Harmful sexual behaviour and death of 17-year-old in 2015 as the result of stab wounds. Child F lived with his mother, and experienced uncertainty related to the family not having their residence in the UK regularised, poverty and poor housing which affected his health. Maternal history of abuse, domestic violence and mental health problems. Father deported in 2006 following imprisonment for serious drug offence. Assessed as child in need in 2011. Behaviour and attendance at school erratic, and several incidences of involvement with others in minor and serious offences, including rape of a 12-year-old and 14-year old. Decision made that prosecution relating to first rape was not in public interest. Learning points identified include: when cases are not pursued in the public interest it is still necessary for the young perpetrator to be given a full understanding of the implications of his actions face to face; lack of support for mental health needs due to referrals to and fro between agencies; good chronologies of key events would help spot risks; impact of long bail periods should be recognised and support should be provided to young person; agencies should take great care when describing sex as consensual when in law it cannot be; young teenagers are often unclear about consent. Recommendations include: review safeguarding approach to child perpetrators of sexual abuse and harmful sexual behaviour; encourage education providers to ensure law around consent is explained clearly; ensure that a young person's stated concern about violent risks to them is taken seriously by agencies.
      
    Serious Case Review No:  2017/C6344  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.                                                                                                                                                          SERIOUS CASE REVIEW INTO SERVICES PROVIDED TO  CHILD F and FAMILY                                                                                                     Independent Reviewer- Alan Bedford     Section  Page 1 INTRODUCTION 1 1.1 Background to the Review  1.3  Terms of reference  1.7 Review process 2 1.10 Independent reviewer  1.11 Family involvement  1.12 Anonymity 3 1.13 Agencies participating  1.14 Report structure  1.16  Family structure     2  HISTORY   4 2.1 Introduction  2.3 Case History  2.34 Summary 11    3  ANALYSIS and LEARNING 13 3.1 Introduction  3.2 Was the harmful sexual behaviour preventable?  3.7 Pathway to the death: preventable? 14 3.14 Decisions about Offences 16 3.21 Consent  17 3.27 Was there sufficient understanding about ethnic, cultural and family background issues? 19 3.28 Gangs  3.32 How much was known about F? 20 3.40 Agency Responsibility 21 3.47 Coming up to 18 23    4 CONCLUSION 24 4.2 What was (or could have been) known about Child F by local agencies, and was sufficient action taken as a result?  4.4 Could S’s harmful sexual behaviour been prevented, and was his ultimately fatal involvement with gangs preventable  4.6 Was there sufficient understanding about ethnic, cultural and family background issues? 25    5 RECOMMENDATIONS 26    App 1 Collated learning points    27 App 2 Acronyms    29        1  1. INTRODUCTION  1.1 Background to the Review: This is a Review into the services provided to F, a 17 year old child who died of stab wounds in 20151. The Chair of the Local Safeguarding Children Board (LSCB) was asked to consider if circumstances of this case met the statutory requirements for a Serious Case Review (SCR) as set out in statutory guidance.2 These are that there should be an SCR for every case where abuse or neglect is known or suspected and either a child dies or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.   1.2 The LSCB took the advice of the Secretariat of the National Panel on SCRs3 as the case was not similar to most SCRs where the harm is committed inside the family, and was advised that the criteria were indeed met.  1.3 Terms of Reference (ToR): The 2015 guidance no longer provides core terms of reference for SCRs, but provides overall guidance on the purpose of Reviews. The following were agreed as the summary ToR   1.4  This SCR will : • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;  • recognise the complex circumstances in which professionals work together to safeguard children; • seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.  1.5 Whilst the key issues should emerge from the Review explorations, the SCR Panel is particularly interested in the following overall questions: • What was (or could have been) known about Child F by local agencies, and was sufficient action taken as a result? • Could F’s harmful sexual behaviour been prevented, and was his ultimately fatal involvement with gangs preventable? • Was there sufficient understanding about ethnic, cultural and family background issues?  1.6 The five years leading up to Child F’s death were set as the core timeframe for study but learning was more important than precise start and finish dates, so key earlier                                             1 Two men were convicted of his death, and both are serving very long sentences 2 Working Together to Safeguard Children (DfE, March 2015) 3 National Panel of independent experts on serious case reviews which is to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory criteria are met and to ensure that those lessons are shared through publication of final SCR reports. The panel reports to the Government their views on how the SCR system is working’. Its remit includes advising LSCBs about the application of the SCR criteria, the appointment of reviewers and publication of SCR reports.  2  information which threw light on the core period was relevant. Agencies could use their judgement to add information which they felt relevant to learning as it was important to learn from whatever emerged from looking at the events and the family in the case..  1.7 Review Process:  The Review used the flexibilities contained in the guidance to follow a methodology which maximised staff involvement and kept the depth of inquiry proportionate to the complexity of the case. Agencies contributed to a combined chronology of professional involvement with the case. There was a ‘staff group’ of professionals who knew the family, or could represent the agency if their front line staff were not available. (A feature of this Review was that very few professionals who worked with the family were still locally employed) The group, which saw summaries of each agency’s involvement, clarified the history, identified the key points of agency interaction with the family for specific focus, and also identified key themes for the Reviewer to explore. This was helpful in both engaging staff in thinking about the possible learning, but also making best use of Review time by agreeing focus. Thereafter, the Reviewer followed up some key issues for clarity, but there was no need for either major agency reports or a comprehensive programme of interviews.   1.8 To support the process there was an SCR Panel  of senior staff from involved agencies which the reviewer could use as a sounding board, and if necessary to facilitate any stumbling blocks in the process. The Panel met with the author  to discuss the initial draft and help shape recommendations  1.9 The staff group reconvened to consider the draft SCR, to advise on whether it was describing appropriately the facts and issues, and to consider what recommendations would be most helpful for their work. The Reviewer would like to thank staff for their openness and commitment to the learning process. All agencies were fully cooperative.  1.10 Independent Reviewer: Alan Bedford was asked by the LSCB to undertake this Review. He has a background in child protection social work with the NSPCC, where he was also national training manager. Following this he spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He has worked independently as Alan Bedford Consulting on a range of issues from infection control, to emergency health care, and to safeguarding. From 2009-11 he was Director of Safeguarding Improvement for NHS London, leading a London wide peer review programme, and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He has conducted many SCRs, is accredited as a SCIE Systems Reviewer, and completed the 2010 and 2013 national training for SCR authors/chairs. Sadly, Alan passed away in October 2016 shortly after completion of this SCR.  1.11 Family Involvement: The family declined the opportunity to contribute to the Review but were kept informed throughout the process.  3   1.12 Anonymity: As the focus of SCRs is about learning, it is inappropriate to identify the child and family concerned.   Additionally the National Panel agreed that to protect the family, the report could be published anonymously to the local authority area.  1.13 Agencies Participating: All involved agencies participated. These included: • Council1 Children’s  and Young People’s Service ( CYPS) - Children’s Social Care - Youth Justice Services ( formerly Youth Offending Service) 4 • Academy School • Further Education College • Local Victim Support • Local Mental Health NHS Trust (MHT) • Local NHS Trust Hospital 1 • Local NHS Trust Hospital 2 • Local NHS Trust Hospital 3  • Local NHS Trust Hospital 4 • Clinical Commissioning Group (CCG)  • General Practice (GP) • Ambulance Service NHS Trust (The ambulance service) • Police Service • Council 2 Children’s Services (CS)  1.14 Report Structure:  This report describes the history in Section 2, appraising professional practice in key events. In Section 3 there is ‘Analysis and Learning’ which identifies the key themes of professional practice and where possible why those patterns of work occurred. The ‘Conclusion’ in Section 4 summarises the learning, and answers the key question about whether protection could have been quicker.  1.15 There are in Section 5 recommendations for the LSCB to consider. They are addressed to the Board rather than each agency separately, given the Board’s collective responsibility for assuring the quality of child protection systems.  1.16 Family Structure. F, who was 17 when killed, lived mainly with his mother (‘mother’). F and his mother had arrived from the Caribbean in 2000, seeking asylum from violence which mother said had lost her several relatives. F had two much older half siblings Y (his mother’s child) and Z (his father’s child) who lived elsewhere. The father (‘father’) was deported in 2006 following imprisonment for a serious drugs offence.   1.17 The Review wishes to make it clear that F was never convicted (for reasons set out below) of the serious sexual offences for which he was charged, but the SCR Panel                                             4 In this SCR the phrases Youth Offending Service (former title) and Youth Justice Service (current title) are the same service  4  agreed that reference needed to be made to the alleged offences because of the major learning to be achieved for agencies  2 HISTORY   2.1 Introduction: This section looks at the history of the case. Most analysis and appraisal is in Section 3, but there are some comments on professional work here. The chronology has around 200 entries setting out agency work. The Review was asked to focus on key issues and so every event is not covered in full detail. Sufficient is set out below to illustrate the themes that were identified in the Review.  2.2 In order to set the context within which professionals worked with F, there are some critical comments about his behaviour or attitude. Section 3 will explore the degree this reflected him being a victim or perpetrator, as guidance is clear how blurred are those concepts when dealing with children (as F was up to his death) who may be both.   2.3 Case History: At the beginning of 2006 there is a record of a social worker assessing for Probation the wisdom of the father returning to the home after a jail sentence for supplying class A drugs. The CYPS conclusion, having talked to mother of F and an older sibling was that the father could return home, and no further action was decided. That year the police report to CYPS that an older sibling had made some complaints against the mother. There was a strategy discussion between a CYPS manager and a police officer, which heard that the sibling did not wish to pursue the matter, and would be living elsewhere. The CYPS submission to the SCR criticises F not being seen alone as part of the deliberations. Three weeks earlier S’s school expresses concerns to CYPS about his late collection from school, mother not attending appointments with the education welfare officer, and that he might not be getting sufficient adult care. There is no record of how this was processed. Father was deported at some point in 2006.  2.4 Agencies reported nothing more to the Review until early 2011 when mother referred herself (and F) to Council 1 as she was to be evicted. She was passed to the No Recourse to Public Funds5 Team. She said she suffered from domestic violence before the father’s deportation. The assessment identified the threat of deportation6 , the potential accommodation needs, and F described himself as depressed and using the school counsellor. No help was to be offered until she attempted to regularise her stay by applying to the Home Office.   2.5 The same month F, with other boys, was a witness to a robbery, but police notes say ‘the boys and their mothers are unwilling to participate’. Two month later F was robbed of his mobile phone. F was said to have cooperated, but suspects were not                                             5 No Recourse to Public Funds (NRPF) is an immigration condition restricting access to public funds, including many mainstream benefits such as welfare and housing 6 They had now overstayed the visitor’s visa by 11 years.  5  found. Police noted that F ‘found it hard to express himself’. Around the same time the school were reporting home to the mother poor punctuality.  2.6 CYPS appropriately challenged the Home Office when they said they had no record of mother, despite the UK Border Agency (UKBA) having been involved earlier. A home visit by CYPS in April found home conditions very cramped, and the rent in arrears, but mother could still not show she had applied to the Home Office. In June 2011 the CYPS case was closed due to that non-application, and because ‘no child protection concerns were identified’.   2.7 In November 2011 the mother reported to Council 1 that she had now applied to the Home Office, that her home was soon to be demolished, and that conditions were ‘very bad’. An initial assessment was planned, and the accommodation found to be quite unsuitable7. The damp was a threat to F’s asthma. F said he had been mugged, and threatened by young people in a neighbouring local authority. His mother said this was reported to the police and he had since been provided with a personal alarm. F was said to ‘have been exposed to local gang culture’. The mother was depressed, and spoke of childhood abuse and violence from several partners. F had been a witness to father’s domestic violence to mother. F was assessed as a ‘child in need’ (CIN). Alternative accommodation was offered in the same neighbouring local authority that he said he had been threatened in.  Mother rejected this as she said F had been threatened by boys from there twice and he was too scared to move. She told CYPS about the April robbery. Further accommodation was offered funded by the NRPF team, with subsistence payments made to his mother. This seems to have been appropriate service. The assessment itself has been seen by the Review. It was thorough and exceptionally detailed about F as a person.  2.8 A home visit, the month after the move, noted concerns about mother’s mental health (she was referred for counselling), but that F was doing better. At home visits a social worker gave him advice about drugs and sex education. The CIN Plan created in January 2012 was about exploring his contact with the local gang culture, ensuring he had drugs and sex education, and supporting his mother. By March 2012 the social worker reported the mother having attended several counselling sessions and the family ‘doing well’. Two months later, without further interim contact, at a CIN Review8 “The Social Worker concludes that the family are much more settled and F’s behaviour has markedly improved. Mother is receiving treatment for depression. Home Office response still outstanding. The family continues to receive subsistence and accommodation”. CYPS report that the CIN Plan was ‘stepped down’, as mother was getting treatment and was awaiting the Home Office decision on immigration status. The case was to be ‘held on duty’. Very                                             7 Rat and cockroach infestation, no hot water, the boy sharing a bed with his mother, and that S’s emotional and social development was being affected. The GP records show a range of chest infections 8 Only mother, F and the social worker attended.  6  shortly after this the school were concerned about F’s ‘poor behaviour’ and phoned the mother about this.   2.9 In February 2013, when 15, F was arrested for the rape of a 12 year old girl. Although the event is described as ‘consensual’ in agency records9, in law a 12 year old is deemed incapable of consent. CYPS was not informed by the Police for 19 days. F was bailed and re-bailed until September 2013 when the Crown Prosecution Service decided it was not in the public interest to take him to court. It is understood that the ages of the children, his having no prior conviction/caution, the victim’s behaviour, and that there was social services intervention for both the victim and F, were among the reasons for non-prosecution. It was also said that prosecution would ‘have a disproportionate adverse impact on his future prospects’. The explanation of what the decision meant for F10 was not explained to him directly but via his mother when he was not in when Police called at his home. This should have been face to face given the magnitude of the circumstances.  2.10 CYPS did know before the Police notification arrived as mother reported it to them, saying F was very confused. He was ‘very clear’ the sexual act was ‘consensual’. The mother came in for an appointment, but apparently F did not wish to see anyone. Nothing further is recorded after that discussion with mother. Around this time the CYPS NRPF team chased the UKBA as they had been supporting the family so long. Interestingly, on F’s arrest, in February 2013, the Police had found out from the Home Office that F had been given leave to remain from 25.1.13 to 25.7.15. The UKBA only told CYPS seven months later in September 2013 that leave to remain had been granted, without recourse to public funds. CYPS asked UKBA to reconsider.  The only other record in 2013 is of the school being concerned on occasions about punctuality, truanting, and a confrontation with a member of staff.  2.11 In early January 2014, the mother told the Council that she could not find anywhere to live as she could not pay the rent. The social worker made an access to benefits request to the Home Office, as the council was still providing financial support. That month F was given detention for poor punctuality at school, and he also had a fight during a lesson. Mother supported school sanctions. By April, the Home Office was saying it could not decide on their immigration status as there was to be a ‘judicial review’.  2.12 In May 2014, a 14 year old girl said she was ushered away from friends and raped in a park by four youths at around 11pm. F handed himself in to the police, and CYPS and the Youth Justice Service were told 4 days later. F denied forcing anyone to have sex.  The case was not put to the CPS until spring 2015, and their decision to proceed was made in the summer 2015. In autumn 2015 he pleaded not guilty and                                             9 This is discussed further in Section 3  10 That the fact of being accused would remain on record and could be used if any future repetition etc.  7  was bailed. He was awaiting an early 2016 trial at the time of his death, having been on bail and re-bailed for 19 months.  2.13 In June 2014, a strategy meeting was held11 to discuss the rape incident. From the minutes, it appears that the focus of the meeting was the victim and two of the alleged perpetrators including F. The minutes incorrectly say F was 13 at the previous rape allegation when he was 15, and that the victim was 11 when she was 12.  Information from the school at the meeting was that there were concerns about disruptive behaviour, truanting, and possibly smoking cannabis. It was decided to assess F. When seen, he said he was ashamed, upset and anxious. He presented as having a ‘very low mood’, but said he had a good support network at school and from his mother and an older sibling.    2.14  The assessment concluded that F had been deeply affected by the incident, that he had a difficult history including witnessing domestic violence and concern over two rape arrests in a year. The social worker, who had helped F with a College application, concluded “I do not feel that there is a further role for Children’s Services at this time as there are no safeguarding concerns, however F will still be linked to NRPF, CAMHS and possibly YOS in future. I recommend the case close to Children’s Services”. As it happened, the NRPF team were off the case by August 2014, and nothing came of the CAMHS referral.  2.15 The social worker had referred F to the Child and Adolescent Mental Health Service (CAMHS), and mother for counselling. CYPS says he was referred to the Multiagency Sexual Exploitation group (MASE)12. However, the Review has identified that it was the victim (about whom there was already concern) who was referred, not F specifically. It was regarded as an assault, not CSE13 and so it seems unlikely this was of any benefit for F. The Youth Justice Service noted their statutory arm could not be involved as he was not on a court order. The referral to CAMHS was accepted but with a 3 month wait, with a plan to transfer to the Youth Offending Service (YOS) if formally charged.14  2.16 However, CAMHS decided that F would be better served by CYPS referring to The National Clinical Assessment and Treatment Service (NCATS) which offered assessment and treatment for children and young people who show high risk of harmful sexual behaviours. The GP was copied into this decision. The referral did not happen as the costs to CYPS were deemed prohibitive. It seems no other option was pursued.                                              11 Present were CYPS, F’s academy school and the victim’s school, YOS, NRPF rep, Police and a community paediatrician 12 The  Multiagency Sexual Exploitation group (MASE) is where child sexual exploitation victims, offenders, locations and themes are discussed. It comes under the multi agency Community Safety umbrella 13 Child Sexual Exploitation   8  2.17 F left school in July 2014. He had been there 5 years. On arrival he was noted as having special educational needs, although at the lowest level. His attendance was 86% in year 7, and did not improve in year 8. Education Welfare contacted the mother in April 2011 concerned about attendance and detentions for punctuality. In year 9 his behaviour was a mix of debits and credits, and he was at the nationally expected level 5 at English maths and science. In year 10, 2012-13 his attendance was ‘improved markedly’ to 95%, and in his last year 2013-14, 11, attendance was 98%. As noted elsewhere there were concerns about behaviour and punctuality, but not at a high level. He obtained 7 GCSEs, although 6 of them were at D or E. The school reported that no agencies raised child protection concerns, nor did it need to refer such concerns.  2.18 In a positive step, in August 2014 the UKBA granted the family leave to remain with recourse to public funds. This meant they left the NRPF accommodation, and NRPF team support. The same month the YJS allocated the case. The case was closed to the NRPF team in September 2014. It appears that it was also effectively closed to CYPS after the June 2014 assessment and onward referrals, as no activity is recorded until October 2014 when a manager’s decision to close the case is noted ‘as F is working with YOS and the immigration matter resolved’.   2.19 Between August 2014 and June 2015, F and his mother were supported by the YJS Prevention Team, and F engaged well, keeping his appointments where he was given the opportunity to discuss and learn about sexual health and substance misuse. He had sexual health checks. He was also offered support around further possible criminal activity (see below). The mother was also supported. The worker made an assessment that there were ‘improvements in terms of being able to form age appropriate relationships, demonstrate an understanding of victim empathy, thinking through the consequences of his actions and demonstrating remorse for his behaviour.’ In June 2015 it was deemed that all scheduled work to be done was completed, and the case was closed. The rape charge was still outstanding.    2.20 Alongside this ongoing work, there were continued concerns about F’s behaviour and vulnerabilities. In early 2015 he was arrested for possession of cannabis and failing to stop for Police. He was referred to the Youth Offending Team as an alternative to prosecution. Council 1 MASH15 was informed but the Merlin16 only went to the YJS and not CYPS. The Police assessed the concern as the second highest level of need on the local Safeguarding Board Thresholds.17 The Police submission notes he attended the Youth Offending Team for assessment and was “deemed suitable for the matter to be disposed of by means of triage (Youth Restorative Justice).” In February, F told the YOS that he had serious concerns                                             15 Multi Agency Safeguarding Hub - a which brings together a variety of agencies into an integrated multi-agency team, where they can share information around vulnerable children, families and adults 16 The Police notification of a child involvement with a police matter 17 Local Thresholds Guidance. “ Level 3: Complex needs likely to require longer term intervention from statutory and/or specialist services. High level additional unmet needs -this will usually require a targeted integrated response, which will usually include a specialist or statutory service. This is also the threshold for a child in need which will require Children's Social Care intervention.”  9  about his safety as he was being targeted by boys from one particular area as his friends were from another area. This was passed on to the YOS Police link.  2.21  In spring 2015 F was stopped and searched with another youth suspected of robbery, but no further action was taken. Also in March the YOS referred him to the Gang Action Group18. The referral contained F’s own words which are repeated here to give him a voice in this Review: “The people that are from x area  have something against me because the friends I have all live in y or z area, the only reason I know all of my friends is because the primary school I went to was in y area and that’s where most of them lived. Also the friends I knew in secondary school lived in either w, y or z  area , and these were the people I grew up around so my face became known and the boys from x area have something against my friends, and because I associate with people from other areas the people from x area  see me as one of the y area boys so they try fight me every time I see them Dangers of living here? I fear that they might find out where my actual house is, which means that I won’t even be safe in my own house and also this will put my mum in danger and I don’t like seeing her stress or frightened. Every time I leave my house, they will see me waiting at the bus stop and will approach me. By the way, I  don’t  want to get the police involved because the situation will get worse, I  just want to move away from this location because the longer I stay here, more of them will start to recognise my face and carry on coming after me even  though I  have nothing to do with their beef.”  2.22 The referral added that F’s mother has told YOS that he had been attacked a few months earlier causing swelling to ear and mouth.  The YOS worker submitting the referral said that F had reported a knife being pulled on him because of where he lived, but concluded ‘In my professional opinion, F does not present as being involved in gang activity’. It said he was studying mechanics at College.   2.23 (F attended College through 2014-15 and achieved a level 1 qualification in motor vehicle maintenance and repair. He returned in September 2015 for level 2 courses. The College says ‘he was making steady progress until his death. He was a popular student with classmates and staff. His attendance reached 55% in term one’.  The College said it was in regular contact with his mother about this. The College did not know about his offending history or stabbing in autumn 2015)  2.24 The response from the Gang Action Group was that he was a victim, ‘with no concrete evidence’ that he was gang member and that he should be referred to Victim Support.  A referral to the Young Victims Worker, (part of Victim Support) a few days later used the same information. Two months later, apparently without having had any contact with F, Victim Support referred F to Victim Support as his bail address was there (his sibling’s home). He attended one appointment in the summer, where he said he was scared to leave his house as he had been threatened by a gang from x area, and also referred to a fellow pupil at College                                             18 A three weekly multiagency panel that looks at gang activity and associations, and to agree multiagency actions and plans. It is under the Community Safety Partnership.  10  whom he believed watched him for the x area gang. Fearing repercussions he did not want Police involvement. He was given a personal alarm. Four attempts to call him across the summer were not successful but in early October he was contacted. F said he was fine, and no longer needed support. He said he had the Victim Support number if necessary. The case was closed.  2.25 In autumn 2015, aged 17, F was treated in Hospital 1 for a stab wound to the thigh which required stitches. He refused to cooperate with police inquiries. The Police say this was the first time they recognised that he may be involved with gangs. As he provided a Council 2 address – his sibling’s house – the Police notification went to Council 2, who had no record of him. He was again assessed as Level 3 on the continuum as need. Council 2 CYPS was going to do a child protection assessment, but when they discovered during the assessment that his main address was in Council 1 he was referred to Council 1 CYPS. In the course of Council 2’s initial inquiries they say they were told there was no further action on both the rapes and the possession of cannabis, but this was wrong on the second rape where trial was awaited. F attended Council 2 CYPS twice which Council 2 said suggested ‘he was willing to engage in services’. Both F and his mother denied he was involved with gangs.  2.26 Although Council 2 had in good faith started to assess the case, Council 1 CYPS did know about the incident as they were told almost straight away by Hospital 1. The hospital’s referral included “There are concerns that F is at risk of serious injury or death”. Four days after the stabbing, it was discussed (like other similar cases) at the paediatric unit’s weekly child protection meeting where the feedback received from the Council 1 CYPS19 was that ‘there was no information to suggest that (F) is at continued risk of harm. Management decision – the referral will be used as information only’. The outcome was that the referral was taken off the discussion sheet. Council 1 CYPS told this Review that they should have called a strategy meeting on hearing of the stabbing.  2.27 The detail of his attendance was passed to the Hospital 1 Gangs Youth Outreach Worker. At the time of attendance the youth worker was commissioned for young people who resided in Council 3 which is served by the same hospital, only as part of the Council 3 Gang Strategy and therefore would not have had any direct contact with Child F.   2.28 Council 2 realised this was really a Council 1 case, and referred back to its neighbour nearly a month after the injury but, as seen above, Council 1 already knew. The Council 1 MASH was also involved as the GP records the MASH Team sought information from them.  Council 1 had decided ‘no further action to be taken by Council 1 CYPS as no child protection concerns identified at this current time’.                                             19 Although not told by the Police, A&E told Council 1 CYPS the day after the attendance. The GP was also informed.  11  Section 3 will look at whether this response accorded with guidance. Neither Council 2 nor Council 1 were therefore involved at the time of his death.   2.29 A few days after the stabbing the CAMHS referred F to a Clinic, a solicitor having asked the GP in July to get a psychological assessment of F.  The Clinic was commissioned to take 18 cases a month from CAMHS. The GP was informed that the case had been allocated to the Clinic. By the time F died a letter had been sent offering an assessment but no contact had yet been achieved.  2.30 The School Nursing service was informed of the incident by the Hospital 1 paediatric liaison nurse. The referral form had the name of F’s school on it, but he had left there 15 months before. An unaddressed letter to CYPS to find out what had happened after the hospital referral is on school nursing notes, but whether anything was actually sent is unclear. There is no record that the nurse checked the academy to see if it was the right school, or of any chasing to find out the outcome of  the referral to CYPS.  Hospital 2, which runs school nursing services in the area, told the Review that this should have been done.  2.31 In late 2015, there was an altercation at the College between F and another pupil.  F told the College “he knew the other student from x area and that the other student has it in for him because the people he hangs about with are from y area”.  The College said a “report was then sent to the Head of School, and the College Police Officer was also informed because of the student mentioning the x/y area issue”. The College was unaware of the recent stabbing.   2.32 Two months later in 2015 F was arrested in possession of a mask, and with a friend who had an 8” bladed knife. A victim’s handbag was found when F was arrested. He was bailed not to associate with (a named person); an 8pm to 6am curfew; not to enter the area and to live and sleep at his mother’s address. F was aggressive throughout his dealings with Police and made no comment.  The Merlin notification was prepared, and provided to Council 1, but again only to YJS and not CYPS.  2.33 One month later20 it is understood that whilst trying to purchase cannabis with an acquaintance, there was an altercation with two men resulting in F receiving two stab wounds – to back and thigh, the latter proving fatal. He was attended quickly by ambulance and helicopter and conveyed to Hospital 4, but was pronounced dead less than an hour after arrival. Two men were charged with his murder and drug offences and subsequently tried and convicted.  2.34 Summary: F was a child brought up in a family where the mother had experienced abuse and violence for much of her life, where his father had apparently perpetrated domestic violence and was jailed for drugs offences. He experienced the uncertainty that went with him and his family not having their residence in the UK regularised, and poverty and poor housing which exacerbated his chest complaints. Although                                             20 This was during the curfew period  12  showing some signs of wanting to do well, his behaviour and attendance at school were erratic and he increasingly became involved, always with others, in minor and serious offences, notably rapes of a 12 and 14 year old. He was also the victim of offences such as mugging, and then a stabbing. There were signs of a serious escalation in what was happening to and with him in the last year of his life, with arrests relating to drugs and robbery, and the stabbing.  2.35 The family received good support when the concern was around immigration, housing, and the need for financial support. An issue for discussion in the next section is whether public services did enough, or in a coordinated enough way, to prevent the escalation of his lifestyle to one of real danger – to both others and himself.                                      13      3 ANALYSIS AND LEARNING  3.1 Introduction: This section looks at the degree to which, if at all, the harmful sexual behaviour and criminal death were preventable, and then explores the issues raised in the conclusion in more detail. It looks at what happened with the public services which had responsibilities relating to the family, how well they worked and, if there were problems, why they occurred.  3.2 Was the harmful sexual behaviour preventable? F was involved in two incidents where, with others, he is alleged to have raped firstly a 12 year old when he was 15, and then a 14 year old when he was 16. It can be concluded quickly that it would be unreasonable to think that services might have prevented the first rape in 2013. There were no indications that he might behave in such an extreme way. The family had been given some good practical help around their immigration status, housing and finances, and both mother and F had been given some personal support and advice. CYPS had closed the case in 2012, but even had their work been more intensive or longer it is hard to see how this could have prevented the first offence.  Even if his knowledge about ‘consent’ had been better, he is unlikely to have been deterred when (apparently) by the statement of the victim some of the sexual acts were volunteered21 and he was in a like- minded group of boys.  3.3 It is not so easy to reach the same conclusion on the second rape. It might be argued that the decision on the first rape that it was not in the public interest to prosecute gave F a mixed message about how ‘bad’ his actions were. The Police reported that the reasons for that decision, and the implications, were never conveyed face to face with F but only via his mother. He never had any specific therapeutic or educative input around this offence which he undoubtedly committed. (His belief that the victim acted consensually is negated by her age). F was not seen by CYPS between the two rapes. There is no evidence that any agency spoke with him about it, and it is understood that neither the GP nor school (which had been dealing with some behaviour and attendance problems between the two offences) were aware of the offence. CYPS was informed by the police, and mother was seen twice but F declined to be involved.  3.4 The fact that there was no prosecution did not mean the offence did not exist (albeit not proven in court). Local Child Protection Procedures require a strategy meeting around a child who harms another. This did not happen. The procedures emphasise multiagency knowledge about such offending, but this did not happen either as it did a year later with the second rape. Maybe the absence of a charge deflected thought from F’s needs and prevention.                                             21 Although in law the victim at 12 was deemed incapable of making informed consent.  14    3.5 It cannot be proven that the absence of any work with  the 15 year old F about sexual behaviour or peer pressure after the first rape led to or failed to stop the second, but at the least its absence may have contributed to his understanding of right, wrong and consent being unimproved. (With the second rape he similarly saw the sexual act as a mutually consensual one).  3.6 Learning Points:   • When cases are not pursued in the public interest, it is still necessary for the young perpetrator to be given a full understanding of the implications face to face • Guidance that there should be a strategy meeting around safeguarding a young offender should be followed even if there is, in the public interest, no prosecution.  • No further action by the CPS does not mean in itself that other agencies should act as if there has not been a serious offence  3.7 Pathway to the death: preventable? The second question is whether the journey of escalating criminality/violence could have been halted or slowed. The following is a table of his contacts with the law. Date Event Comment Feb 2011 Victim of a robbery when stopped by older boys and mobile phone stolen  Feb 2013  Arrested age15 for rape of 12 year old girl In Sep 2013 the CPS decided it was not in the public interest to prosecute May 2014 Arrested  age16 for rape of 14 year old girl Charged in July 2015, and due in court in early 2016. F was killed late in 2015 2015 Age 17, arrested for possession of cannabis, and failing to stop for police Referred to  the Youth Justice Service as an alternative to prosecution 2 months later 2015  Stopped and searched with another youth suspected of a robbery No further action 5 months later 2015  Charged with rape, he appeared at Crown Court Pleaded not guilty to rape. Trial set for early 2016 one month later 2015 Age 17, stab wound to thigh requiring stitches  Refused to cooperate in any police investigation of the assault. Police believe he is involved in gangs, and might have been present at another stabbing the previous day.  two months later 2015  Still 17, arrested on suspicion of robbery. Had a mask. With another youth who had a knife Investigation ongoing at the time of F’s death.  Bailed on condition of 8pm-6am curfew, living at family address, not going to certain parks,  15   3.8 The first event in 2011 will sadly not be that unusual, and both mother and son reported being supported by the Police at the time. The first rape did indicate he was acting with a group of youths, and the previous paragraphs have described how no action was taken with F over his behaviour. This was a missed opportunity. After the second rape, there was the required strategy meeting and an assessment of F’s needs. Although seen by CYPS it seems that the fact that he was denying the offence and had made ‘no comment’ was seen as a reason not to discuss the offence itself with him. CYPS soon decided there was no further role for them and closed the case having referred F to CAMHS. They in turn wanted him referred to NCATS, so the case was referred back to CYPS but apparently it was decided this could not be funded. He therefore ended up with no specialist emotional support about his then predicament. He also lost the support of the NRPF team, although for the positive reason that the family had been given leave to remain in the UK.  3.9 From August 2013 CF did have the support of the YJS, which was on a voluntary basis as he was not charged until after they ceased involvement. This seemed to be a positive involvement. However, during this period he was arrested for possession of cannabis and failing to stop and was referred to the YJS as an alternative to prosecution. He had a number of sessions with YJS about sexual health and drugs. CYPS was not informed by the Police so did not have the opportunity to consider re-opening the case. F told YJS about his fears for his own safety which were passed to the Police, and he was referred to the Gang Action Group and, with his consent, to Victim Support.   3.10 In 2015 F was stopped and searched regarding a possible robbery. 3 months later, YJS closed the case as it was deemed all scheduled work was done. This seems questionable given the CPS had yet to decide about prosecution for the second rape. At that point no CYPS, YJS, or mental health services were involved at all. While it would be unreasonable to say that this led to the later escalation of violence, it does raise the question about whether there should have been no involvement when he was still on bail for a second rape, had had a drugs arrest that year, and had been expressing fears for his safety. The issue of which agency needs to take an overview of a young person’s needs in this sort of situation is discussed later.  3.11 By the time he was stabbed in 2015, he had been arrested twice for rape (and awaiting trial on one rape), been arrested for a drugs offence, and suspected of a robbery – which might suggest that he was getting into serious circumstances. Yet there was no strategy meeting, and CYPS saw no need to become involved. Whilst not associating with (named) person. One month later 2015  Stabbed in thigh and back, the thigh wound proving fatal. With an associate, F was apparently in an altercation with older drug dealers. This was during the curfew period.  16  again it could not be concluded that the lack of involvement led to his death, it would be fair to say that as far as F was concerned he was on his own after the stabbing, and with a trial hanging over him too. Of course, he may not have accepted any help or intervention offered.  3.12 There was one more opportunity when, a month before his death, F was arrested on suspicion of robbery with another youth. Between them they had a mask and knife. He was still at 17 technically a child. Again Council 1 YOS but not CYPS was informed of ‘an arrest for possession of an offensive weapon’. No action by YOS is recorded22. Even if CYPS had been told there can be no assumption that doing ‘something’ would have stopped the late night altercation over drugs a few weeks weeks later, but it does highlight again the question of who takes overall responsibility for the safety of a teenager in these circumstances and those around him.  3.13 Learning Points:   • The ease with which a teenagers mental health needs can go unsupported as referrals go to and fro between agencies • Good chronologies in each agency of key events would help spot accumulating and escalating risks  3.14 Decisions about offences: Getting a case to a position where there is evidence to put before the Crown Prosecution Service (CPS) is not easy, especially when there is limited cooperation from the young person/s concerned. And even after the decision there are inevitable waits for court hearings. However, it is worth reflecting on the length of time that F spent waiting for a decision or a trial, and on the impact of the decision not to proceed.  3.15  F was arrested for the first rape at age 15 in February 2013, and was bailed and re-bailed until September 2013 when the CPS decided not to prosecute, a period of 7 months. The mother was told and had the implications explained in October, but F never had a direct explanation. Given we know that F did not understand the law on consent (he thought a 12 year old girl appearing to him as willing made it all right) it is possible that he saw the no further action as vindication of his position. It is also possible that he saw the no further action as meaning he did not commit an offence. This is speculation, but there was a need to try and ensure F was well guided on his future behaviour. In the future, in similar circumstances, the Police must make sure the young person has a full explanation of the implications.  3.16 The second rape case had not been heard when F was killed, 19 months after the offence. A hearing was due the following month.  The wait for forensic evidence/phone analysis  amongst other things meant the case was not put to the CPS for evidential review until March 2015, ten months later, and the CPS decision                                             22 By this time Council 1 YOS had a very limited service for anyone not on a court order  17  was not taken until a further four months, when he was charged. Trial was booked for early 2016, which would have been 20 months after the offence. The time from offence to trial would have amounted to almost 10% of his life. The Review has not examined the decision process, but raises the issue of the impact on F, the child concerned.  3.17 It is known that F was (not surprisingly) low about the process. He had expressed remorse to the social worker. He would inevitably be anxious about what it was all leading to. But when the CPS decided to prosecute he had not been seen by CYPS for a year, and the YJS work had stopped the month before. Council 1 CYPS had also decided not to be re-involved after his drugs arrest in 2015, or the stabbing later that year, and the YOS did not get involved after the robbery arrest in late 2015 – all before he had got to trial for the rape. When there are such delays in decisions about prosecution, or long waits for trial should not one of YJS or CYPS be providing some sort of support, or even a watching brief?  3.18 The fact that he denied an offence, and later pleaded not guilty at the preliminary hearing,  may have acted as a disincentive for agencies to act as if he was ‘guilty’ by proactively trying to engage. But he was a child in law, and whatever the technicalities of what can or cannot be discussed about a specific offence before trial, there is a need to do whatever is possible to protect him from himself or others. It was not as if his life was going smoothly while on the extended bail, as four of the events listed in the chart in 3.7 above occurred during this time, two of which were when no agency was involved. The SCR Panel also identified the issue that children might still need services even if there is a decision not to charge, and therefore it is important that a no prosecution decision does not blind services to a child’s needs.  3.19 CPS guidance is that children of 13-15 years old, of the same or similar age are highly unlikely to be prosecuted for engaging in sexual activity, where the activity is mutually agreed and there is no abuse or exploitation. It is interesting that the ages in the first rape were 15 and 12, which are not really ‘the same or similar’. See ‘Consent’ below.  3.20 Learning Points:  • When a case is not taken forward as not in the public interest it is essential the alleged perpetrator is provided with a thorough explanation of the implications, and that it does not mean that no offence may have been committed. • No prosecution does not necessarily mean a child has no service needs. • The impact on a child/young person of long bail periods must be recognised, and support provided especially to those with known vulnerabilities. • Agencies should be wary of closing cases whilst major decisions about offences are still pending. • Denying an offence, does not negate the need for the child/young person to be supported or worked with to protect themselves or others.   18  3.21 Consent:  In law, no one under 16 can consent to sexual activity, although, if the child is aged between 13 and 16, and the adult reasonably believed the child to be 16 or over there may be a defence. There is no such defence if the child is under 1323. A child under 13 is deemed unable to give consent.  It is interesting that several Police entries in their chronology and in other agency files the act for which F was arrested in 2013 was described as ‘consensual’ when the law deems it impossible for a 12 year old to consent. It is also interesting that although at 12 the victim was in law unable to consent, the CPS decision considered how the victim behaved in its decision not to prosecute F.  3.22 The Review understands what is meant in agency files by ‘consensual’, that is that apparently the victim claimed the sexual activity was as a willing participant, but the point of the law is to protect young children from situations where they engage in sexual activity at an age when they are deemed unable to consent. This being the case it would be better if agency records did not describe the activity as consensual sex, as in law it was not. The risk is that by so describing the activity, it somehow becomes less serious, but the offence is the same (‘rape’) regardless as to the motivation and behaviour of the victim. There is also a risk that the perpetrator may also see it as somehow less grave if professionals deem that the activity can be consensual. F could not understand that he had offended because he saw the victim as consenting but a 12 year old cannot consent.  3.23 With the second rape, the victim said she had gone to the park for consensual sex with a friend, but had then been orally raped by three strangers (one of whom was F). F’s statement was that he did nothing forcibly, and again he presumably did not know that such sexually activity was an offence, forcible or not as she was under 16.   In this case the CPS must have disagreed with his assessment or they would not have decided on a prosecution.  3.24 The local Child Protection Procedures24 says there is a high incidence of rape of girls involved with gangs. “Some senior gang members pass their girlfriends around to lower ranking members and sometimes to the whole group at the same time”. It says girls can be groomed at school using drink and drugs which act as a disinhibitor. This Review does not know enough about the rapes in this case to know if they were connected to this dynamic, and neither case was heard in court.  3.25 At the Staff Group,  the need for schools/colleges to ensure that the law around consent was covered well was emphasised.  3.26 Learning Points:                                             23 Sexual Offences Act 2003, section 5-15.    24 Local Child Protection Procedures- Section 12 ‘Safeguarding Children Affected by Gang Activity/Serious Youth Violence’.  19  • Agencies should take great care when describing sex as consensual when in law it cannot be. This helps avoid the risk of such offences being seen as less serious than they are, and to avoid any possibility of that message reaching the perpetrator. • Young teenagers are often very unclear about the law around consent. • Schools and colleges are well placed to ensure the law around consent is clearly explained to pupils.  3.27 Was there sufficient understanding about ethnic, cultural and family       background issues? CYPS had on file a very good assessment of F’s family background and his own interests and attitudes. Similarly with his mother.  There is no indication that agencies which worked with the family were unaware of his own background, which was of course highlighted by the immigration issues. The YOS was also well aware. The services which F’s family required as immigrants with NRPF seemed to have been well provided by Council 1.  3.28 Gangs: National guidance on safeguarding and gangs25 chooses the following definition: “A relatively durable, predominantly street-based group of young people who see themselves (and are seen by others) as a discernible group for          whom crime and violence is integral to the group’s identity”. It gives a three tier description. Level 1 ‘peer group’- a relatively small unorganised group where involvement in crime is not integral to its identity. Level 2 ‘street gangs’, more durable groups, street based, and seen as a group where crime and violence is integral to identity. Level 3 ‘criminal gangs’ where crime is so integral it could be seen as the members’ occupation. The guidance focusses on Level 2 which seems to be the highest level with which F was involved. And, as described in section 2,  the YOS concluded that F, at 17, did not seem to be involved in gang activity. However his contribution to the referrals to Council 1 Gang Action Group, and Victim Support, described quite well how he was involved in a culture where geographically based groups were violent to those from other areas, simply because of residence. The Gang Action Group decided he was more of a victim than a gang member.  3.29 The national guidance emphasises the overlap between being victim and perpetrator. For example, victims of violence can take revenge later. Perpetrators can become the victim of revenge attacks. Both may well have the same disadvantaging features in their past. The local guidance says “Potentially a child involved with a gang of serious youth violence could be both victim and perpetrator. This requires professionals to assess and support his/her welfare and well-being needs at the same time as assessing and responding in a criminal justice capacity”. The importance of a good assessment is emphasised in the guidance but, after he was stabbed, Council 1 CYPS decided without assessment that there were ‘no child protection concerns’, both at the time and later when Council 2 realised he was living in Council 1 and referred back there. There should have been a strategy meeting, or                                             25 ‘Safeguarding children and young people who may be affected by gang activity’. HM Government 2010  20  assessment or both. F was still a child at 17, was well known to agencies, and had been wounded in an assault. When, not long after the stabbing F was arrested with a knife and believed to be planning robbery, the YOS apparently took no action when informed by the Police. As within a period of two months he was seen as both a victim and a potential perpetrator, this should have been a sign of him being pretty heavily involved in a violent world. (CYPS was not informed).  3.30 Whether or not someone is said to be involved in ‘gangs’ and any other subcategory that might appear in guidance, is to some extent not relevant. What matters is simply what is happening to and with the child, and what the risk is of being a victim or perpetrator. Being in a gang may enhance the risks, but not being in one and being part of much less formal activity, does not necessarily mean less risk- as this case shows.  3.31 Learning Points:  • In the violent world of some young groups, workers at assessment must consider that being a victim and being a perpetrator is very closely related. • Assessment needs to work out the respective risks and to determine what intervention/pathways may be best to reduce those risks. • What is actually happening to the young person in the round  needs to be the focus - an approach not deflected by a ‘no-gang’ conclusion.  3.32 How much was known about F? From information supplied to the Review, it seems that what was currently known receded as he became older and the risks grew. The CYPS assessment in 2011 was excellent, and YOS worked hard with him between summer of 2014 and summer 2015. But by the autumn of 2015, when his stabbing and then the offensive weapon/robbery arrest were not followed up by either CYPS or YOS (who were both by then not involved at all) neither would have an up to date understanding of risks to him. He was at College from September 2014 to his death, but the College had no idea about his offense related issues, and it does not seem that other agencies informed the College of anything. The College did report to the College police officer the turf related altercation F had in late 2015, but this was presumably not seen as significant enough for the officer to log an intelligence report. It appears that the school nurse who was informed did not identify that F was now at college in a neighbouring borough.  3.33 In October 2015, Council 2 Children’s Services, after the stabbing when they thought he was permanently in the borough, did start an assessment- which was not completed and referred back to Council 1. Council 2 did find out from F’s GP who had seen him in July, that F had said ‘he has had history of stress and anxiety for long time (though presented for the first time at the surgery) and has deteriorated over the last two years, with poor concentration, feeling depressed and poor sleep, though not suicidal’.   21  3.34 The GP’s last contact was in summer 2015 when he saw F as he was asked to make a CAMHS referral. F reported being sexually abused as a child (but by whom is unknown) and gave the history reported in the previous paragraph. The hospital did tell the GP about the stabbing but seems just to have been noted. The GP was asked by the MASH and by Council 2 Children’s Services for a briefing after the stabbing, but nothing extra more was known by the practice after the July contact.  3.35 As the College did not know about his involvement with violence/offending (although it did know about the geographically based altercation F was involved with) it means that, other than Council 2’s fleeting involvement, F’s predicaments and risks were pretty unknown or unrecognised in the last few months of his life.  3.36 Although the school attended the strategy meeting in June 2014 which discussed  the second rape, there is nothing in school records about this and the College which he moved to that autumn had no knowledge about his alleged history in relation to younger girls. The SCR Panel debated whether say the police should have told the school/college so they could be alert to possible risks to other pupils, and this Review recommends that the LSCB explore with agencies the ethics around such an exchange of information.  3.37 As this Review shows, there was quite a lot to be known about F, and a need to assess what it all meant. Other than one strategy meeting, focussing on the victim, there was no multiagency meeting at any time to discuss F. This meant that there was never a forum where all the information could come together. If say after the stabbing there had been a multiagency meeting, it is possible that the combined information from two CYPSs, hospital, YOS, Police, GP, CAMHS/onward referral agencies, Victim Support, and College might have identified the growing risks. Local agencies will need to consider how this might be achieved in future cases.  3.38 F made a number of references to agencies about the geographically based conflicts of which he was nervous. It does not seem this was ever analysed for the real risk.  3.39 Learning Points: • This case shows how a teenager can drift off the radar, even with a serious offence still pending • The absence of multiagency discussions can make it much more likely risks are not fully assessed. • Agencies need to consider what might trigger such a meeting in future cases • When a child or young person says they are at risk this should be taken seriously and explored  3.40 Agency Responsibility: At the Staff Group and Panel, those present were struck by the range of services involved to one degree or another, but also the lack of clarity about which if any had the responsibility to take the overview on F. There are two related issues.   22   3.41 The first is the contrast between apparent good intentions and in the end very little seeming to happen. At some point F was referred to CAMHs, MASE (or was said to have been), Victim Support, and Council 1 Gang Action Group, and there was a plan to refer to NCATS. He was also referred to the Clinic. This Review has been unable to identify that anything of any significance occurred as a result of these referrals- and it all seems to wither away. As said in the previous paragraph there was never any multiagency discussion about F to pool knowledge, assess risks, and plan how to minimise them. Each agency carried out what it understood to be its own role, but none seemed to be pulling it all together and answering the question ‘is what we all doing, put together, are making a difference?’  3.42 The second issue is who was responsible for holding it all together? At 17 F was still the child protection responsibility of Children’s Social Care under CYPS, and guidance is clear that referrals of concern about under-18s involvement in gang (or similar) related violence needs to use child protection procedures as it involves protecting the young person or others from the young person. The Youth Offending Service, which is also part of the Council, is responsible for supervising young offenders in the community or custody, and through its preventive arm supporting ‘children, young people and their families who are at risk of offending’. CYPS had closed the case in July 2014 (but knew YOS was involved) and the NRFP team (properly) stopped in August 2014. CYPS declined to reopen it after the stabbing in the autumn of 2015.  YOS had formally closed the case in summer 2015 while F was still awaiting trial for rape, and did not become re-involved after the late 2015 robbery arrest. When things seemed to be getting violent in the autumn of 2015, neither department initiated an assessment, which seemed warranted under national and local guidance.  3.43  At the Staff Group and Panel, given that there cannot be a major response to every youth that gets into trouble, there was a discussion about just how common was the cluster of events with which F got involved? (See chart in 3.7). There was no consensus at first, but the more that emerged about F the more the conclusion was ‘not that common’.  The lesson that emerges from this is the need for one agency to ensure there is a proper overview of a case like this, and to ensure a full assessment. To achieve this there needs to be greater clarity of the respective roles of Children’s Social Care and YJS which are part of the same organisation. This should include being clear which is going to have responsibility for assessing the whole young person and reaching conclusions about the overall risk. In other words, taking everything into account what is the risk to or from this child/young person?  3.44 Staff involved in discussing this case with the Review were struck by the range of organisations involved, and it is hard to understand where each fits and what is the limit of their involvement. It is probable that this is even less clear when the person concerned varies between being a victim and a perpetrator, where the person’s status as an offender is not yet clear as there have been no ultimate hearings to  23  determine this, where the age is close to adulthood, and where it is not clear if ‘gangs’ are involved or not.  3.45 There was also a communication weakness about the police notification system for children and young people coming to notice. Procedurally these should go to CYPS, but in this case on some occasions they only went to the YOS component. Police may have expected that as both are in the Council they were in effect communicating with both, but this was not the case. And YJS would have assumed that Children’s Social Care knew as per procedure.  CYPS for example did not know about the offensive weapon/possible robbery shortly after the stabbing, and only knew of the stabbing as other agencies, not the Police, informed them.  It is important that both internally and externally the relationship between children’s services and youth justice services within Council 1 are clear.  3.46 Learning Points: • It is important to be clear what referrals to other organisations have led to, and not to assume they have made a difference. • One agency, presumably Council 1 through either its CYPS Social Care and Youth Justice Service, needs to be take  the lead in maintaining the overview of the child/young person’s progress, and assessing the accumulating and overall risks. • There needs to be clarity of the respective roles of within CYPS around older children. • There are many organisations set up to support children like F but their respective roles, and the connections between them may not be clear. • Police, Children’s Social Care  and YJS need to clarify communication routes about young people coming to the notice of police involving offending. • Is there a need to clarify school nursing responsibilities on over 16s in college, and what information they should receive?  3.47 Coming up to 18: At both the Panel and Staff Group meetings concern was expressed that as a teenager approaches 18, and adult services, there is an increased chance of service response being less than ideal. F would have been 18 the month after his death. It was in the months leading up to his death that services several times declined to become involved. This is not just a matter of service attitude as teenagers of that age can act in an adult way and appear to be, so to speak, young criminals rather than wayward children who are very hard to engage. Nevertheless Children’s Services have legal responsibility for the protection of children up to 18. The Review will recommend that the LSCB reviews with its members the service response to older teenagers.  3.48 Learning Points: • Care needs to be taken that statutory responsibilities are considered appropriately when a teenager approaches 18.   24           4. CONCLUSION  4.1 In terms of the three main questions asked of this Review, there are no absolute answers, but rather issues identified for further thought and possible learning.   4.2 What was (or could have been) known about Child F by local agencies, and was sufficient action taken as a result? The Review has shown that quite a lot was known about F and his family, but how this diminished the older he got. The sum total of  his inherent vulnerabilities from his childhood history, what he conveyed to agencies about his fears of geographically related violence, and his ongoing brushes with the law including some very serious incidents, would if ever put together at least have identified significant risk. It would also have showed in the last few months an escalation of concern. Help was appropriately given by the Council around immigration and housing, and later by YOS on drugs and sex education, but later he had no special support, and onward referrals including for emotional support seemed to come to nothing. One factor in this was that he was not seen to be involved in ‘gangs’ so this limited intervention/support. It does not appear that his references to inter area conflicts were ever studied to assess the depth of the risk  4.3 One of the questions that was discussed at the staff group/panel was whether, if F was one’s own child, would we have thought enough was done given the serious situations he kept being involved in? The general view was no. It is important to point out that doing more would not have been easy. On some occasions F declined support, on others he specifically asked for no Police involvement, and on others he clearly would not have volunteered information about his own offending. On the other hand, at 17, he was still deemed in law to be a child, and needed whatever help, protection, or control which might have made a difference.   4.4 Could S’s harmful sexual behaviour have been prevented, and was his ultimately fatal involvement with gangs preventable? The Review concluded that his first sexual offence was not preventable, as it was out of the blue. However, it can be argued that lack of action on that first offence, or at least the failure to explain to him in person what taking no further action meant, did nothing to lessen the chance of reoccurrence. F had just the same misunderstanding of consent when he committed the second rape, and there had been very little discussion with him about  25  the first offence. As far as we know he did not commit a third sexual offence after YOS provided educational input so it may have made an impact..  4.5 The Review cannot conclude that F’s death was preventable, but does raise issues about the lack of follow through of agencies, and that he was essentially without any agency monitoring or support in his last few months. This seems related to there being no clear process for pooling information about the accumulation of concerns, especially when the teenager is not deemed to be involved in ‘gangs’. Whether he was or not can be debated, but his own accounts were of geographically related threats from other groups. The case will provide much food for thought for local agencies on how they work together to assess and work with teenagers caught up in risky behaviour, whatever label is given to it. However, any conclusion that more might have been done, does not imply a conclusion that the death would have been prevented particularly as the criminal trial found no connection with his murder and his history.  4.6 Was there sufficient understanding about ethnic, cultural and family background issues? There was on CYPS file an excellent assessment of F’s family background issues. YOS also had a good understanding of this. There was enough information available for his vulnerabilities from parental background and early childhood to be known. If there was an area not explored enough, it was his references to the geographically based violence of which he was afraid.  4.7 One of the striking features of the evidence gathered in this Review is the lack of reference to ethnic issues, other than as they related to his origin in Caribbean. No agency has made any reference to this as an issue for this Review, nor has anyone suggested his ethnicity impacted on how agencies did or did not respond to him. Local services to the family with NRPF in the UK from the Caribbean seem to have been good                   26             5 RECOMMENDATIONS  5.1 Introduction: The recommendations here are in addition to the learning points in section 3 which the LSCB and agencies can use as they see fit to focus learning from the review. The recommendations are on the more overarching issues and are addressed to the LSCB to oversee. It is for the LSCB to prioritise the recommendations in light of its own assessment of how widespread locally are the issues seen in this case.  5.2 Recommendations:  The LSCB should….   (1) Ask Council 1 to clarify the relationship between, and the mutual responsibilities of, its Children’s Services and Youth Justice Service in relation to older children. (2) Review with member agencies the safeguarding approach to child perpetrators of sexual abuse and harmful sexual behaviour, including support when the decision is not to prosecute. (3) Seek assurance that strategy meetings are considering the needs of both child victims and child perpetrators. (4) Review with member agencies how children can get ongoing support during long waits for prosecution decisions or trials. (5) Review the process of referrals and access to child mental health services to ensure proper and timely decisions and care. (6) Consider with Police, CYPS and Education as to what information about offences (including those not proceeded with) should be appropriately given to, or passed between, schools, colleges and related health services. (7) Emphasise to all agencies the benefits for chronologies of key events to help identify patterns of behaviour and increasing risks. (8) Encourage education providers to ensure that the law around consent to sexual activity is explained clearly to pupils. (9) Ensure a young person’s stated concern about violent risks to them is taken seriously by agencies.    27             Appendix 1   Collated Learning Points This appendix collates the learning points listed in section 3 Analysis and Learning. On was the harmful sexual behaviour preventable • When cases are not pursued in the public interest, it is still necessary for the young perpetrator to be given a full understanding of the implications face to face. • Guidance that there should be a strategy meeting around safeguarding a young offender should be followed even if there is, in the public interest, no prosecution. • No further action by the CPS does not mean in itself that other agencies should act as if there has not been a serious offence.  On- Pathway to the death: preventable? • The ease with which a teenager’s mental health needs can go unsupported as referrals go to and fro between agencies. • Good chronologies in each agency of key events would help spot accumulating and escalating risks.  On decisions about offences • When a case is not taken forward as not in the public interest it is essential the alleged perpetrator is provided with a thorough explanation of the implications, and that it does not mean that no offence may have been committed. • No prosecution does not necessarily mean a child has no service needs • The impact on a child/young person of long bail periods must be recognised, and support provided especially to those with known vulnerabilities. • Agencies should be wary of closing cases whilst major decisions about offences are still pending. • Denying an offence, does not negate the need for the child/young person to be supported or worked with to protect themselves or others.   28  On Consent • Agencies should take great care when describing sex as consensual when in law it cannot be.  This helps avoid avoid the risk of such offences being seen as less serious than they are, and to avoid any possibility of that message reaching the perpetrator. • Young teenagers are often very unclear about the law around consent. • Schools and colleges are well placed to ensure the law around consent is clearly explained to pupils.   On gangs  • In the violent world of some young groups, workers at assessment must consider that being a victim and being a perpetrator is very closely related. • Assessment needs to work out the respective risks and to determine what intervention/pathways may be best to reduce those risks. • What is actually happening to the young person in the round needs to be the focus - an approach not deflected by a ‘no-gang’ conclusion.  On how much was known about F?  • This case shows how a teenager can drift off the radar, even with a serious offence still pending. • The absence of multiagency discussions can make it much more likely risks are not fully assessed. • Agencies need to consider what might trigger such a meeting in future cases. • When a child or young person says they are at risk this should be taken seriously and explored.  On agency responsibility  • It is important to be clear what referrals to other organisations have led to, and not to assume they have made a difference. • One agency, presumably Council 1 through either its CYPS Social Care and Youth Justice Service, needs to be take  the lead in maintaining the overview of the child/young person’s progress, and assessing the accumulating and overall risks. • There needs to be clarity of the respective roles of within CYPS around older children. • There are many organisations set up to support children like F but their respective roles, and the connections between them may not be clear. • Police, Children’s Social Care and YJS need to clarify communication routes about young people coming to the notice of police involving offending.  29  • Is there a need to clarify school nursing responsibilities on over 16s in college and what information they should receive?  On coming up to 18 • Care needs to be taken that statutory responsibilities are considered appropriately when a teenager approaches 18.  Appendix 2 Acronyms  MHT Mental Health NHS Trust CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CIN Child in Need CPS Crown Prosecution Service CYPS Children and Young People’s Service LSCB Local Safeguarding Children Board MASH Multiagency Safeguarding Hub NCATS National Clinical Assessment and Treatment Service NHS National Health Service NRPF No Recourse to Public Funds SCR Serious Case Review ToR Terms of Reference UKBA United Kingdom Border Agency VS Victim Support YOS Youth Offending Service YJS Youth Justice Service          