentoring, he did not miss any sessions and seemed to really enjoy the relationship he and his mentor had developed. From his mentor’s perspective, Lilo felt safe and able to be himself when they were together; this included Lilo using his crutch which he needed to aid his walking. Lilo had shared with his mentor that he did not always feel comfortable using his crutch when out with his friends, as he had a desire to ‘fit in’.56  6.14. During the period Lilo received mentoring support, he achieved several AQA’s57, including one focused on meditation to help Lilo with his anxiety. His mentor was concerned that he was not accessing appropriate education for his needs and learning, so decided to provide Lilo with 1:1 tuition, alongside his enrichment activities. From Lilo’s mentors’ perspective, this increased confidence and belief within Lilo that he could achieve and do something positive with his life. Lilo’s mother and stepfather both shared a deep gratitude to his mentor and acknowledged the support and care provided to him.   7. Conclusion   7.1. Lilo was a vulnerable child whose needs were not always understood and considered by professionals across the safeguarding system. Lilo did not have the capacity to always understand risk and comprehend unsafe situations. This was exacerbated due to many professionals interacting with him not being able to recognise that his neurodiversity compounded his risk and vulnerability to extra-familial harm.  7.2. As a Black neuro-diverse boy with a physical disability, Lilo navigated the intersections of gendered racism and ableism. This was prevalent in aspects of his educational experience, negative racial stereotypes and the lack or delayed curiosity of the wider professional network to engage and consider the impact trauma was having on his life.    7.3. Adultification bias was present which means racism influenced how Lilo was protected as a child. There was an overlooking of Lilo’s need for safety when at risk of and experiencing harm. Apart from one supervision record in children’s social care, the primary focus of children’s social care , education and CAMHS was on his ‘risk taking behaviour’ rather than his vulnerability to risk and harm.  7.4. The difficulties of meeting the threshold for an EHCP needs assessment, should not hinder or absolve the responsibility of schools to provide high quality SEN plans. The lack of support and understanding of Lilo’s needs meant for most of his education he went without the expected effective support to assist him in fulfilling his potential. Furthermore, this lack of understanding, influenced how professionals perceived Lilo, in terms of his risk, vulnerability and how that presented through his behaviour.   7.5. For any child protection system to work, professionals must share and analyse information to inform the best possible outcomes for children. Whilst information sharing continues to be a perennial issue, at different points all agencies had knowledge of Lilo’s vulnerability to risk; this includes direct disclosures from Lilo and his mother. Therefore, the challenge was not solely about the sharing of information, it was how agencies analysed and responded to the information they had sight of.   55 Support provided as part of short breaks via children with complex needs and disabilities service 56 Account taken from 1:1 meeting between independent author and LILO ’s previous mentor 57 Assessment and Qualifications Alliance  26  7.6. The voice and experiences of parents must be included in planning and decision making, where they are recognised as experts. Where there are no concerns about parental abuse or neglect, the professional network must make every effort to include parental experience and insight in the child protection system. This includes meeting them where they are at, centring this within a Think Family approach.     7.7. Understanding extra-familial harm has increased over the past several years across safeguarding systems in England. At the time of Lilo’s death, practitioners shared that contextual risk was a new and emerging issue. However, even without a good understanding of this type of harm, opportunities were missed to safeguard Lilo due to basic child protection procedures not being adhered to. This includes the lack of coherent strategy meetings, planning and record keeping, failures to act upon disclosures and not sharing information when concerns regarding the potential risk to safety became apparent.   7.8. The role of the local authority CAMHS as a statutory safeguarding partnership requires improvement. Whilst this review highlights issues across most agencies including children’s social care, it became increasingly evident during the review that CAMHS does not fully understand its role and duty in child protection. The medicalised focus seemed to obscure the child protection issues and his wider emotional needs arising from trauma. The issue is not one of the past but present based on concerns raised during the undertaking the review which are endorsed by the independent reviewing author.  7.9. Thresholds for CAMHS support and waiting times is a national issue, however, this review found that Black boys waited one and half times longer for support in comparison to white boys in this London Borough. This is concerning and raises serious questions about the inclusivity, accessibility and discriminatory practice in mental health provision. For Lilo, he experienced significant trauma, but this was not reflected in the support he received.  7.10 Whilst Lilo did not always have access to therapeutic support, outside of his family network, he had some professionals, including his mentor and those in YJS, who understood him and provided care, nurture and support. However, without the wider system providing wrap around support for Lilo, it was easy for him to fall out of sight and receive an ineffective response to the harm he was suffering.  7.11 The death of a child has a reverberating impact on loved ones, including the professional network. Leadership must reflect and act on ensuring that practitioners have access to support when working with children impacted by extra-familial harm.   7.12 Since the death of Lilo, new and emerging positive practice has started to shape professional understanding regarding extra-familial harm. This is an important step towards building safety for children impacted by contextual risk. However, this review also found examples of practice and attitudes which require further improvement. Therefore, even with the death of Lilo occurring two years’ ago, it must not be assumed that the partnership including Education does not have more to learn.  The professional network must be assured that the safeguarding system can prevent and overt risk as best as possible. For Lilo the partnership must reflect if the response and support he was provided was good enough for a child who needed its help.      27 8. Recommendations: All 10 recommendations must be included in a partnership action plan related to learning from this review and any other related LCSPRs.   Recommendation  Responsibility  When by? Recommendation 1:   Education must undertake a review of the EHCP process.    The LSCP must gain assurance from relevant education services that when a child has an SEN support plan it always follows the child throughout the different educational setting   It must be expected that SEN support plans are updated and where they are not meeting the needs of children, an EHC Needs Assessment is progressed by the education setting.  Education and the LSCP must gain assurance that SEN support plans are robust, effective and provide a clear understanding of the needs of the child and how these needs are met in order to ascertain if and what further support is required, such as an EHC Needs Assessment.  (See para 5.2.33) Education within 6 months Recommendations 2 and 8:   Review workforce development offer and commission further learning to improve professional understanding across all agencies to ensure a better understanding of trauma, intersectionality, adultification bias and neuro-diverse children in the context of extra-familial harm always considering language and framing of children.   Identifying, acknowledging and challenging bias within the education system: (see para.2.32)  Improving understanding trauma in the context of intersectionality (See para 5.4.17) LSCP Updated learning and development programme: within 3 months  Evaluation of impact: within 8 months Recommendation 3:   The importance of the voice of the child that is heard and integrated into plans. Children’s Social Care to ensure that staff are aware of expected practice across children’s services regarding child in need planning and reviewing processes. Namely,  • it is expected that children (where possible) are involved in planning and reviews  • It is expected that all professionals working with children are invited to attend or contribute to child in need planning meetings and reviews. (See para 5.3.25) Children’s Social Care Ongoing  28 Recommendation 4:  For Lewisham children’s services to take steps to ensure that all social workers and managers working with children can recognise and respond to extrafamilial harm. Especially for children with additional needs that increase their vulnerability to grooming and exploitation. (See para 5.3.25) Children’s Social Care Within 6 months  Recommendation 5:  Improving the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner  o Lewisham Safeguarding Children Partnership must gain assurance that there is regular management oversight of children who are open to CAMHS service but do not have an allocated care co-ordinator and performance around this expectation is reviewed in the LSCP Monitoring Evaluation and Service Improvement subgroup  o To gain assurance that CAMHS (South London and Maudsley) understands their role as statutory safeguarding partner and provide assurance of their capacity to recognise and respond to children at risk of and experiencing extra-familial harm.   (See para 5.3.25) LSCP & CAMHS Immediate Recommendation 6: Improving the quality of record keeping and assessments   Lewisham Safeguarding Children Partnership must gain assurance that CAMHS assessments of extra-familial risk meet expected standards.   Lewisham Safeguarding Children Partnership must gain assurance that:  • strategy meetings are happening when risk or potential risk is identified • These meetings are attended by all relevant partners • These meetings are recorded, and a copy of the plans are shared with all agencies that are contributing to the safety plan.   (See para 5.3.25) LSCP & CAMHS Within 3 months Recommendation 7:   CAMHS must introduce multi-disciplinary review meetings when a child is referred more than three times and does not meet threshold for intervention  CAMHS Immediate   29 The learning from this review must be considered in how South London and Maudsley CAMHS service supports and responds to children impacted by extra-familial harm. CAMHS must ensure that a multidisciplinary review meeting is triggered when a child is referred more than 3 times and does meet the threshold for intervention. This will enable a review of the child’s needs and potential signposting of other support services  (See para 5.4.17) Recommendation 9:   CAMHS must monitor and improve access and support for Black and ethnic minoritised children  The learning from this review has highlighted that there is a disparity in which children are referred into CAMHS, including the waiting times for first contact. CAMHS must monitor and improve the inclusivity and accessibility of its services for Black and minority ethnic children. This includes improving the quality of data and ensuring data is used to improve service design and provision   (See para 5.4.17) CAMHS Within 12 months, including a 6-month progress report shared with the LSCP Recommendation 10:   Improve workforce wellbeing and mental health offer to professional network  • Lewisham Safeguarding Children Partnership must gain assurance the need wellbeing and mental health needs of professionals are being met.   • Lewisham Safeguarding Children Partnership must undertake a review to explore what current wellbeing provision is available to practitioners, with a plan improve provision where needed. Including utilising learning from the YOS Therapy Hub   (See para 5.5.9) Single Agencies with LSCP oversight Within 6 months     