Child sexual abuse in the context of child sexual exploitation and trafficking of a 14-year-old child over a significant period of time. The abuse was perpetrated by males ranging from older adolescents to adult men, who were known either to Child 9's mother or some of her relatives. Learning includes: frequent local movement around education providers is an indicator of risk; the use of victim blaming language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child's distress; there should be no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area are subject to elective home education or are missing education; practitioners in urgent care centres should always be prepared to "think the unthinkable", and finding the time to secure communication with a child alone should be a central focus; the use of hypothesis in safeguarding assessment and planning is crucial; attendance and active participation in child protection meetings should be a priority for services to ensure effective information sharing. Recommendations include: highlights the ongoing development needs of the multiagency workforce when working with children who have escalating and complex safeguarding needs, working with troubled children, hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work; ensure that responsive restorative services are available for children who are victims of rape and sexual assault; examine issues and demonstrate improvements around children missing education and children subject to elective home education.
      
    Serious Case Review No: 2022/C9524  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.      LOCAL AUTHORITY 1 SAFEGUARDING CHILDREN PARTNERSHIP      Child 9     Local Safeguarding Child Practice Review  (LSCPR)   Full Document: Final Version  3rd April 2022   Independent Reviewer: Jane Carwardine      This  LSCPR has been fully anonymised to protect the identity of Child 9 and involved practitioners. It will be published on the NSPCC repository only. An executive summary is available.        LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 2 of 28  CONTENT PAGE     SECTION SUB SECTION PAGE CONTENT    2 A Current Pen Portrait  1  3 Methodology  1.1  3 The LSCPR Process  1.2 4 Participation  1.3 5 Parallel Enquiries 2  5 Background  to the LSCPR.  2.1  5 The Family Unit  2.2  5 Family Dynamics  2.3 5 The Incident  3  6 A Summary of Child 9’s Life Experiences   3.1 6 Historic Events Pre-Dating the LSCPR Timeline  3.2  9 Child 9: Events from 1st May 2018 to 7th February 2019 whilst resident in Local Authority 2.  3.3 16 Child 9: Events from 7th February to 11th December 2019 whilst resident in Local Authority 1. 4    22 Conclusion 5  24 Recommendations  6  25 Appendices    25 1. Abbreviations Used    25 2. Reviewers Biography   26 3. Rapid Review Panel    27 4. Case Review Panel Membership   28 5. Agency and Practitioner Participation    CHILD 9 – A PEN PORTRAIT  1. Throughout the review process Child 9 was resident in a secure placement outside the boundaries of local authority 1(LA1), whilst remaining under the care of LA1. She remained subject to an interim care order with welfare decisions made under the inherent jurisdiction1 of the family court of protection; through an order made under the Deprivation of Liberty Safeguards2 (DOLS) and under Section 25 of the Children Act 1989 3 in order to maintain her safety. Practitioners in contact with Child 9 described her as polite, lovely and liked to be well presented. She enjoyed good health which was monitored through the school nursing service and general practitioner (GP) services. She regularly accessed urgent care centres for advice regarding minor ailments. When in class she behaved well and was keen to complete her work. The behavioural challenges relating to her distress mostly occurred outside of the classroom e.g., in the playground. They were frequently linked to the use of social media by Child 9 and other children. She could be cautious and reluctant to engage with practitioners until they had been able to gain her trust. The review has been informed Child 9 is currently making positive progress and is always keen to accommodate new experiences and activities. She enjoys experiencing new foods, trips to the theme parks, is motivated by boxing activities where she also is a supporter of younger children and is engaging well educationally.   1 The inherent jurisdiction means a residual jurisdiction to make decisions for people who need it when there is no other framework 2 DOLS ensures people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.  Arrangements are assessed to check they are necessary and in the persons best interest.  Downloaded SCIE 4.12.21 These orders can be used to detain children in homes when alternative suitable accommodation cannot be found. 3 Section 25 of the Children Act 1989 provides for the placement of looked after children in secure accommodation for the purpose of restricting their liberty   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 3 of 28   SECTION 1: METHODOLOGY  1.1 The LSCPR Process  2. Until early 2018, Child 9 lived in local authority 2 (LA2) when she moved to LA1 with her maternal great grandma (MGGM) and maternal great uncle (MGU). Education provision was provided in LA1. Policing was provided by three different police forces, across neighbouring boundaries. Children’s social care (CSC) and health provision (walk in centres, general practitioner and school nursing) were accessed by the family across both local authority areas. Two regional sexual assault referral centres (SARC)4 had contact with Child 9. In the Spring 2018, Child 9 lived intermittently for short periods with her mother in local authority 3 (LA3), she was not known to services in that area. The Safeguarding Children Partnership (SCP) in LA1 took the lead responsibility for coordinating this review process and ensured robust participation from LA2.  3. In November 2020, a child safeguarding incident notification was submitted to the National Panel,  following concerns Child 9 had been subject to sexual abuse committed in the context of child sexual exploitation and trafficking. In December 2020, a senior management multiagency case review group (see appendix 3) was convened to undertake a rapid review.5 The group unanimously agreed the criteria to undertake a local safeguarding child practice review (LSCPR)6 was met due to the longevity of child sexual abuse and exploitation whilst her case was open to multiagency services and subject to child protection planning.   4. The following key lines of enquiry (KLOE) were identified;  KLOE  1 The effectiveness of multiagency local authority cross boundary partnership working. KLOE  2 Supporting the risks for children with complex safeguarding needs who become subject to elective home education. KLOE  3 Understanding the workforce challenges when working with “disguised” compliance. KLOE  4 Maintaining a focus on the child at risk of child sexual abuse. KLOE  5 Securing effective, responsive, child focused, multiagency planning arrangements. KLOE  6  Escalation and de-escalation in CSE/CSA case management.  Additional KLOE identified during the analysis of information were to be highlighted by the independent reviewer. The review was to reflect multiagency improvements made since the rapid review and highlight potential gaps in multiagency practice when working with children and young people and their families who are at risk of child sexual abuse and child sexual exploitation whilst  receiving services across local authority boundaries.   5. The National Panel agreed the criteria to undertake a LSCPR was met. There was a delay in initiating and completing the review due to; challenges in securing relevant information, agency capacity to respond to the review process due to the impact of the Covid-19 pandemic and latterly the independent reviewer’s unplanned absence from the workplace. The methodology planned was the  4 SARC centres (SARC) offer medical, practical and emotional support to anyone who has been sexually assaulted or raped regardless of age or gender or whether the victim reports the incident to the police or not. SARC services can deliver services to both recent and non recent victims. SARC services can support police and forensic investigations. Some services offers a paediatric SARC service staffed by paediatricians, paediatric nurses, and other staff. These services are jointly commissioned by NHS England, CCG’s, Local Authorities and the Criminal Justice System Downloaded NHS England, Service Spec 30, 24.2.22 5 Guidance is found in Working Together to Safeguard Children (2018) and advice published from the national panel “joint communication from the Child Safeguarding Practice Review Panel and the DFE. 6  Described in Chapter 4, Working Together to Safeguard Children. Published 2018. HM Government.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 4 of 28  systems approach,7 using elements from the Welsh model.8 The review was asked to summarise key learning from historic events. The timeline for information gathering regarding key events was from 1st May 2018 to 11th December 2019, having been extended during the review process to include the period when Child 9 was subject to elective home education (EHE). A multiagency chronology was formulated using information from agency records. Further attempts were made to secure additional evidence as gaps in information became evident. Significant attempts have been made to ensure the completeness of the information however it should be acknowledged the data may not be complete.  6. On the 29th April 2021, following the appointment of an independent lead reviewer (appendix 2) working alongside the SCP business unit (LA1), an initial case review panel virtual meeting was convened (see appendix 4). The governance of the review was provided through the case review panel, who met virtually on four occasions. The initial draft review was shared with the case review panel in early December 2021, with the final version shared for ratification and final ammendments in early March 2022. The SCP (LA1) ratified the review on the 14th March 2022 and further plans were made to share with the SCP (LA2). The learning will be shared with the practitioners/agencies who participated in the review process and will be disseminated to the wider multiagency workforce. The anonymised review will only be published on the NSPCC repository in order to maintain Child 9’s anonymity. Relevant agencies will be asked for their responses and improvements to the review’s findings.  7. In September 2019, children services (LA2) were assessed inadequate during an Ofsted Inspection.9 The services have been subject to improvement planning, scrutinised by an improvement board, working in partnership with the Department for Education. In July 2021, improvements were evidenced during a follow-up focussed visit by Ofsted.10 In January 2017, children services (LA1) were assessed good overall during an Ofsted Inspection.11 Since March 2019, three focussed visits have taken place and the authority has undertaken ongoing improvement planning. During their involvement with Child 9, both local authority children’s service departments experienced workforce capacity challenges which impacted negatively on the delivery of services. Both areas have improvement plans in place which are intended to stabilise and develop the workforce. Creating a stable workforce is a national issue for local authority children’s service departments.  1.2 Participation  8. Child 9 has been required to participate in interviews as a potential witness in the criminal proceedings. She has been informed of this review by her key worker, however, did not feel able to participate due to feeling overwhelmed at the time. The participation of Child 9’s family members could not be secured due to ongoing criminal proceedings. They  have been informed of the review by the SCP (LA1) business unit.   9. It was hoped to secure the participation of involved multiagency practitioners, line/senior managers and relevant others across the local authority areas’ multiagency provider and commissioning organisations, in order to enhance the knowledge gained from the written information. In June 2021, a virtual practitioner learning event was facilitated. Optimal attendance at this event could not be secured as many practitioners had left their respective employers and could not be located. Additional virtual practitioner conversations were convened between August and October 2021 (see appendix 5), but very few conversations were possible with practitioners who had worked directly with Child 9 and her family as many were no longer in employment locally.   7 SCIE Learning Together to Safeguard Children: A Systems Model For Serious Case Reviews. 8 Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. 9 LA2 , Inspection of Children’s Services, September 2019. Downloaded files.ofsted.gov.uk 6.1.22  10 Focussed Visit to LA2 Children’s Services, July 21, Ofsted. Downloaded files.ofsted.gov.uk 6.1.22 11 Ofsted, LA1 Children’s Services Inspection, focused visits downloaded files.ofsted.gov.uk 6.1.22   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 5 of 28  1.3 Parallel Enquiries  10. Parallel enquiries have been considered to avoid potential conflict of interest. At the time of writing there were ongoing criminal proceedings which impacted on the participation of the victim and family members. Agencies were requested to share incident investigations arising from this case however, none were disclosed during the review process.   SECTION 2: BACKGROUND TO THE LSCPR  2.1 The Family Unit  FAMILY MEMBER AGE* RESIDENCY  Child 9   14 yrs 6mths Resident with MGGM and MGU in LA2 till early 2018 then moved into LA1.  Maternal Great Grandma (MGGM)  68 yrs Held parental responsibility and a residency order for Child 9 from birth. Grandma  (MGM) 49 yrs Lived separately and in same locality as Child 9, MGU and MGGM until early 2018. Maternal Great Uncle  (MGU) 41 yrs Resident with MGGM and Child 9.  Mother  30 yrs Lived in LA3  with her 4 children who are Child 9’s half siblings. Minimal contact.        (*age at the time Child 9 became a child looked after in December 2019)  2.2 Family Dynamics  11. From around 8 weeks of age Child 9 lived in a complex family network, primarily residing with MGGM who held a residency order and parental responsibility. MGU was resident with MGGM and MGM lived in a nearby locality. MGU, MGGM and MGM jointly provided care to Child 9. It is understood this decision was taken by the family who thought Child 9’s mother was too young to provide Child 9 with adequate care around the time of her birth. More recent maternal disclosures identified there were “bonding” issues after Child 9 was born. Her father’s identity is not known to the review. Her mother lived 40 miles away (LA3), with her four children who are not included in this review. There is evidence Child 9 had gained recent contact with her mother and half siblings through social media, with no significant prior contact. The contact ceased in July 2018, following an incident when Child 9 was allegedly sexually assaulted by a male whilst staying with her mother. This incident will be discussed later in this review.  2.3 The Incident  12. In September 2018, following an initial child protection conference (LA2) Child 9 became subject to planning under the category of emotional abuse. It has not been possible to determine why the category of emotional abuse was used, as prior to the conference her social worker had recommended the category should be child sexual abuse. Whilst Child 9 was subject to child protection planning there was insufficient focus on Child 9 as a child at risk of child sexual abuse/exploitation. Analytically reflective practice was not evidenced with more focus on front facing practice which lacked the required level of reflective analysis. There then appeared to be a delay in case transfer to LA1 when the family re-located and a  further delay in case allocation to a key social worker following transfer. The focus on managing Child 9’s risks as a victim of child sexual abuse/ exploitation was confused with her case de-escalated from specialist child exploitation teams despite the known risks and professional concern. There was a later a delay in the instigation of legal proceedings prior to her being removed into care under a care order. Throughout the period under review there was insufficient focus on the assessment of parental capacity or parental motivation to   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 6 of 28  maintain Child 9’s safety despite considerable evidence of her carer’s behaviours in relation to disguised/non- compliance to the planning in place.  13. In December 2019, Child 9 then aged 14yrs 6mths, had been able to form a trusting relationship with a secondary school 2 teacher. This enabled her to disclose to the teacher that between July 2018 and December 2019 she had been a victim of child sexual abuse by various adults visiting the home. Child 9 had told her trusted carers (MGGM, MGU) about an incident who dismissed the disclosure saying, “he was only playing with her.” She disclosed offender 2 had lived in the family home during part of that period. He shared a bed with her and she alleged offender 2 had repeatedly sexually abused her during that time. MGM had suggested offender 2 should hide and his property be out of sight when the social worker visited. Child 9 was removed into local authority care in December 2019 and placed with a foster carer. However, she regularly went missing and was found in substantial risk situations. Sometimes she was found with family members and reported she had been asked to change her evidence. Child 9 was then placed in a secure placement by LA1 in an attempt to maintain her safety.  14. Whilst in the care of the local authority Child 9 continued to make disclosures reflective of her traumatic experiences related to child sexual abuse and exploitation, perpetrated over a significant period of time. The abuse was committed by males ranging in age from older teenagers to adult men. The men were known either to her mother, MGU or MGGM and it is now hypothesised they used their familial relationship with Child 9 to facilitate her abuse. There was a general lack of professional curiosity and ready acceptance of Child 9’s denials without deeper investigation and analysis. There was suggestive evidence of the use of victim blaming language12 throughout documentation when referring to Child 9. This may have contributed to her distressed behaviours as she was regularly perceived as a challenging child rather than a child who was experiencing the trauma of child sexual/emotional abuse on a regular basis. Her behaviours became the focus of initial management strategies. There was insufficient evidence her distressed behaviours was explored, with limited focus on therapeutic support to manage the psychological aftermath of the trauma she was enduring. There was limited curiosity into the impact of family, environmental factors and parenting capacity on Child 9 despite the known historical concerns about family functioning and the longevity of Child 9’s distressed behaviours.  SECTION 3: A SUMMARY OF CHILD 9’S LIFE EXPERIENCES   15. This section will provide a narrative, analysis and learning related to the most significant events in Child 9’s life. Service improvements made following the rapid review will be highlighted. The timeline reviewed was from when Child 9 commenced elective home education (1st May 2018) to when she became a child looked after (11th December 2019). This timeline was extended to incorporate a period of elective home education. Relevant historical information pre-dating the timeline of the review is also included as this provides some insight into Child 9’s early life experiences when early help may have been an opportunity to secure improved outcomes for Child 9.   3.1 Historic Events Pre-Dating the LSCPR Timeline  16. Primary Education: Child 9 attended at least four primary schools in the same locality (LA1), moving between the schools on several occasions. It is not understood why MGGM decided to move her around education providers so frequently. This behaviour should have been seen as an indicator of risk related to parental avoidant behaviour. It could have triggered an early help assessment. (LP1)  Research shows moving schools multiple times has a devastating impact on academic attainment, the development of social relationships and a child’s emotional wellbeing. This movement also created safeguarding challenges for education being able to keep a focus on Child 9 welfare.   12 Victim blaming Language is terminology that could imply the child is complicit or responsible for their abuse. Appropriate language should always be used to ensure the child is referred to in a way that does not place the blame on the child i.e., challenging behaviours could be seen as distressed behaviours which may be reflective of a child’s everyday experience.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 7 of 28   Learning Point 1: Legally parents/carers can choose to move their child around education providers however, Child 9’s frequent local movement was an unusual pattern of parental behaviour. Research13 14 highlights the negative outcomes of this type of behaviour pattern for children which should be linked to parental avoidant behaviours. It is an indicator of risk which should be understood. It is important this cohort of children are identified to enable an early multiagency response, thereby ensuring an early assessment inclusive of parental capacity and family and environmental factors is undertaken. A key question for consideration is : Can local education provision identify and maintain a focus on the cohort of children who move around local education provision in order to safeguard their welfare?   17. Early Safeguarding Concerns: There had been historical child in need15 involvement by CSC (LA2) due to the distressed behaviours Child 9’s presented whilst in school. During primary education, it was known she was active on social media, potentially making profiles of others, had watched inappropriate online videos which used violent and threatening language, had been brought up in a violent home and used sexualised language inappropriate for her age. In March 2017, the school acted appropriately raising another safeguarding alert with CSC (LA2). The contact did not convert to a referral which would have provided an opportunity for further multiagency information gathering and assessment. A plan was formulated which included direct work in school, support via an early help assessment tool (EHAT),16 support to MGGM and a referral to the school nursing service. There is no evidence of the outcome of this intervention as the early help assessment could not be located. Given the known history this was a missed opportunity to undertake a more comprehensive children and families assessment by CSC(LA2) . (LP2)   Learning Point 2: In 2017, there was a missed opportunity following a contact with CSC (LA2) to undertake a more comprehensive assessment of Child 9’s welfare. The contact did not convert to a referral despite the known historical indicators of risk. The outcomes of contacts that do not convert of a referral are now monitored through quality effectiveness measures in the area. There is no evidence the early help plan developed as a result of the contact, was effectively coordinated or its outcome demonstrated. Early help provision (LA2)  has developed since that time with improved leadership, strategic oversight and performance monitoring. The area (LA2) offers early help support  for their children to schools  across the boundary (LA1). (Good Practice)   18. Victim Blaming Terminology: Primary education reported “academically she had done quite well, with mathematics being her greatest challenge.” The use of victim blaming language was documented “Child 9 could be lovely in class however also loved to be involved in gossip”. Her primary school suggested “this brought out the worst in Child 9.” The use of such language in written documentation should be avoided when working with children, to ensure the presenting behaviour is seen as a representation of the child’s distress. The documentation created a hypothesis of a challenging rather than distressed child who was subject to family violence and was experiencing a range of adverse childhood events on a regular basis. This created a missed opportunity to explore the traumatic events she may have been experiencing at that  time. (LP3)  Learning Point 3: Multiagency documentation regularly evidenced the use of victim blaming language. The use of such language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child’s distress. The documentation created a hypothesis  13 Rodda M et al (2013) Between the cracks, July RSA Action, and Research Centre.  Downloaded thersa.org 1.1.22 14  Downloaded sec-ed.co.uk 1.1.22. The alarming impact that moving school; frequently can have on students.  15 A child in need is a child assessed to need additional support from a local authority to meet their potential.  Section 17 of the Children Act 1989 places a general duty on all local authorities to “safeguard and promote the welfare of children within their area who are in need.  Downloaded scie.org.uk 11.11.21 16 EHAT is a tool used for gathering information and a standard approach in assessment for the identification of early help needs. Its intention is to support practitioners to gather and understand information about the needs and strengths of  children and their families.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 8 of 28  of a child being challenging/troublesome rather than distressed. This created a missed opportunity for practitioners to explore her adverse experiences and may have inhibited Child 9 from disclosing her experiences at an earlier stage. The use of victim blaming language is subject to audit by CSC in both areas and practice standards have been developed. The NHS provider organisation (LA1) responsible for school nursing has also developed a training programme. Whilst some agencies have made improvements this is not evident across all multiagency partnerships. Further multiagency workforce development would ensure the complexity and risks of victim blaming language are fully understood. All agencies should consider improvements that minimise the use of victim blaming language through development opportunities and quality effectiveness measures.   19. Distressed vs Challenging Behaviour: In September 2017, on entry to secondary school 1, Child 9’s distressed behaviours continued to be a cause for concern. During September and October three incidents were recorded related to her involvement in the use of social media. In one of the incidents, she had been threatened with “rape” by another student, however she retracted this allegation. In another she sent a student a photograph depicting self-harming behaviours whilst also threatening to kill herself. There is no evidence of intervention to assess the risks relating to threats to kill. In the last incident it is alleged she threatened a fight with another student. Secondary school 1 put behaviour modification interventions in place within a few weeks of Child 9 commencing the school, in line with expected practice. MGGM was always kept informed and considered to be supportive. In January 2018, Child 9’s distressed behaviours continued to escalate; she was placed on an individual behaviour plan17 (IBP) and a period of exclusion. The impacts of exclusion will be discussed later in this review. At this point, the discussions were positive, reinforcing the idea of IBP as a supportive mechanism for helping to modify/improve behaviour. In April 2018, following an incident resulting in a 2-day exclusion, incidents involving Child 9 continued to escalate. This prompted a meeting with MGGM to discuss the possibility of Child 9 going into an education respite placement or escalating her IBP to a pastoral support programme18 (PSP) which is considered a more serious level of monitoring. The focus of the work with Child 9 was about helping her to contain her behaviours within the school environment. There is no evidence that individual work was undertaken with Child 9 to explore deeper understanding of her distressed behaviours or to support her emotional wellbeing. (LP4)  Learning Point 4: The focus of the work with Child 9 pre-dating the review’s timeline was to contain her behaviours within the school environment through differing education behaviour modification programs and exclusion processes.  There is no historical evidence of individual work with Child 9 to gain a deeper understanding of the root cause of her distressed behaviours, to support her emotional wellbeing, to gain a greater understanding of her experience of being parenting or her family and environment factors.  When children are showing recurring distressed behaviours providing the right environment for a child to develop trust to be able to disclose her feelings should be the priority for intervention.    20. In conclusion; the historical information provided an indication of the range of difficulties Child 9 had to navigate throughout her primary/secondary education and within her home life. Her behavioural responses were reflective of a distressed and vulnerable child; however, the predominant hypothesis presented was that of a troublesome child with challenging behaviour. Her emotional distress and threats to end her life were not effectively managed or supported through multiagency working. Differing interventions including exclusion from education focused on the management of her behaviour in school rather than creating an understanding of her safeguarding needs as a child with complex health and social needs. A hypothesis should have been tested that Child 9 was growing up with vulnerability and risks that she had to accommodate on a daily basis. The historical indicators of  17 An individual behaviour plan a document that helps all staff to have a consistent approach to behaviour with a child enabling them to achieve the most from their education. 18 A pastoral support programme is a school based process intended to support a child if school based strategies have not been successful. The aim being to involve everyone in the shared challenge of improving a child’s behaviour and social skills and ensuring social and educational inclusion.   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 9 of 28  risk regarding family and environmental factors/parental avoidant behaviours were known, however an appropriate multiagency early response was not sufficiently evidenced. There are significant challenges for education providers when balancing the needs of individual children alongside the safety of the school population. The work is complex and multifaceted. However, at the core of this work it is always necessary to undertake an accurate early help assessment not only of the child’s needs but inclusive of the parenting capacity, family functioning  and environmental factors. Greater emphasis should be placed on enabling the child to develop the confidence to trust to be able to share their worries and anxieties and may support greater understanding of the child’s journey through everyday life.  3.2 Child 9: Events 1st May 2018 to  7th February 2019 whilst resident in Local Authority 2.  21. Elective Home Education (EHE): On the 1st May 2018, Child 9 left secondary school 1 to become subject to EHE. MGGM later suggested to education practitioners a secondary school 1 practitioner had actively encouraged her to home school, otherwise Child 9 would have to attend a pupil referral unit. During the rapid review process there were concerns expressed that “off rolling”19 may have occurred which is against the expectations of  practice guidance. During a conversation with a deputy headteacher (secondary school 1), as part of the review process it was confirmed MGGM had presented a formal handwritten letter. This was thought to be in her own handwriting, outlining her intention to withdraw Child 9 to home educate. The practitioner suggested the school thought MGGM had been assisted in writing the letter due to its use of formal language. Access to proformas to support EHE are easily accessible on the internet. At the time the school was shocked at MGGM’s decision and outlined their concerns. The school highlighted the responsible local authority team would make checks about the EHE offer. Child 9 remained subject to EHE until joining secondary school 2 on the 5th November 2018. The review has not been able to explore this incident with MGGM to gain deeper understanding of her decision making.  22.  The education inclusion team20 (LA1) was informed of the decision by secondary school 1. The reviewer’s conversation as part of this review, highlighted an inadvertent error had been made during the notification process. LA2’s EHE team should have been notified rather than LA1’s team, as Child 9’s resident address was a LA2 postcode. It was wrongly thought to be a LA1 postcode. On the 18th July, 11 weeks later, Child 9’s case was transferred to LA2’s education welfare team by LA1. The reason for the delay in processing the information remains unclear. The education inclusion service (LA1) has been subject to improvement strategies to identify children who may be subject to “off rolling” and to EHE. The improvements include an electronic notification system, a flagging system to identify children with safeguarding needs and weekly off roll checks through a commissioned provider. The improvements should be monitored to ensure there is no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area and are subject to EHE or are missing education. (LP5)    23. During conversations it was identified the teams with responsibility for children subject to EHE in both areas work closely with their local education providers. They have systems to identify and minimise the risk of “off rolling” and to support children subject to EHE. The school is expected to inform the responsible council team according to the child’s postcode address. The education database also creates alerts when a child is removed from a school roll which initiates follow up by the relevant team. In addition, LA2 have more recently collaborated with neighbouring local authorities the implementation of the STAR standard. This has been developed to support cross boundary information sharing when children are identified as having safeguarding needs and leave school at transition points or mid-term. (Good Practice) Currently not all local authority areas link into this standard which could be a future consideration for LA1 if the standard is evaluated positively. During  19 Off rolling is the practice of removing a pupil from the school roll without using permanent exclusion, when the removal is primarily in the best interest of the school. This includes pressuring a parent to remove their child from the school role. 20 LA1 has an educational inclusion team which is responsible for the support of children and their families  who are subject to elective home education. The service also supports children and their families with special educational needs and disabilities.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 10 of 28  practitioner conversations it was highlighted that timely cross boundary information sharing about children not in school could sometimes be delayed due to the processing of information through LA1’s multiagency safeguarding hub onwards to the relevant team. It was suggested having the opportunity for direct verbal communication between the two cross boundary teams would enhance timely information sharing.  Learning Point 5: In May 2018, there was a 11-week delay in sharing a EHE notification between the two local authorities.  Both areas have introduced failsafe systems to identify vulnerable children subject to EHE and have made improvements to their systems.  These systems should be monitored to ensure they remain effective in notifications across local authority boundaries.  Contributory factors related to information remaining un-processed (LA1), challenges in securing cross boundary communication between the teams with responsibility for EHE and a simple misunderstanding of postcodes.  LA2 have supported the recent implementation of the Star standard 21 and if proven effective could support information sharing across local authority boundaries.  These issues should be a consideration to strengthen the current system.    24. Attendance Urgent Care: On the 1st June 2018, Child 9 attended an urgent care centre (LA2), accompanied by MGGM, with a history of intermittent vaginal bleeding during the preceding months, which had recently worsened. MGGM advised Child 9 was anxious and in her opinion the bleeding was normal menstrual bleeding. Child 9 and MGGM denied she was sexually active or there was a risk of pregnancy. The practitioners advised them a gynaecological examination was out of the remit of the service. Child 9 and MGGM were given follow-up advice and the general practitioner was notified. The urgent care centre followed expected practice in referring Child 9 back to her GP. The assessment being there was no indication for screening or onward referral regarding sexual health issues or safeguarding concerns. The service has clear guidance22 on how practitioners should respond when a child under 13 years attends the service and workforce development has been provided. The review has been unable to ascertain whether Child 9 was spoken to alone or in MGGM’s presence, which is a key factor to support a potential disclosure. Her type of presentation accompanied by parental carer is not unusual in urgent care centre settings and would not have triggered further enquiry relating to child sexual abuse. However, with hindsight we know at this time Child 9’s daily life was unsettled, chaotic and with the likelihood of child sexual abuse a significant risk. Providing opportunity for Child 9 to discuss her health issues alone without her MGGM could have supported her opportunity to disclose her situation. (LP 6) Learning Point 6: Child 9 and MGGM accessed urgent care centres across the local authority areas on a number of occasions.  In June 2018, Child 9 attended a centre (LA2), accompanied by MGGM, with a history of intermittent vaginal bleeding.  She was under 13 years and her presentation could have prompted professional inquisitiveness into her everyday life experience, which with hindsight we know was unsettled and chaotic.  The review has been unable to ascertain whether Child 9 was spoken to alone or only in MGGM’s presence, who we now know exhibited “disguised compliance” behaviours.  The opportunity for a child to speak alone and the recognition of parental disguised compliance is a key factor to support potential disclosure.  During that and other urgent care attendances the focus on her safeguarding risks was not evident within the review process.  When working with children the early identification of child sexual abuse requires all health practitioners to assess the risk of abuse in order to instigate a prompt referral to the police and CSC.  Practitioners in urgent care centres should always be prepared to “think the unthinkable” when working with children and parents, to enable the early identification of children at risk of child sexual abuse and exploitation.  Finding the time to secure communication with a child alone should always be a central focus.    21 The STAR standard (2021) is a recent initiative agreed by several local authorities to transfer safeguarding information across local authority boundaries when children leave a school roll 22 LA2 SCP procedures, Underage Sexual Activity, downloaded sthelens.proceeduresonline.com    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 11 of 28  25. Safeguarding Referral: In recognition of the concerns for Child 9’s welfare the education welfare (EWO) team manager (LA2) responded promptly to the EHE notification. It was a priority to ascertain Child 9’s whereabouts. MGGM and mother were contacted on the same day and a visit was arranged to assess her welfare, including the EHE offer. (Good Practice). It was clarified Child 9 had gone missing ten days previously to live with her mother, 40 miles away (LA3) and she no longer resided with MGGM. Child 9 had intermittently travelled alone to and from LA3 to sometimes stay with MGM. At the time MGGM and mother suggested Child 9 had gone missing due to; MGU always being drunk which caused family arguments and Child 9 had witnessed inappropriate language. Child 9 verbalised to her mother she did not want to reside with MGGM and MGU, who she said treated her badly. MGGM reported she had made a referral to CSC (LA2) a few days earlier and was awaiting a response. There was no record of MGGM’s referral.  26. On the 18th July, the day following notification, the EWO team manager (LA2) made a safeguarding referral to CSC (LA2). The referral clearly summarised the concerns and risks, suggesting further assessment was undertaken including exploration of Child 9’s wishes, feelings and care arrangements. (Good Practice) Following the referral MGGM contacted the school nursing service who was proactive in undertaking further EHE checks and this contributed to positive information sharing with CSC. (Good Practice).The referral was accepted with a plan to progress to a child and family assessment. The information shared by MGGM and MGM was conflicting as to Child 9’s domicile and the family circumstances leading to Child 9 going missing.  27. Child Sexual Abuse Disclosure: On the 10th August 2018, Child 9 and MGGM attended the GP’s surgery, requesting a pregnancy test. She disclosed sometime between 8th and 15th July 2018, whilst visiting her mother (LA3) she had been sexually abused/raped by a 15 year old male (offender 1). Offender 1 was alleged to be her mother’s friend; they were in a relationship. Information highlighted her mother knew of the incident and had stated Child 9 was “lying and the boy is lovely”. The incident was reported to have occurred after she had been given alcohol and tablets and whilst recovering from the effects of a hangover. The GP followed practice guidelines and made a safeguarding alert. Child protection processes were followed and Child 9 was medically examined at  SARC 1.23 The outcome was indicative she had experienced child sexual abuse. Police Force 1 led the criminal investigation, as the incident had occurred in LA3. Child 9 was offered access to short and long term support by a local rape and sexual abuse support centre.24 The GP was informed of this provision should Child 9 request access in the future. Subsequently Child 9 did not access the provision. Child 9 thought at that time she was fine and did not want any support “as she could speak to her family”. On the 25th September, CSC (LA2) were advised by Police Force 1 no further action would be taken and the criminal case would be pended. CSC (LA2) received further information of intimidatory behaviour as a result of this incident towards Child 9 and her family by friends and the family of offender 1. Child 9 was distressed as a result of this intimidation. There is no evidence of further action taken to support Child 9.   28. In line with expected practice a strategy meeting was coordinated and a plan to undertake section 47 enquiries to ensure Child 9 was safeguarded. The outcome of the initial enquiries were; Child 9 would continue to live with MGGM and MGU, a child and family assessment would be undertaken and an initial child protection case conference (ICPCC) would be convened. The family were asked not to allow Child 9 to spend time alone with MGU. Intelligence was being investigated regarding MGU and inappropriate behaviours that could pose a risk to Child 9. In addition, Police Force 2 were investigating an allegation of a sexual assault that occurred in May 2018, against MGM by MGU. Child 9 denied MGU had ever done anything to her when asked by MGGM. It is not known whether Child 9 was ever spoken to alone by a social worker assessing these issues. MGGM did not believe MGU was a risk, although she agreed not to allow MGU unsupervised access or to provide care to Child 9. MGGM was advised should Child 9 go missing this should always be reported.   23 The service offers a paediatric SARC service staffed by paediatricians, paediatric nurses, and other staff.  24 Provided by a registered charity that aims to provide crucial specialist support, independent advocacy, counselling, help and information for those affected by rape, sexual assault/or abuse> downloaded 12th January 2022.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 12 of 28   29. The safety plan regarding MGU’s contact with Child 9 was unrealistic given MGU and MGGM lived together in a two bedroomed property, with Child 9 sharing a bedroom with MGGM. Practitioners involved should have been “thinking the unthinkable”  due to intelligence about the family’s potentially dysfunctional relationships. Practitioners should have heightened their curiosity regarding family functioning, rather than accepting MGGM’s agreement at face value. There had been discrepant messages verbalised by Child 9 regarding the familial relationships and MGGM had stated she did not believe MGU to be a threat despite the ongoing investigations Therefore, it should have been hypothesised until proven otherwise she was unlikely to follow the safety plan which in reality was not realistic. (LP7)  Learning Point 7: The use of hypothesis in safeguarding assessment and planning work is crucial. Reflective practice supports practitioners analysis about a child’s experiences rather than accepting what is presented at face value. Practitioners should have been “thinking the unthinkable” due to the information received about the family’s dysfunctional relationships and Child 9’s discrepant messages in respect of her relationships rather than the acceptance of MGGM’s agreements at face value.   30. Child Protection Process (LA2): The social work report prepared for the ICPCC was comprehensive. It described Child 9 and MGGM as having “a good relationship” and Child 9 as a happy and confident child who took pride in her appearance. It highlighted key areas of concern related to family functioning and identified risk factors regarding MGGM’s capacity to provide care in the long term to Child 9. The report identified concerns relating to EHE and the lack of concern expressed by MGGM when she went missing or exhibited distressed behaviours. It recommended Child 9 should become subject to child protection planning under the category of sexual abuse.   31. On the 6th September, ICPCC members unanimously decided Child 9 should be made subject to child protection planning under the category of emotional abuse. It is unclear why a decision was taken to change the category despite the social worker recommendations and Child 9’s recent sexual assault experience. CSC (LA2) as part of its improvement programme has completed an audit of child protection planning categories and undertaken development with conference chairs to ensure understanding of the nature of concern is clear within case conferences. Multiagency conference members also have a responsibility to reflect on the information presented during a conference, however there was no evidence of dissent or constructive challenge by conference members. (LP8)  In line with expected practice the core group membership was identified and an initial protection plan was formulated. The child protection plan was; inclusive of safety planning, recommended the involvement of a family intervention worker, strategies to support MGGM should Child 9 go missing, suggested further risk assessment of MGU and management of Child 9’s general health.   32. The child & family assessment was completed in line with expected practice. CSC(LA2) allocated two practitioners to undertake family intervention work, one working with MGGM and the second with Child 9 (Good Practice). The intervention methodology used was the triple p positive parenting programme25. The whole course could not be delivered as a number of sessions were cancelled by MGGM. However, during a practitioner conversation, it was highlighted the practitioners were not concerned about MGGM’s intention to keep Child 9 safe and that MGGM did everything asked of her. It was difficult to secure Child 9’s engagement, she was shy and reluctant to work with the practitioners. The work undertaken was based around managing the risks relating to missing episodes.   25 The Triple P Positive Parenting Program is a parenting and family support system designed to prevent as well as treat behavioural and emotional problems in children and teenagers. It is delivered to parents of children up to 12 years with a teen program for older children downloaded https://www.triplep.net 3.2.22     LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 13 of 28  33. Subsequent review and core group meetings were convened in line with the local child protection pathway. However multiagency representation was not always sufficiently evidenced in the meetings. This would have impacted negatively on information sharing, case analysis and communication as Child 9’s situation became more complex. Attendance and active participation in child protection meetings should always be a priority for universal services when working with children with complex and escalating safeguarding needs. The core elements of the plan were developed during the core groups, however, there was insufficient focus on the counselling for Child 9 following her allegation of rape which should have been a central consideration to reduce the risk of post-traumatic stress disorder. She later disclosed that from July 2018 she was regularly subjected to child sexual abuse at home by family friends, counselling or therapy may have provided the environment for an earlier disclosure. (LP8)  Learning Point 8: During the ICPCC it is unclear why the decision was taken Child 9 should become subject to child protection planning under the category of emotional abuse when there was dominant evidence to support child sexual abuse. This resulted in less focus on planning support to aid her psychological recovery following her allegation of rape. The focus on her traumatic experience of child sexual abuse started to become obscured. Children’s services (LA2) have made improvements; undertaking audit and development work to ensure conference chairs categorise cases accurately. Multiagency partners also have a responsibility to reflect on information presented during child protection meetings and should confidently challenge decisions made. There was no evidence of reflective practice or challenge by multiagency partners. Attendance at child protection meetings (core groups and review case conference) across both areas was not always reflective of services involved with Child 9 and her family. The reason for non-attendance is unclear. However, these meetings are the forums to coordinate multiagency planning and ensure interventions for children who are subject to child protection planning are demonstrating better outcomes for children. Attendance and active participation should always be a priority for services to ensure effective information sharing when working with vulnerable children whose daily experience can rapidly change. Improvements in attendance and participation by multiagency practitioners should be monitored.   34. Re-entry into Secondary Education: In November 2018, Child 9 re-commenced mainstream secondary education in secondary school 2. Within a few days she had begun to exhibit distressed behaviours which were described as “manipulative” and she began to truant school. (LP3) Despite MGGM’s agreement with CSC (LA2) there was evidence Child 9 was being picked up from school by MGU and this should have been recognised as evidence of non-compliance to the safety planning. CSC (LA2) also received an anonymous contact detailing an incident involving Chid 9 when an adult, thought to be a family member was seen  “shouting, swearing and aggression to a child”  Additional concerns were expressed with the referrer saying “ MGU drink drives with the child”. (LP10)  35. Escalating Safeguarding Risk: In the weeks following the ICPCC the escalating risks for Child 9 were documented in agency records. Shortly after the conference, Child 9 went missing for two nights. The police found her at the home of a 17 yr old male (offender 2), who lived with his mother. At the time there was insufficient evidence of professional inquisitiveness or challenge, given the age difference. (LP9) Child 9 wanted to stay another night, which was agreed by MGGM. This agreement should have heightened professional curiosity in respect of MGGM’s parenting capacity and Child 9’s safety. There was no evidence of professional enquiry regarding MGGM’s ability to manage the risks or understanding gathered in respect of  her motivation in allowing Child 9 to stay another night. (LP10) Child 9 disclosed “she had been stressed” following the recent sexual assault incident and needed some ”head space” from her family. She disclosed taking two overdoses but had no desire to self-harm. Further specialist assessment was not sought nor were interventions provided to assess or support Child 9’s emotional wellbeing. (LP8) In subsequent child protection meetings her association with offender 2  was regularly referred to as a relationship which detracted the focus on Child 9 as a victim of child sexual abuse. The use of victim blaming language has previously been highlighted in this review (LP3)     LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 14 of 28  Learning Point 9 : During her initial missing from home incident the police found Child 9 at the home of a 17yr old male (offender 2), who lived with his mother. Their association was initially queried and their denial of a sexual relationship accepted. There was insufficient evidence of professional curiosity regarding their sleeping arrangements, or the power imbalance given the age difference at the time or during later professional discussions.   Learning Point 10: In September 2018, Child 9 went missing from home. When found she wanted to stay for a third night, which was agreed by MGGM. This decision was not in the spirit of the safety planning and should have heightened professional curiosity in respect of MGGM’s parenting capacity. There was no evidence of professional enquiry to understand MGGM’s motivation in allowing Child 9 to stay another night. This was a missed opportunity to reflect on MGGM’s behaviours as being reflective of disguised compliance behaviours. Practitioners should always recognise that disguised compliance may be a hypothesis in safeguarding case work and remain cautiously optimistic until parenting capacity is robustly assessed.   36. In September 2018, following the initial missing from home incident a referral was made to the missing and child sexual exploitation service (LA2) 26 to provide Child 9 with keep safe intervention. The return interview was convened (13 days later) and Child 9 reported she felt safe whilst missing. Ongoing keep safe work was undertaken, a needs assessment completed 9 weeks later. She was assessed to  be at  “moderate risk” and it was documented she was feeling overwhelmed by the professional involvement. On completion of the assessment professional concerns were expressed by the police and the social worker that Child 9 was not being honest about the relationship with offender 2 due to the age gap. On the 5th January it was assessed Child 9 was at medium risk during another child exploitation meeting (LA2) with a plan to share relevant information with the  safeguarding team (LA1) as Child 9 had moved to the area.   37. In December 2018 during the review case conference, it was documented some practitioners raised concerns that Child 9 was at risk of child sexual exploitation. The documentation again described her being in a “relationship” with offender 2 rather than using language to describe her as a victim of child sexual abuse. Further information was requested in respect of offender 2 due to concerns about his behaviour towards Child 9.   38. On the 16th January 2019, during a child exploitation review combined core group meeting Child 9’s risk of child exploitation was changed to low. There was no further evidence of Child 9 going missing. Child 9’s truancy from education was discussed and the police were investigating allegations against Child 9 in relation to sending malicious texts and bullying. There were concerns MGGM may not be reporting all missing episodes and health records identified multiple concerns for Child 9’s welfare but suggested there was “no real evidence” of exploitation. There was repeated evidence of the use of victim blaming language being used by practitioners. Descriptions such as  “manipulative,” “in a relationship with an 18 year old male” were observed in records. This language detracted from Child 9 being seen as a victim of child sexual abuse or at risk of child exploitation. (LP3) A decision was taken her case would  not to be formally transferred to the child exploitation team (LA1). An action was taken the social worker would ensure the child exploitation team (LA1) were aware of the work that had been undertaken in LA2 as further monitoring may be necessary.    39. The decision to de-escalate her risk of CSE at this time is not understandable. It was not based on a robust reflective analysis of the risks she faced, the intelligence known or MGGM’s capacity to maintain her safety but simplistically on the number of disclosed missing from home episodes. LA2 has improvement planning in place to provide assurance this situation is not replicated. This will again be discussed later in the review. (LP14)    26 LA2’s Missing and Child Sexual Exploitation Service that works alongside young people, their families and the police to find  out what has caused them to run away and prevent them from running away again in the future downloaded 28th January 2022.   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 15 of 28  40. Case Transfer to LA1: During the Autumn 2018, MGGM began bidding for houses across the border (LA1) due to relationship problems in the community. The police were investigating two community incidents relating to alleged inappropriate behaviours by MGU. On the 19th December 2018, it was known the family had moved, although CSC (LA2) had not been formally notified by MGGM. On the  29th December, at the core group a plan was to make transfer case request and it was noted Child 9 was happy in her new home. The case was formally closed in August 2019.   41. In January 2019, prior to the case  transfer, Police Force 2 began an investigation due to an allegation of bullying against Child 9 by another child in the school. A crime was recorded against Child 9 and the matter referred to the neighbourhood unit who made follow up visits. On 29th January, the school received social media information from other pupils, who had seen photographs which provided intelligence Child 9 was in a sexual relationship with offender 2 and might be pregnant. This notification was managed by Police Force 2. Comprehensive police checks occurred including a discussion with Child 9 and MGGM who denied being pregnant or in a relationship with offender 2. A strategy meeting was not convened which would have been expected practice. This incident was referred through to the CSE team (LA1) but not heard till after the transfer in ICPCC. The SW manager (LA1) was present and agreed the allocated social worker would explore the CSE concerns. However, the case remained unallocated to a social worker due to workforce capacity for around three months.  42. In conclusion; the period between 1st May 2018 to 7th February 2019 must have been a challenging time for Child 9. She had commenced secondary school 1, however her distressed behaviours were difficult to manage as education tried to balance  her needs with the associated risks to the school population. Planning was underway to support her in education however MGGM chose to remove her under the pretext of EHE. There were EHE monitoring systems in place however the two failsafe notification mechanisms were not sufficiently responsive or effective across local authority boundaries to be able to assure agencies of the education plans for Child 9.   43. The level of adult supervision for Child 9 was of concern. Child 9 was free to move around the community and across local authority boundaries for eleven weeks. She is now  known to have stayed at differing family homes whilst travelling alone to and from the differing local authorities. MGGM was known to be struggling to provide care for her on a daily basis and Child 9 had discussed some of her adverse family experiences. There was a positive safeguarding response by the EWO manager (LA2) which effectively triggered multiagency child protection processes. During her EHE period Child 9 was in contact with her birth mother, was a victim of rape whilst staying with her mother in LA3 and was then a victim of intimidation by the perpetrator’s relatives after she reported the incident. There was no criminal prosecution in respect of these incidents and her mother did not believe her. During professional contact with Child 9 a hypothesis emerged that her family was supportive so she did not require the support of SARC services. This was accepted at face value rather than gathering greater understanding of the child’s daily experience. Safety planning with MGGM could not be effective as MGGM would say what she believed practitioners needed to hear. An example being she agreed for MGU not to be in contact with Child 9 but she did not believe MGU was a risk. MGU started picking Child 9 up from school. There is no evidence this was ever challenged. The preference was to believe information given at face value by family members rather than gaining a deeper understanding of family functioning or the adults’ capacity to provide Child 9 with a safe environment.  44. Once the child protection process (LA2) were triggered a robust children and family assessment was completed which accurately highlighted Child 9’s  risks of sexual abuse and the family’s capacity to keep Child 9 safe. The child protection meetings were coordinated according to expected guidance, however, over time there was significant limitations in how the case was managed. Attendance at core group meetings by multiagency practitioners was not consistent. Ongoing reflective analysis/constructive challenge by multiagency practitioners was not evidenced within case-management supervision or within subsequent child protection meetings. There were indicators of the CSE/CSA risks Child 9  faced yet she remained registered under the category of emotional abuse. There was limited focus on her risks of sexual abuse. The planning process followed was unclear, plans were developed but it is unclear how the outcomes were evaluated. A growing body of   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 16 of 28  information was available but “the “jig saw” was not put together so the risks were ineffectively managed at all levels. Child 9 and MGGM were invited to and attended the relevant meetings. It was known that MGGM demonstrated behaviours related to “disguised compliance”  but it is unclear whether Child 9 was ever spoken to alone or whether she was at the centre of the planning process. Once the family had decided to move areas Child 9 had thought this would mean they would not be subject to the same level of scrutiny. In practice when they moved this seemed to happen and despite the indicators of risk her case was de-escalated by the specialist CSE team. During the transfer period the social worker was unable to secure management oversight as risk incidents were arising. CSC (LA2) has now implemented improvements to assure case management scrutiny.  45. Throughout this period there was documentary evidence of the use of “victim blaming” language which may have contributed to Child 9 being perceived as challenging rather than a troubled young person at risk of abuse. There were workforce capacity issues and service transformation which may have impacted on practitioners capacity to respond effectively at that time.  3.3 Child 9: Events 7th February to 11th December 2019 whilst resident in Local Authority 1.  46. LA1 Child Protection Processes: On the 7th February documentation clarified the transfer-in ICPCC was convened in line with expected timelines, however, it was not clearly documented when the agreement to accept the case was agreed. The concerns relating to Child 9 as a victim of  child sexual exploitation, including the possible un-assessed risk of pregnancy and MGGM’s ability to keep Child 9 safe were all discussed. Her association with offender 2 was considered, although victim blaming language continued to be used when referring to her association with offender 2 as a “relationship”. This underplayed the risks relating to child sexual abuse. (LP3) CSC (LA1) now undertakes a monthly record audit to check the quality of practice and the use of inappropriate language. A decision was taken to register Child 9 under the category of emotional abuse and her case was not transferred to the local CSE multiagency team. CSC (LA1) has re-issued guidance around the management of case transfer to support responsiveness and improvements in case management. The outcome of audit measures demonstrate an upward trend in  improvements.   47. Core group meetings were convened but initially not always in line with practice guidance. This improved following the allocation of the key social worker, around 3 months after transfer. Practitioner participation at core groups was not always reflective of service involvement for example; police, CSE and child and mental health (CAMHS) practitioners were not in attendance. (LP8) There was positive evidence of participation by school nursing and education. During the initial core group meeting it was recognised Child 9 would benefit from support of SARC services. Secondary school 2 made a referral to the regional SARC service 2, which was a different service to the one Child 9 had previously accessed. The use of victim blaming language was again documented within some core groups which may have detracted from Child 9’s being perceived as victim child sexual abuse. (LP3) In June, the documentation highlights practitioner concerns which were escalated to the newly allocated social worker after MGGM and Child 9 had left the core group. The specific nature of these concerns is not clearly documented and conversations with involved practitioners has not been possible. During a core group (September) there were concerns MGGM was not adhering to elements of the safety plan. All these concerns should have prompted practitioners to focus on greater understanding of MGGM’s capacity/motivation to keep Child 9 safe and provided the opportunity for case escalation through agency supervision processes or by legal services.   48. The delay in case allocation and ineffective multiagency participation impacted negatively on case coordination, interagency communications, information sharing and risk management as Child 9’s situation became more complex. At the time there were significant workforce capacity issues in CSC (LA1). Improvement planning is ongoing to create a stable workforce. New quality effectiveness systems have been developed throughout CSC inclusive of  the conference chair’s unit to  provide assurance of improvements in case oversight when children are subject to child protection planning. Performance monitoring measures should become embedded in governance arrangements to ensure children who transfer in and are subject to child protection planning are responsively allocated a key   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 17 of 28  social worker and that case oversight remains a focus to ensure optimal outcomes during and following case transfers. (LP11).   Learning Point 11: When Child 9’s case was transferred to LA1 there was a delay in case allocation by CSC and ineffective multiagency participation impacted negatively on case coordination, interagency communications, information sharing and risk management at a time her situation was becoming more complex. Significant workforce capacity issues in CSC (LA1) was a factor. Improvement planning is ongoing to create a stable workforce. New quality effectiveness systems have been developed throughout CSC, with the conference chairs unit provides assurance of improvements in case oversight when children are subject to child protection planning. Performance monitoring measures should become embedded into ongoing governance arrangements to ensure children who transfer in and are subject to child protection planning are responsively allocated a key social worker and that case oversight remains a focus to ensure optimal outcomes.  49. Subsequent review case conferences were coordinated in line with practice guidelines. The decision was taken that Child 9 should remain subject to planning under the category of neglect. It remains not understandable why this category was used when there were significant indicators, she was a victim of child sexual abuse. She had been referred to the local CSE team and offender 2 had been served with an abduction notice to prevent him being in contact with Child 9 by the time the initial conference took place. Police Force 1 were not represented. Police attendance at case conferences was at that time dependent on the outcome of risk assessments undertaken locally by case management teams  CAMHS had undertaken an assessment due to concerns for Child 9’s mental health, agreeing the plan for her to be supported by regional SARC services, however the service also was not represented. Multiagency participation was not representative of the service involvement. As part of quality effectiveness improvement measures the function of conference chairs should be reviewed to ensure there is adequate opportunity for case reflection in relation to the categorisation of abuse and planning to secure optimal outcomes. There was no evidence of multiagency discussion/challenge related the categorisation of registration. Conference attendees should always actively participate in discussions, actively reflect on the information presented and be prepared to constructively challenge decisions made during the conference process. This practice expectation has not been evidenced during this review. (LP8)  50. In the months following the case transfer there was evidence of Child 9’s and MGGM’s participation in child protection meetings although it is unclear how they were involved in the subsequent  planning. GMP coordinated regular CSE DGM meetings to share relevant intelligence to which some practitioners where invited. However, the review has identified there are significant challenges in ensuring all involved practitioners are able to participate in the range of meetings held or have access to the information shared. The commitment to attend meetings remains a challenge for many multiagency practitioners due to a complexity of reasons including workload capacity. This remains an area for improvement.  51. Exclusion from School: In early 2019, following two periods of education exclusion, Child 9 was referred for additional targeted educational provision.27 The key issues identified were; relationships with peers, engagement in learning and adhering to staff instructions. Following a lesson observation, a pastoral support programme was initiated working with Child 9 on a weekly basis. Included in this programme were 6 sessions of Change Your Mind 28 intervention. Child 9 engaged well and was able to use the techniques learned whilst in school. She expressed; her desire to have a better life in school, demonstrated self-awareness but at times struggled to regulate her responses. As the school year progressed the adverse incidents decreased, better attendance in lessons was noted and her relationships with peers improved. Effectively the intervention had ceased by the autumn term and  27 Targeted Education Support Service is specialist, qualified, experienced teachers and educational practitioners who work with schools to support children and young people when learning, emotional or mental health are causing concern. The service is bought in bi local education providers. 28 Change your Mind intervention is a type of cognitive behavioural therapy.   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 18 of 28  her case was closed to the pastoral support programme. This intervention appeared to have contributed to achieving positive outcomes for Child 9. (Good Practice)  52. The recognition of the need to maintain Child 9 in education through the use of alternative strategies was positive intervention. Research 29 has identified exclusion as an adverse approach for vulnerable children and potentially increases the risk of child sexual abuse and exploitation due to children having more unsupervised time within communities. (LP12) If education is considering exclusion, this practice should be avoided. There should be robust multiagency engagement to discuss alternative solutions, including opportunities to support the young person’s emotional welfare as well as interventions to reduce the risk.  Learning Point 12 : Exclusion30 has been shown to have a negative impact on a child’s emotional wellbeing, can further isolate a troubled child, creating opportunities to increase the risk of CSE/CSA. Child 9 was subject to exclusion in both secondary schools, however during these periods we now also know she was also at significant risk of harm due to  child sexual abuse/exploitation. If education is considering exclusion, this practice should be avoided. There should be robust multiagency engagement to discuss alternative solutions, including opportunities to support the young person’s emotional welfare as well as  interventions to reduce the risk.   53. Missing From Home:  One day in April, Child 9 was seen by education practitioners going towards the area (LA2) where offender 2 resided, rather than being in school. She had been reported missing by MGGM. Following the missing episode and in line with expected practice Police Force 3 had served a child abduction warning on offender 2 and informed Police Force 2 who created an intelligence record in line with expected practice. There was evidence of valuable information sharing between the school and the Police Force 2 and across boundaries with Police Force 3 at this time. The attending police recognised Child 9’s distress linked to the trauma of the previous sexual assault and made a CAMHS referral the same day. (Good Practice) CAMHS was responsive offering a same day appointment but Child 9 could not attend. Safety planning was undertaken with MGGM and a home visit undertaken to complete an initial mental health assessment the following day   54. During the mental health assessment Child 9’s distress was well documented. She discussed the trauma following the rape incident, her challenges in education causing her to have suicidal thoughts and her self-harming behaviours. The outcome of the assessment was that the impact of sexual harm due to the sexual assault was the key factor in Child 9’s unhappiness. The plan to  support her through SARC 2 was thought to be the best intervention. (Good Practice) This plan was discussed and agreed with MGGM who agreed to support Child 9. At this time CAMHS referred Child 9 onwards to the local young people’s advocacy service . It is unclear why Child 9 was not enabled to access the support that had been previously offered by SARC 1 which will be discussed in the next section of this report.   55. Provision of SARC Services: In February 2019, Child 9 had been known to SARC 1 services and a few months later she was referred for the support by SARC 2 services. SARC 1 had made arrangements for Child 9 to access the provision should it be needed in the aftermath of the sexual assault she had  experienced in August 2018. These arrangements had been shared with her GP. However, the family then moved to LA1 and changed GP practice. It is unclear whether involved practitioners or the core group knew about the previous offer of SARC 1 service provision or whether the referral was made to the SARC 2 services as that was the provision normally accessed by children locally. The review process has not been able to secure conversations with the services.  56. The core group and the CAMHS practitioner assessed SARC 2 services would provide the most beneficial provision to support Child 9. CAMHS had withdrawn in the period believing the SARC 2 services would be a responsive provision. In October 2019, secondary school 2 followed up the  29 NCMD (Oct 21)  Suicide in Children and Young People, Data from April 2019 to March 2020. 30 NCMD (Oct 21) Suicide in Children and Young People, Data from April 2019 to March 2020.   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 19 of 28  progress regarding the SARC referral. The delay in offering provision was due to the capacity within the service which was then undertaking other child sexual exploitation work. An initial contact was offered at the end of November 2019. Child 9 had said she did not want MGGM to accompany her so the allocated social worker agreed to go with her. However, for reasons unknown to the review the social worker could not  accompany Child 9 on the day. She was accompanied by MGGM. Child 9 and MGGM stated the situation had improved and Child 9 declined counselling. It is not known whether the counsellor alone saw Child 9. There was a subsequent delay in the counsellor contacting the allocated social worker to discuss concerns arising during the appointment. The counsellor was told by the social worker MGGM “puts pressure on Child 9 to not accept counselling”. However, by this time Child 9 had become a looked after child. Documentation suggests during communications victim blaming language was used again referencing Child 9 being in a “relationship” with an 18 year old male. For reasons unknown this referral/contact was not scanned electronically onto the SARC 2 system as would be an expectation of practice.  57. The provision of regional SARC services includes therapeutic support to enable the recovery of  children who are victims of child sexual abuse. The SARC 2 regional service could not be sufficiently responsive to be able to support Child 9 in her recovery. This provision may have provided an opportunity for Child 9 to gain trust and disclose her ongoing experiences of CSA/CSE. A key question for the partnership should be ; Do local children who victims of CSA/CSE have access to specialist therapeutic provision to support their recovery and can this service be sufficiently responsive to meet their needs. The review process has not been able to secure conversations with the service to assure the accessibility of this provision for local children The accessibility and effectiveness of this provision in providing therapeutic support for local children should be assured  (LP13)   Learning Point 13: The provision of regional SARC services includes therapeutic support to enable the recovery of  children who are victims of child sexual abuse. The regional service was not sufficiently responsive to be able to support Child 9 in her recovery as a victim of CSA and rape. This provision may have provided an opportunity to disclose her ongoing experiences of CSA/CSE. The review process has not been able to secure conversations to assure the accessibility of this provision. This accessibility and effectiveness of this provision in the provision of therapeutic support for local children should be assured.   58. Child 9- The Escalation/De-escalation of CSE Risk: As previously discussed Child 9’s case had been de-escalated by LA2’s CSE team prior to the case transfer as it had been assessed Child 9’s risks related to CSE had reduced; the main factor being less reported missing from home episodes. (para 38)  In February 2019, during a local GMP CSE meeting (CSE DGM)  a child protection social work manager was in attendance who agreed Child 9’s child protection social worker (CPSW) would share information with LA1’s  CSE multiagency team. The CPSW would then manage the CSE risks highlighted by her secondary school (January 2019) in respect to ongoing contact with offender 2. There was a delay in allocating her  case to CPSW however the CSE DGM meetings continued to review the intelligence in respect of offender 2, highlighting the risks in relation to Child 9.  59. In April, following a CSE DGM meeting her case was opened by the multiagency CSE team (LA1), with a meeting scheduled for May 2019 to plan intervention. There were concerns at that time offender 2 was breaking the terms of the abduction notice in regard to his contact with Child 9. The GMP CSE DGM meetings were effective in tracking and recording the outcome of the CSE risk assessments and her risk was set at medium. Information sharing was effective by Police Force 2 with multiagency partners and the case conference process. Her case was de-escalated from s CSE team (LA1) in August 2019 as the score31 placed her at low risk of CSE; she engaged well within sessions and her knowledge base was thought to have increased. The work was home based despite previous  31 The Phoenix Project  uses a child sexual exploitation measurement tool used across Greater Manchester to support a collaboration of 3rd sector and the public sector partners in their risk assessments when working with young people at risk of CSE. The project is led by GMP.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 20 of 28  suggestions that it should be undertaken away from home and MGGM’s influence. Child 9’s CSE worker did not attend the core group meetings which were relevant to the child protection planning especially around CSE. At that time whilst a CSE worker was assigned to the case, the allocated CPSW was managed by a different service which may have impacted on the focus related to CSE. Practice has now changed with a social worker being co-located within the CSE team (LA1) thereby providing improved scrutiny of cases that are also subject to child protection planning.   60. In June 2019, offender 2 engaged in malicious communication with Child 9; making attempts to contact her, demanding the return of gifts. When Child 9 asked offender 2 not to make contact, the offender made threats against her so she informed the police. Further intelligence provided evidence offender 2 had shared an inappropriate photograph with one of Child 9’s peers. This issues were shared effectively with relevant multiagency practitioners and partnerships. (Good Practice) In July 2019, Police  Force 2 received further intelligence from Police Force 3 linking Child 9 to an incident. It  was alleged Child 9 had taken two young girls (aged 13yrs and 15yrs) to meet offender 2. The 13yr old girl was alleged to have been sexually abused, through intercourse, by offender 2. The intelligence indicated offender 2 and Child 9 were in regular contact. A strategy meeting was coordinated. In September 2019, additional intelligence was received from Police Force 3  to confirm offender 2 remained in contact with Child 9. The use of victim blaming language was again used as this contact was determined to be a “relationship” which detracted from Child 9 being seen as a victim of child sexual abuse. A delayed strategy meeting was coordinated (9 days). There was some confusion as to whether her case was re-referred or accepted into the local CSE team. However, the outcome was that Child 9’s case was not allocated by the CSE team for further assessment or intervention.  61. Child 9’s case was de-escalated by the CSE team (LA1) despite significant intelligence offender 2 was making contact with Child 9. A notice had been served on offender 2 in an attempt to disrupt his association with Child 9. The CSE worker was not linked into the child protection multiagency planning arrangements and whilst Police Force 2 provided information they were not in attendance at crucial child protection meetings. The de-escalation decision appears to have been based on Child 9’s willingness to engage in the work programme and her understanding of the issue rather than deeper reflective analysis of the risks she faced from a potential offender and MGGM’s failure to safeguard. Since this case has been highlighted an improvement plan has been developed to improve the effectiveness when working with children at risk of CSE. The improvements include;  • A review of the step up / step down pathway arrangements and the development of practice standards relating to CSE • The development of whole service transition arrangements and re-structure of the service  • The development of thematic performance clinics to review children subject to CSE monitoring.  • A regional audit review and learning group are undertaking a multi- agency audit around CSA to consider learning and development themes arising  The partnership should be assured the planning is sufficient to secure optimum outcomes for children at risk of CSE.  (LP14)  Learning Point 14: In both local authority areas Child 9’s case was de-escalated by the local CSE teams despite significant intelligence in relation to offender 2’s  behaviours  and his intention to sexually abuse Child 9 under the pretext of a “relationship,” The decision was not based on a deeper reflective analysis of the risks Child 9 faced or her MGGM’s capacity to protect her but on simplistic indicators such as the number of missing from home episodes or her engagement in intervention. Since this case has been highlighted improvement plans have been developed and their implementation is ongoing to assure effectiveness when working with children at risk of CSE. The partnerships in both local authority areas should be assured the planning is sufficient to secure optimum outcomes for children at risk of CSE.  62. Escalation into Legal Proceedings: Following Child 9’s disclosure in school in December 2019 the police, education and CPSW were responsive and followed due process in respect to the referral.   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 21 of 28  The key CPSW informed education practitioners a police protection order (PPO) could be secured and would discuss this with the appropriate manager. There is no evidence a PPO  was secured and Child 9 was placed in foster care under a Section 20 order. 32 However, Child 9 went missing from her foster placement within 4 days of arriving. She then stayed with MGM and then with MGGM. A few days later Child 9 returned to her foster carer The CPSW tried to secure a court slot to instigate care proceedings but there were significant delays due to the holiday period. During January 2020, Child 9’s family members continued to make contact urging her to “change her statement” and by shouting at her.   63. At the time management oversight of the case was not robust and the CPSW was unable to escalate the case to assure Child 9’s safety which resulted in ongoing intimidation by family members. As part of the improvement planning there is now more robust management scrutiny of such cases to ensure more responsive case escalation into legal proceedings. Assurance should be provided that practice guidance has been reviewed and provides a clear pathway to follow when case escalation into legal proceedings is required (LP15)  Learning Point 15: Case escalation into legal proceedings was not supported through management case supervision in children’s social care. As part of the improvement planning there is now more robust management scrutiny of such cases to ensure and support more responsive case escalation into legal proceedings. Assurance should be provided that practice guidance has been reviewed and provides a clear pathway to follow when case escalation into legal proceedings is required  64. In conclusion; In February 2019 Child 9’s risks of child sexual exploitation and her carers ability to keep her safe were known. Despite this during the ICPCC she was registered under the category of emotional abuse  and her case was not formally transferred to the local CSE multiagency team. The delay in allocating a key social worker may have impacted on the coordination of core groups. Two review case conferences were coordinated in line with practice guidelines. It is not understandable the category of emotional abuse was assigned when she was a clearly a victim of child sexual abuse. Multiagency representation within these meetings was not always representative of service involvement and although practitioner concerns were highlighted case escalation during agency case management supervision was not evidenced.   65. Child 9’s and MGGM’s participation in child protection meetings was evidenced although it is unclear how they were involved in the subsequent planning. It was known that MGGM ‘s actions did not always equate to the plans she had agreed to follow. Following two periods of education exclusion, Child 9 was referred for additional educational provision. This intervention appeared to have contributed to achieving positive outcomes for Child 9. The recognition of the need to maintain Child 9 in education through the use of alternative strategies was positive intervention. Research   has identified exclusion as an adverse approach for vulnerable children and potentially increases the risk of child sexual abuse and exploitation.   66. In April, Child 9 went missing and was found at the home of offender 2. Police Force 3 served a child abduction notice on offender 2. Police Force 3 also made a CAMHS referral the same day. Safety planning was undertaken with MGGM and a home visit undertaken to complete an initial mental health assessment the following day. During the assessment Child 9’s distress was well documented and included trauma following the rape, suicidal thoughts and self-harming behaviours. The impact of sexual harm due to the sexual assault was the key factor in Child 9’s unhappiness. The plan to offer her support through SARC 2, was thought to be the best intervention. It is unclear whether involved practitioners knew about the previous offer of support from SARC 1. Unfortunately, due to the limited capacity the service did not offer an appointment until November 2019. The accessibility and effectiveness of this provision in providing therapeutic support for local children should be assured.  32 Section 20 of the Children Act 1989 provides the local authority with the power to provide accommodation for children without a court order when they do not have somewhere suitable to live. It is known as voluntary accommodation because the parents must agree to the child being accommodated    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 22 of 28  Whilst her case was opened to the local CSE team and she was assessed as medium risk of CSE her case  was de-escalated after a brief period of intervention. This was  despite the Police Force 2 intelligence that offender 2 remained a risk. Requests to re-open her case to the CSE team later in the year were not effective.  67. Throughout this period the use of victim blaming language was used. Following Child 9’s disclosure in school in December 2019 the police, education and social worker were responsive. A police protection order was not secured and Child 9 was placed in foster care under a Section 20 order. At the time management oversight of the case was not robust and the social worker appeared unable to escalate the case to assure Child 9’s safety which resulted in ongoing intimidation by family members towards her.   68. During this period there were significant challenges in CSC (LA1) in maintaining a stable workforce with sufficient capacity to undertake the range of work. The area has introduced a range of quality effective measures since the rapid review to assure improvements are made in response to the issues this review has highlighted.    SECTION 4: CONCLUSION  This section will provide an overview of the principal issues for discussion.  69. The multiagency response to support children with complex safeguarding needs who are living with the risk of CSE/CSA on a daily basis is both challenging and complex in front line practice. The commitment, passion, motivation of multiagency practitioners to influence the outcomes for Child 9 was evident. However, the review has identified significant practice and system challenges when supporting children like Child 9  within the current systems and pathways. These challenges are not unique to this case and are understood locally and nationally. Evolving improvement plans are in place across both local authority areas to drive long term and sustainable change.  70. The review has highlighted a number areas of good practice within multiagency working arrangements; LA2’s early help offer is accessible to schools in LA1 when children from LA2 are on the school role, the implementation in LA2 of the Star protocol to track children with safeguarding needs who leave school is a positive innovation, the inquisitiveness and responsiveness demonstrated by EWO service (LA2) in locating Child 9, the inquisitiveness and enquiry about Child 9 demonstrated by the school nursing service (LA2), the allocation of a worker to Child 9 by the family intervention service (LA2), the targeted education intervention provided by secondary school 2, information sharing with multiagency practitioners by the police forces, police force 3 recognition and response to Child 9’s mental  distress and the core groups(LA1) attempts to secure trauma based support for Child 9 through SARC services,    71. It is positive the review process has identified many areas of effective communication and information sharing between multiagency services across the local authority areas. This was demonstrated in health, the police and children’s social care. There is also evidence that during the case transfer relevant information was shared so the risks were understood at that time but the delay in the allocation of a CPSW created challenges in securing the ongoing flow on information as Child 9’s case became more complex.  72. The use of victim blaming language was evidenced throughout the timeline of the review. This helped to create the hypothesis that Child 9 had an older boyfriend rather than she was trying to manage the risks of child sexual abuse and exploitation. Her distressed behaviours were not openly recognised as an outcome of her daily journey through life and adverse childhood experience. The inadvertent hypothesis developed was that of a challenging, troublesome child rather than a troubled child. The use of victim blaming language is complex but should be avoided. This is a workforce development need.   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 23 of 28   73. The review has highlighted the risks for children who have to manage difficult family lives on a daily basis and are missing from education. The review heard that in front line practice this is an increasing challenge which has been exacerbated by the COVID pandemic. Therefore, a key question for the partnership is are agencies able to keep track and support these children in the longer term until desired outcomes are achieved. Whilst the review has highlighted there are systems in place to monitor children subject to EHE, these were not sufficiently effective (LA1) at the time. Improvement plans are in place locally however the partnership should be assured of their effectiveness.  74. A consistent theme has emerged during the review process in that there was limited evidence of reflective practice in the multiagency work undertaken or child protection processes. There was a growing body of information indicative of the CSA/CSE risks Child 9 faced yet her situation was remained categorised as emotional abuse. Her situation was not effectively analysed or understood during the child protection processes or within front line practice. The preference being to manage issues  and plan on a “front facing” basis. Contextual safeguarding enables practitioners to consider a range of hypothesis and the push and pull factors impacting on Child 9 and is a development need. Multiagency case management supervision and scrutiny was not sufficiently robust  at that time. The review has been informed that there were challenges in securing a stable workforce and service transformations underway which may have impacted on the opportunity to reflect. Improvements are ongoing.  75. During the assimilation of information there was a range of information known about the family and suspicions about the adults “disguised compliance” behaviours.  The review process has identified professional concerns about the adults but not been able to determine how the risks were assessed or how the adults would be challenged.  This is a development need for the workforce.   76. It is not understandable why Child 9’s case was de-escalated from the CSE team in both local authority areas. The intelligence made available to this review indicates the CSE risks she had to manage on a daily basis were known at the time. The decisions made to de-escalate were based on a lack of reported missing events despite the suspicion MGGM was not reporting events and that Child 9 had sufficiently engaged in the CSE work. The decisions did not seem to include the intelligence known about offender 2. CSE service improvements have been made across both local authority areas, with regional multiagency CSE review also underway to drive further improvements   77. The review has identified that once Child 9 gained trust she engaged effectively in therapy. It is of concern that her access to sexual assault therapy was delayed. Earlier therapy with Child 9 might have supported an earlier disclosure.  The partnership should be assured that restorative work with child victims of rape/sexual assault is accessible for local children.                     LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 24 of 28   SECTION 5: RECOMMENDATIONS   1. The partnership should seek assurance from partners that the learning and recommendations have been responded to and evidence demonstrates improvement to local practice. Improvement plans have currently been shared by children’s services and the safeguarding units  (LA1, LA2), Police Force 2, NHS trust (LA1) and secondary school 2.  2. This review has highlighted the multiagency workforce’s ongoing development needs; when working with children who have escalating and complex safeguarding needs, working with troubled children,  hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work.   3. The safeguarding children partnership should seek assurance that responsive restorative services are available for children who are victims of rape and sexual assault.  4. Both local authority areas have both introduced governance arrangements to assure improvements in child protection processes. These systems are not embedded so there needs to remain a focus on implementing the improvements.   5. There is a  growing concerns for  children missing education and children subject to EHE. These issues should be subject to ongoing scrutiny that demonstrate improvements.        LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 25 of 28  APPENDIX 1: ABBREVIATIONS USED   CAMHS Child and Mental Health Services CSA Child Sexual Abuse  CSC Children Social Care  CSE Child Sexual Exploitation DOLS Deprivation of Liberty Safeguards  EHAT Early Help Assessment Tool  EHE Elective Home Education  EWO Education Welfare Officer GP General Practitioner Services IBP Individual Behaviour Plan ICPCC Initial Child Protection Case Conference KLOE Key Lines of Enquiry LSCPR Local Child Safeguarding Practice Review MGGM Maternal Great Grandma MGM Maternal Grandma  MGU Maternal Great Uncle PSP Pastoral Support Programme SARC Sexual Assault and Referral Centres SCP Safeguarding Children Partnership  SW Social Worker    APPENDIX 2 : INDEPENDENT REVIEWERS BIOGRAPHY  Jane Carwardine has worked as an independent safeguarding consultant (children/adult) since April 2015, completing around 25 reviews (serious case reviews, concise practice reviews, thematic reviews, RCPCH invited service reviews). She holds an MA in Child Care Law and Practice (Keele) and a BA Honours in Health Studies (Bolton). Her practitioner background is nursing (nurse, health visitor and midwife now lapsed) with over 42 years NHS experience. She has undertaken a range of NHS strategic, provider and commissioning management roles. Jane had 15 years dedicated specialist safeguarding experience prior to her current role, in a variety of NHS leadership roles. These roles included; senior and line management, named nurse, designated nurse for safeguarding (including adults and children) and head of safeguarding. Examples of previous safeguarding activity includes; supporting the completion of serious case reviews, multiagency safeguarding development leadership, the delivery of safeguarding learning events, safeguarding assurance work with the workforce and exec boards, complex case management scrutiny, the development of multiagency teams, development of reflective supervision systems, development organisational safeguarding advisory teams, membership on safeguarding boards, chairing multiagency safeguarding sub-groups and providing advice to a range of strategic boards. Jane has worked intensively to improve the quality effectiveness of the case review process. She has not been employed by any organisation aligned to this review and has previously undertaken independent consultancy work for each of the local authorities involved.    LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 26 of 28  APPENDIX 3: RAPID REVIEW PANEL   Organisation Representative  Local Authority 1: Safeguarding Children Partnership • Business Manager, (Chair)  • Learning and Improvement Officer  • Business Support Manager (minutes)  Police Force 2 • Detective Constable, Serious Case Review Unit   Police Force 3 • Detective Chief Inspector  Healthcare NHS Trust • Named Nurse for Safeguarding Children • Safeguarding Children Specialist Nurse  Local Authority 2  • Head of Service Safeguarding and Quality Assurance • Education Welfare Service Representative • Head of Service, Social Work Assessment Service   Teaching Hospitals NHS Trust  • Named Nurse Safeguarding Children   Local Authority 1: CCG • Deputy Designated Nurse  Local Authority 1 • Service Lead, Practice Improvement & Quality Assurance, Children’s Services • Targeted Education Support Service Representative  Local Authority 1: Secondary School 2  • Assistant Headteacher, Inclusion and Welfare  Local Authority 1: NHS Trust • Head of Safeguarding • Specialist Nurse, Children’s Safeguarding       LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 27 of 28  APPENDIX 4: MEMBERSHIP OF CASE REVIEW PANEL  Organisation Representative  Independent Reviewer • Lead Reviewer and Chair  Local Authority 1: Safeguarding Children Partnership • Business Manager • Business Support Manager/Assistant  • Learning and Improvement Officer  Police Force 2 • Detective Sergeant  Police Force 3 • Detective Chief Inspector  Healthcare NHS Trust  • Safeguarding Children Specialist Nurse  Local Authority 2: NHS Trust  • Named Nurse Safeguarding Children  Local Authority 2: CCG • Designated Nurse for LAC  Local Authority 2 • Safeguarding Coordinator • Head of Service, Social Work Assessment Service • Head of Children & Partnership Work • Head of Service Safeguarding and Quality Assurance  Local Authority 1: CCG • Designated Nurse Safeguarding Children & Children Looked After   Local Authority 1 • Service Lead, Practice Improvement and Quality Assurance, Children’s Services • Interim Service Manager, CSC  Local Authority 1: Education • Assistant Headteacher, Inclusion and Welfare, Secondary School 2 • Targeted Education Support Service Representative  Local Authority 1: NHS Trust • Specialist Complex Safeguarding Nurse                   LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP  Page 28 of 28  APPENDIX 5 : PARTICIPATION   Organisation Representative  Police Force 2 • Detective Officer, LA1 Complex Safeguarding Team  Local Authority 2: CCG • Designated Nurse for Safeguarding and LAC  Local Authority 2 • Head of Children & Partnership Work • Safeguarding Coordinator • Safeguarding Children in Education • Family Intervention Worker  • Head of Service, Social Work Assessment Service • Head of Service Safeguarding and Quality Assurance • Head of EWO service • Safeguarding Coordinator, Children’s Safeguarding Unit  Local Authority 1: CCG • Designated Nurse Safeguarding Children & Children Looked After • Practice Manager.  Local Authority 1 • Service Manager, Multiagency Safeguarding Team & Complex Safeguarding  • Head of EWO service • Service Manager, Inclusion • Independent Reviewing Officer • Social Worker, Advanced Child Exploitation Worker, Complex Safeguarding Team  • CSE Team • IRO CSC  Local Authority 1: Education • Deputy Headteacher, Secondary School 1 • Teacher Targeted Education Support Service Teacher, Secondary School 2.              