Death of a 16-year-old boy. Carl's death was caused by fatal stabbing. Lessons include: the impact of multiple house moves and homelessness on children's wellbeing and education; the risks from large gaps in a child's education; insufficient attention to family history in assessments and interventions; the importance of involving housing agencies in the safeguarding process; understanding contextual risk for young people; early identification and help for children and their parents. Recommendations to local safeguarding children partnerships and agencies include: promote a collaborative approach when working with homeless families by involving local housing services in guidance and best practice around multi-agency safeguarding; protocols outline each agency's role and responsibilities for homeless families where children are identified as children in need; raise learning from this review and similar reviews where a family's housing situation impacts on children's welfare to the National Child Safeguarding Review Panel; review early help strategies to ensure they capture issues raised in this review, including: parental substance misuse, poor school attendance, challenging behaviour in school, unaddressed speech and language difficulties; a robust multi-agency response which prioritises young people's safety where risk factors include serious youth violence in the community; the need for communication and collaboration when dealing with parents with complex needs; assessments consider a family's longer term history and any issues arising from neurodiversity, particularly when there are long gaps in children's education.
      
 Title:  Safeguarding practice review: “Carl and Max”. LSCB: Croydon Safeguarding Children Partnership Author: Jane Doherty Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Safeguarding Practice Review“Carl & Max”March 2022AuthorJane DohertyIndependent Social Work ConsultantThe review benefitted from learning from the experience of and views expressed by Carl’s Mother and Grandmother. It was also assisted by the reflections of the practitioners who had worked to support the family in the three years prior to Carl’s death.Eleven recommendations to improve local multi-agency work were made and have been accepted by the Croydon and Wandsworth Safeguarding Children Partnerships.The key lessons outlined are: The impact of multiple house moves and homelessness on children’s wellbeing and education The risk from big gaps in a child’s education Insufficient attention to family history in assessments and interventions to support the family The importance of involving housing agencies in the safeguarding children process Understanding contextual risk for young people Early identification and help for children and their parentsThey include actions to: Improve work with families experiencing homelessness at practice and strategic and whole systems levels. The value of service design to maintain good relationship work with adolescents who may find it hard to engage with services. Review the early help strategy. Assessing risk to young people from peers. Clarity about expectations on obtaining family history and the history of agency involvement in new Child and Family Assessments. The importance of school records transferring and that children are not ‘off-rolled’ without a new education placement or the relevant local authority being informed.   Executive SummaryCarl was 16 when he was fatally stabbed. At the time he and his family were in receipt of services from various local children’s agencies and he and his brother were subjects of a Child Protection Plan.It was agreed to undertake a Child Safeguarding Practice review to learn from the ways in which agencies had sought to work with Carl, his Mother and younger brother, Max.A key feature learned was that the family had been experiencing homelessness, eviction and unsuitable housing for some time. This had impacted on them and had led to no schooling for two years. The forced house moves also meant that the family moved at times with short notice across borough boundaries, breaking links with services which were trying to support them.As Carl moved further into adolescence, he became more involved in criminal activities and was thought to be on the edge of possible gang activities though there was no explicit evidence that he was a member of a gang. There was however a suggestion of possible risk to him as a result of “postcode” issues and rivalries between young people from different areas.   RecommendationsThe recommendations below have been accepted by the Croydon and Wandsworth Safeguarding Children Partnerships and an action plan has been put in place to implement them.1.1  To promote a more collaborative approach when working with homeless families, Local Safeguarding Children Partnerships should ensure that their guidance, best practice, and training around multi agency safeguarding meetings involves relevant local Housing services.1.2  To promote and support best practice between the Local Authority Housing Services, local larger scale independent housing providers and Children’s Social Care, Croydon and Wandsworth Safeguarding Children Partnerships should review relevant protocols to ensure effective joint working. This is with particular relevance to families where housing issues are identified as an additional need or are integral to children’s protection. The protocols should clearly outline each agency’s role and responsibilities for homeless families where the children are identified as children in need. Where possible, moving homeless families away from the local authority area where they are settled with schools and other services should be avoided, except where it is for additional protection. NB this work has already commenced in Wandsworth as a result of a previous multi agency review.1.3  As a result of learning from this review and similar multi agency reviews where a family’s housing situation has been noted to be challenging and to impact on the child’s welfare, Croydon Safeguarding Children Partnership should raise this matter with the National Child Safeguarding Review Panel. This may be an area which should be considered nationally as well as locally. Alternatively, or additionally the NSPCC could be advised and asked to consider undertaking a thematic review of case reviews where housing deficiency has been an important dynamic in the multi-agency support system.1.4  In the redesign of services, Croydon Council and partners should build on the positive work already achieved to maintain the relationship-based approach for adolescents throughout the partnership.1.5  Croydon Safeguarding Children Partnership to collaborate with Croydon Council and all partners (statutory and voluntary) to review the early help strategy to ensure that it captures the issues and challenges raised in this review that are likely to emerge in adolescence. Specifically, this should include,   Parental substance misuse   Young children with poor school attendance   Young children displaying challenging behaviour in school   Children with unaddressed speech and language difficulties1.6  Wandsworth Children Partnerships should review their practice to ensure that where risk factors include serious youth violence in the community, there is a robust multi agency response which prioritises young people’s safety. This includes risk arising from peers.1.7  Wandsworth and Croydon Children Partnerships should review their current practice and guidance in relation to expectations for accessing historical information. If necessary, both Partnerships should develop clear guidance about how practitioners will be supported to carry this out and in what circumstances it is necessary.1.8  It is essential when children move schools that school records transfer with them so that all professionals are aware of education history and needs. Before taking children off roll, schools should confirm that there is another suitable education provision in place. If schools are unable to ascertain this, it is essential that they contact the Local Authority where the children reside. Croydon and Wandsworth’s education services should review their practice regarding this and provide assurances to their respective Safeguarding Children Partnerships that they are compliant with government guidance and regulations.1.9  The findings from this review should be shared with Croydon Safeguarding Adults Board. All member agencies to provide assurances that their staff understand their safeguarding responsibilities towards children and the need for communication and collaboration when dealing with adults with complex needs who are also parents.1.10  Wandsworth and Croydon Children Partnerships should seek assurance through audit (or other Quality Assurance means) that current approaches to assessment routinely consider and take sufficient account of a family’s longer term history and any issues arising from neurodiversity, particularly where they are long gaps in children’s education.1.11  Findings from this review to be presented to all relevant Safeguarding Children Partnerships where the family resided to ensure that the learning is embedded.The full review is available on consideration of a request via CSCP@croydon.gov.ukJane DohertyIndependent Social Work ConsultantMarch 2022