Child sexual exploitation and neglect of an adolescent girl. An incident of rape and sexual abuse of a 15-year-old girl by teenage males in February 2019 involved other children as victims, perpetrators or witnesses. Review focuses on one child, BR19. Criminal proceedings ongoing at the time of the review; BR19 and her sibling have been taken into care. Maternal history of Adverse Childhood Experiences (ACEs) including sexual exploitation; being in care; and domestic abuse. Mother had BR19 as a teenager; was imprisoned when BR19 was young. BR19 lived with Father until aged 10-years-old, when she returned to Mother. Both BR19 and her sibling were made subject to Child Protection Plan in 2013 for neglect. BR19 was not in school throughout most of an 18-month period; concerns expressed by Mother of possible child sexual exploitation (CSE) of BR19; became subject to a Child Protection Plan in September 2017 and 2019 due to ongoing concerns around CSE and Mother's ability to protect BR19. Ethnicity or nationality of family not stated. Learning includes: multi-agency planning and analysis of risk; impact of CSE and services for survivors of CSE who are parents; parental engagement and consent; professional challenge and escalation; professional curiosity of the child's lived experience; contextual safeguarding and perception of sexual activity between teenagers being consensual. Identifies good practice from professionals. Recommendations include: strengthening multiagency decision making and practice in relation to child protection processes; understanding and responding to the link between adolescent neglect, CSE and contextual safeguarding; understanding the impact of traumatic adverse life experiences on parenting through partnership assessments.
      
    Serious Case Review No:  2020/C8549  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.    Classification: OFFICIAL SENSITIVE  1  Classification: OFFICIAL-SENSITIVE            Serious Case Review BR19      REVIEW REPORT   Independent Reviewer: Alex Walters     This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with Local Area 1 Safeguarding Children Partnership prior to publication.           Classification: OFFICIAL SENSITIVE  2  Classification: OFFICIAL-SENSITIVE     CONTENTS Item Page  Introduction    3  Process for conducting the review   4  Family Structure and views   5  Relevant background information prior to the timeframe under review and brief summary of engagement   6-9  Involvement of agencies in SCR time frame and single agency learning  9-15   Findings & analysis  - The quality & effectiveness of information sharing and risk assessment - Impact of CSE and services for survivors of CSE - Parental engagement and consent  - Professional challenge and escalation - Professional curiosity of the child’s lived experience - Contextual safeguarding     15-20 Effective Practice   Recommendations  20    21-22        Classification: OFFICIAL SENSITIVE  3  Classification: OFFICIAL-SENSITIVE  1  Introduction 1.1 Local Area 1 Safeguarding Children Board (LSCB) commissioned a Serious Case Review (SCR) following a decision by the LSCB Chair that the circumstances met the statutory criteria for an SCR because a child had suffered serious harm as the result of abuse or neglect.  1.2 Local Authority 1 notified the Department for Education (DfE) of a serious safeguarding incident in February 2019, which related to the rape and sexual abuse of a 15-year-old girl by other teenage males. There were a number of other children who were involved as either, victims, perpetrators or witnesses. However, facilitated by the LSCB the key agencies undertook a Rapid Review process as required by Working Together 2018, which specifically focused on the child subject to this review, BR19. The Rapid Review requires all agencies to undertake a review of their records and to submit a timeline, analysis and summary of agency involvement.  1.3 The Rapid Review Report was submitted to the national Child Safeguarding Practice Review Panel in March 2019.  There was subsequent agreement between the Independent Chair and the National Panel that the criteria had been met in relation to BR19 and a Serious Case Review was commissioned on 01/05/2019.  It was recognised that the review could indicate, if appropriate, any areas for future exploration and learning relating to the circumstances of other young people involved in the case.    1.4 BR19 and Sibling 1 are subject to current care proceedings. Criminal investigations are still ongoing and there have been no charging decisions made. This review has been undertaken in a proportionate way to ensure the key learning is identified to support improvements in practice. It is, therefore, deliberately not detailed but provides a summary of the family circumstances and key agencies’ engagement with the family.  1.5 The purpose of a SCR, as confirmed in the current statutory guidance, Working Together to safeguard children 2018: Chapter 4 is clear that the focus is on learning, not holding individuals or agencies to account.  1.6 Much work has been undertaken by the Local Area 1 to improve the partnership response to child sexual exploitation (CSE) and this has been recognised by subsequent statutory inspections. This SCR report will seek to offer consideration around whether  improvements in services were reflected with this families’ experience.   Classification: OFFICIAL SENSITIVE  4  Classification: OFFICIAL-SENSITIVE  2  Process for conducting the SCR 2.1 The LSCB recognised the criteria for undertaking a SCR was met and there was potential to learn lessons from this review regarding the way that agencies work together in Local Area 1 to safeguard children.  2.2 An SCR Panel was established and met in May 2019 to discuss the Rapid Review and scope the Terms of Reference (TOR).  This was attended by the Independent Reviewer Alex Walters. Alex is an independent safeguarding consultant, experienced Local Safeguarding Children Board and SCR Panel chair and SCR author, fully independent of the LSCB and its partner agencies. 2.3 An Agency Report Authors briefing was held in June 2019 with the Independent Reviewer to discuss the scope and TOR in detail. Agency reports provided agencies with the opportunity to consider and analyse their practice and identify any systemic issues. They provide details of the learning from the case within their agency, but also allowed agencies the opportunity to reflect on actions and make recommendations for improving practice within their own services. Information reports were requested from agencies where there was less involvement. 2.4 Agency reports were submitted from 9 organisations/functions from Area 1. In addition, background information reports were provided from Local Area 3 and Local Area 2 Local Authorities, Probation and Health services and Local Area 1 Clinical Commissioning Group (CCG) for the GP service. 2.5 The Authors of the agency reports and the SCR Panel then all met together in July 2019 to discuss their reports, identify the learning, areas of effective practice and identify any further information required. Further information and clarification was subsequently sought by the Independent Reviewer through follow up e-mail exchange.  It was agreed that the timeframe under review would be from 1 February 2017-January 2019. Relevant information prior to these dates was also considered, particularly historical involvement with the family. 2.6 A central component of the SCR process is understanding the perspective of front-line practitioners and the opportunities and challenges about the 'system' within which they work to analyse why incidents occurred and the contributory factors rather than just what occurred. A key element of the methodology, which underpins this review, was therefore the learning event for front line practitioners. There were some limitations as some front-line staff had left, but their managers contributed instead. Th Event was held in September 2019 and involved 11 practitioners or team managers from:  - Local Authority 1 Children’s Social Care including the Specialist CSE Team;  - Early Help multi-systemic therapy service;   Classification: OFFICIAL SENSITIVE  5  Classification: OFFICIAL-SENSITIVE - School nursing and CSE specialist nurse;  - the local Secondary School; - ISVA service.   Practitioners considered key themes identified by the Independent Reviewer, and the perspectives and opinions of all those practitioners involved at the time were discussed at the event and have significantly informed this SCR report.   2.7 The contribution of family members is an important part of the review.  It was agreed that Father, Mother and BR19 would be informed of the SCR process and invited to participate. A letter was drafted and with the support of the social worker this was delivered to Mother by the Local Area 1 LSCB Business Manager and to BR19 following liaison with her key workers in her residential placement. Father and Paternal Grandmother were also advised by the social worker of the SCR but did not wish to contribute to the SCR. The Independent Reviewer has, however, been able to meet with both BR19 with the support of her residential key worker and with her Mother and their views were most helpful and highly valued by the reviewer in identifying improvements and are incorporated into the review and its recommendations.   3 Family Structure and views 3.1 The relevant family members in this review are:  Family member To be known as: Subject child  BR19 father to subject child  Father  mother to subject child  Mother  sibling 1 to subject child Sibling 1  3.2 The independent reviewer met with BR19 in her residential placement. BR19 was supported by her keyworker who then helpfully undertook some follow-up discussion the following day with BR19, which she agreed to share with the independent reviewer. BR19 is clearly thriving in her placement.  She described feeling scared throughout that period of time under review and wanted to speak to a professional but was worried that she would be judged. She wasn’t speaking to many family members and didn’t speak to her Mother feeling she would take out her anger on those involved.   Classification: OFFICIAL SENSITIVE  6  Classification: OFFICIAL-SENSITIVE 3.3 When BR19 was asked what might have helped her or her family she felt that if she had stayed living with dad, he would have been stricter with her and that might have helped. She recognised that she probably needed boundaries put in place from either family or professionals and that perhaps becoming Looked After earlier would have reduced her risk. She felt her mum wasn’t given enough support, particularly around domestic abuse and that there were lots of people involved with the family but a lack of consistency; particularly from social workers although she was positive about one professional who she felt she could trust. She reflected that she needed someone who she trusted to see her on a regular basis that she could have talked to and she has since experienced this. She also said she wished she’d had a part time timetable and phased introduction back into school after so long out of school as she felt that led to the education breakdown. 3.4  The Independent Reviewer also met with Mother at her home supported by her Independent Sexual Violence Adviser (ISVA). Mother held the view that overall her experience with statutory agencies historically had not been positive. She felt this had not changed over her involvement in the previous 6 years and meant she had no trust in practitioners.  She described providing the police with information about BR19 and the risky situations which she had found herself in which she felt had not been responded to. She also felt that social workers and police had been judgemental and felt that as a survivor of  sexual exploitation herself she was automatically seen as a bad parent and was blamed rather than helped.  She felt the steps she was trying to take to minimise risk for BR19 were not recognised and that she needed more practical parenting advice. She described situations where information about her daughter’s abuse had not been shared with her sensitively and felt a lack of consistent social worker had not been helpful in the understanding of her situation and the help she needed. She also felt that her attempts to complain resulted in a punitive response from local police. Mother was, however, positive about the Multi-Systemic Therapy (MST) service she’d received, the support of the ISVA service and the specific parenting support that she is receiving now in relation to BR19’s sibling.   4 Relevant background information prior to the timeframe under review  4.1  As a child, BR19’s Mother experienced a number of Adverse Childhood Experiences (ACEs) including sexual exploitation. Research regarding ACEs identifies the long-term impact of toxic stress on individuals who have suffered a number of ACEs including sexual exploitation, violence, abuse, separation, loss and neglect as a child. Mother also had BR19 at a young age and had herself  Classification: OFFICIAL SENSITIVE  7  Classification: OFFICIAL-SENSITIVE been a Looked After Child. The impact of her abuse and the need for support for survivors as parents has been highlighted.  4.2  Mother was imprisoned when BR19 was young and so BR19 lived with Father until aged 10 years and then returned to Mother. Mother had another child, Sibling 1 who lives with Mother. BR19 and Sibling 1 were made subject to a Child Protection Plan (CPP) in 2013 for neglect. 4.3  Mother has experienced domestic abuse from previous partners and was subject to a Multi-Agency Risk Assessment Conference (MARAC) process in March 2018. Mother was made subject to a 12 month Community Order in 2016 following conviction for an offence of common assault. 4.4 The family have had a number of moves, some to move away from perceived risk to BR19 and some due to Mother living in an environment/community where many of her abusers are still resident.  4.5 BR19 was not in school throughout most of an 18 month period when living outside Local Area 1. Local Area 3 Childrens Social Care Services became involved in September 2016 due to concerns expressed by Mother of possible CSE of BR19. BR 19 also received, at her request, contraceptive advice at age 13 in September 2016. 4.6 Local Area 1 Childrens Social Care Services became involved following referral by Local Area 3 Childrens Social Care Services on the families return to Local Area 1 in February 2017 and BR19 became subject to a CPP in September 2017 due to ongoing concerns around CSE and Mother’s ability to protect BR19.  4.7 BR19 was subsequently removed from a CPP in May 2018 following a period of involvement by the Multi-Systemic Therapy (MST) team for 2 months and the case remained open as a Child in Need (CIN). The case was closed to Children’s Social Care Services in September 2018 and subsequently reopened in November 2018 following concerns from the police around BR19 being seen at night in the local community and from the school around her behaviour and rumours around sexual activity involving BR19. 4.8 Father has maintained some contact with BR19 since the age of 10 but this has not been consistent.  4.9 Following the incidents of serious harm, BR19 became subject to a CPP in February 2019 and Childrens Social Care Services initiated care proceedings on BR19 and Sibling 1. BR19 is now subject to a Care Order and living in a residential placement. Sibling 1 is subject to a Supervision Order and remains at home with Mother.    Classification: OFFICIAL SENSITIVE  8  Classification: OFFICIAL-SENSITIVE 5  February 2017 – January 2019: Brief summary of engagement with agencies 5.1 Following the families return to Local Area 1 in February 2017, there was referral to and involvement with the Children’s Social Care Specialist Team (a multi-agency team with a specific remit for CSE) who worked with the family given the concerns around risk of CSE, which had been identified by Local Area 3 Childrens Social Care Services function. Following increased episodes of missing and an incident in July 2017 when BR19 was found by Mother in a local hotel room with older males, the case was appropriately escalated and an initial Child Protection Conference (CPC) was held in September 2017 with BR19 becoming subject to a Child Protection Plan (CPP) under both emotional and sexual abuse categories. Her sibling did not become subject to a CPP but remained an open case to Childrens Social Care Services as a Child in Need. The CPP for BR19 included a referral for a Family Group Conference (FGC) to identify family/community support for BR19 and her Mother as well as ongoing work with BR19 to keep herself safe and recognise risk. 5.2  A review Child Protection Conference was held  in December 2018 and the CP Plan had not progressed due to poor engagement from Mother, linked potentially to her own experiences of childhood sexual abuse, CSE and domestic abuse. BR19 had disengaged from her CP Advocate, there had been no engagement in the planned CSE sessions for six weeks and the Family Group Conference had not taken place. There was then a unanimous decision that a Child Protection Plan continued and that a Legal Gateway Planning Meeting (LGPM) is held to consider the instigation of care proceedings.   5.3  Significantly the case records reflect that the decision to progress to LGPM was reviewed by a Service Manager following the Child Protection Conference, with the outcome being to ensure there was progression to “Edge of Care Panel” and Family Group Conference before care proceedings were explored further.   5.4  The second review Child Protection Conference was held in May 2018 and there were five agencies in attendance. The CSE specialist team had ceased their involvement once the MST service began working with Mother, which was accepted practice. The conference heard from the MST worker about the programme, which started in April 2018 and Mother, is viewed as positively engaging and incidents having decreased with BR19. School reported attendance at 77% and engagement with the school counsellor, but that BR19 was lacking in confidence. Minutes of this meeting evidence that 3 out of the 5 agencies attended with the view that the CP Plan should continue. However, following further discussion and by a majority, the Child Protection Plan was ended in favour of a Child in Need plan.  5.5  The case continued as a Child in Need and was then closed to Childrens Social Care Services in September 2018. Further referrals were made by the School Nurse and the Police in November 2018 outlining continuing concerns that BR19  Classification: OFFICIAL SENSITIVE  9  Classification: OFFICIAL-SENSITIVE was going missing and from the school around information of sexual activity.  The case was reopened by Childrens Social Care Services and a single assessment undertaken which found that Mother did not accept ongoing risk of CSE and reported improvement in her relationship with BR19. The case was therefore due for closure but reopened following receipts of further concerns from school and Police in the week before Christmas 2018. There was further discussion at the multi-agency CSE Intelligence meeting in January 2019 and the school also reported further information received from students and evidence of the sexual abuse, which led to a Strategy Meeting held in January 2019 and a further complex strategy meeting also in January 2019.   6 Agency involvement and improvements identified through the agency report process: Local Authority 1 Children’s Social Care 6.1  Allocation in February 2017 to the specialist CSE team was appropriate and they undertook some effective work with the family and escalated the case appropriately to child protection. They then continued to co-work the case with the Locality Team once BR19 was made subject to a CPP in September 2017. However, the social workers faced continued challenges in engaging Mother and BR19 consistently although some of the safety planning work was carried out. There is evidence of good liaison between the two social work teams and then with the MST team and joint visits undertaken. The decision at Review CPC in May 2018 is interesting in that both the social worker and MST changed their view through this process and this is a wider learning issue around professional challenge as identified in this SCR.  6.2  The response by Childrens Social Care Services to the information of extensive bruising on BR19’s arm seen by the Specialist Team Nurse in September 2017 was followed up but did not lead to further examination by Childrens Social Care Services/Paediatrician because BR19 provided an explanation. This was a child where CSE was recognised as a real risk and BR19 was subject to CPP and Child Protection procedures should have been overtly followed.  6.3  Following case closure, the re-referral to Childrens Social Care Services in October 2018 was not allocated to the previous social work team which would have been accepted practice given the 12 week rule (case being re-referred within 12 weeks after closure returns to the original team). This was because the social worker had left Local Authority 1. However, it is now recognised that the Team Manager would have had historical knowledge and overview and this was a missed opportunity to ensure that Local Authority 1 effectively engaged the knowledge and experience they already had in working with this family to ensure the assessment of need and risk, in the context of her history, was better understood.  Classification: OFFICIAL SENSITIVE  10  Classification: OFFICIAL-SENSITIVE  6.4  The issue of the decision not to progress to a LGPM by Childrens Social Care Services which had been agreed at the December review CPC needs to be considered as it was replaced by a referral to the Edge of Care Panel and ultimately in a service from the MST team. This decision was not undertaken through the multi-agency CPC process and was a single agency decision. This is reflected in the Childrens Social Care Services agency report but there needs to be consideration of running processes concurrently rather than sequentially particularly when engagement is clearly limited. Whilst all options of support and assistance should be considered prior to entering the legal arena, there was significant history attached to the case and the family, which evidenced that previous interventions had not been successful in creating positive change for BR19. The poor engagement by Mother was a continuous concerning factor, though she did positively engage with the MST.  6.5  It is recognised by Childrens Social Care Services that the Screenings and Concerns analysis undertaken by a social worker in a different team within the First Response Service on re-referral in December 2018 was a helpful piece of analysis which demonstrated that “concerns had not lessened since 2016” for BR19.   Improvements identified: 6.6  Childrens Social Care Services have recognised a number of areas for improvement and there are recommendations to further develop the use of case mapping, further enhance the Signs of Safety and use of reflective supervision. Some of the recommendations are also picked up in the multi-agency overview recommendations around professional challenge and escalation, the review of the MST service and the need to further promote a Signs of Safety approach to wider partner agencies to support multi-agency assessment of risk.  Local Authority 1 Early Help services  6.7  The Initial Child Protection Conference (CPC) in September 2017 made recommendations that there should be a referral for a Family Group Conference (FGC) and in February 2018 a referral to the Edge of Care Panel resulted in referral for Multi-Systemic Therapy (MST). Both these services are line managed through the Early Help arm of the Children’s Services Directorate. In relation to the FGC the referral was made in September 2017 however FGC requested further information/clarity. This resulted in a delay to the revised referral of over 2 months and the case was allocated in December 2017, which was 11 weeks after the original referral. The family then didn’t engage, and the case was closed.      Classification: OFFICIAL SENSITIVE  11  Classification: OFFICIAL-SENSITIVE Improvements identified for FGC: 6.8  The FGC service have recognised the need to minimise drift and delay as an area for improvement and have identified a need for a protocol and measures to monitor timeframes.  6.9  The MST service did, however, engage with Mother following referral to the Edge of Care Panel in February 2018.  The referral was considered at the meeting on 6th March, where MST accepted the case.  An initial visit to the family was made on the 22nd March and the case became active on 9th April. As a result of concerns around possible firearms linked to domestic abuse, the work took place outside of the family home in community venues, which didn’t impact on Mother’s engagement.    Improvements identified for MST: 6.10  It is important to note that the learning from this case has led to a review of how MST works alongside the Social Worker, who retains overall responsibility for the family.  Part of the MST model is to provide interventions directly to the family, reducing the number of relationships the family needs to build.  However, there is evidence from this case that this practice model is not well understood across all of the workforce leading to other agencies feeling that they need to conclude their work with a family i.e. the CSE Specialist Team ceased their role. The learning from this case has triggered a need to ensure this service is understood by practitioners and also improvement noted to ensure that timeframes are monitored from referral to contact with the family.   Local Authority 1 Housing services  6.11  Mother was given priority housing in October 2016 by Local Authority 1 following concerns around BR19 and risk of exploitation in Local Area 3. Mother took up her tenancy in January 2017. Mother had a previous tenancy in Local Area 1, which had been problematic with complaints from neighbours. Between January 2017 and June 2018, the tenancy had the locks changed three times and there were issues with rent arrears. In January 2018 BR19 was issued with an Acceptable Behaviour Contract (ABC) and Mother with a tenancy warning letter due to anti-social behaviour (ASB) and this was increased to an injunction warning letter following another incident of ASB by BR19 in August 2018 and then a notice of possession in December 2018 for rent arrears.   Improvements identified: 6.12  There have been a number of areas for improvement identified by the service, primarily in relation to communication between the different housing functions and the need to share information proactively with other agencies or refer for early help and support. This lack of information sharing was further undermined as Housing was not routinely invited to CPCs and was, therefore, not asked to share  Classification: OFFICIAL SENSITIVE  12  Classification: OFFICIAL-SENSITIVE information. There is a clear need to ensure that Housing Services are formally invited to all CPCs if the family is known to any of their functions.    Local County Police   6.13  The Police had a number of contacts with the family over the time period under review. They were having contact with BR19 as a victim and a potential perpetrator of criminal activity. There were a number of missing episodes for BR19 which were all responded to and some allegations of threatening behaviour verbally, on social media; anti-social behaviour in the community; and another instance where BR19 was damaging the house.   6.14  On some occasions the Police did not automatically inform Childrens Social Care Services through their Gen 117 referral process and not all neighbourhood information/intelligence was shared within Local County Police itself. This was linked to neighbourhood police not always sharing information and intelligence with other areas of Local County Police or Childrens Social Care Services. This created a further missed opportunity to understand the broader context around BR19 and her friendship group, but this picture was not always well understood across the different elements of the police themselves; or effectively communicated and understood by agencies involved.  Improvements identified: 6.15  Local County Police have identified two areas of improvement, which related to strengthening the systems of communication and ensuring engagement in CPP processes/conferences and reviews. These areas are further explored in their report and highlight a desire to strengthen relationships with partners locally and nationally.   The Local Area 1 NHS Hospital Trust - provider of acute hospital and community services  6.16  Involvement with the family was through the CSE Nurse within the specialist multi-agency CSE team and the School/Specialist Community Public Health Nurse who saw BR19 whilst at school. The CSE Nurse became involved in March 2017 for a period of 8 months and offered a holistic health assessment and sexual health work. Improvements identified:  6.17  In terms of improvement areas, local Area 1 NHS hospital trust have recognised that there were internal issues in relation to compliance with policies on photographic information - the school nurse had photographed the bruising on  Classification: OFFICIAL SENSITIVE  13  Classification: OFFICIAL-SENSITIVE BR19’s arm. They also recognised the breadth of the caseload for the Specialist Community Public Health Nurse and are piloting a scheme to prioritise the focus of work on those children who are Looked After or subject to CP or CIN processes.   The local Secondary school 6.18  BR19 joined the secondary school on 23/03/2018 after a lengthy period of time out of education before the family returned to Local Area 1. The school clearly were highly involved with responding to BR19’s behaviour, missing episodes and ensuring all information and concerns were shared and undertook many home visits. Despite being unable to contact Mother on numerous occasions school staff were proactive in their efforts to ensure BR19 was safe and well.  Improvements identified: 6.19  The school have recognised three areas of improvement. Firstly, to ensure that at the point of admission all background information and contact with agencies involved with the family is undertaken to ensure the right level of support is provided from the beginning. Secondly, to instigate a new starter curriculum to phase return to education and, finally, to review the sanctions and rewards policy and exclusion policy to ensure exclusion is used as a last resort following appropriate risk assessment and doesn’t lead to an increase in risk.   Local Area 1, Local Area 4 and Local Area 5 NHS Trust – provider of adult and children’s mental health services  6.20  The Independent Sexual Violence Advocate (ISVA) referred Mother to adult mental health services in June 2017 but Mother did not attend her appointment and was discharged from the service. In September 2017 a further referral was made by the ISVA, which required additional information, which was received in December 2017.  Mother then missed two appointments and she was discharged from the service. The ISVA referred again in July 2018 and Mother was seen and assessed in August 2018 by the Access team who referred on to the Community Therapy team who attempted to contact Mother in October 2018. Mother then failed to attend an appointment offered to her in early 2019 and was then referred to and put on a waiting list for counselling. Mother has since moved to another area and was referred to their local adult mental health service but by December 2019 was still awaiting her assessment.   6.21  The CSE Specialist team discussed concerns around BR19 with the Child & Adolescent Mental Health services (CAMHs) function in July 2017, but it was felt that BR19’s issues didn’t meet the criteria for a direct relationship with CAMHs. Concerns were also expressed by the school in May 2018 to the CAMHs Locality  Classification: OFFICIAL SENSITIVE  14  Classification: OFFICIAL-SENSITIVE practitioner but again it was agreed that BR19 did not require a direct input from CAMHs.    Improvements identified: 6.22  The service has identified areas for improvement around the mode of communication with adults needing to be more flexible and the consideration of non-engagement on parenting capacity. There is also a new service now – the CSE pathway for CAMHs.  This includes internal support within CAMHS to improve access and highlight the needs of any current child victims of CSE including through CAMHS locality practitioner’s, although consultations direct to schools can be accessed, and a pathway from the social care specialist CSE service into CAMHs has more recently been staffed to include joint assessments as well as consultation. The CAMHs service now also includes work around the children of those who were subjected to historical adverse childhood experiences within CAMHS. At this time of the SCR the service was in its infancy, however, consultation was sought and provided in line with the CSE pathway. The service recognises the impact of adverse childhood experiences /mental health dichotomy and supports children who fall between the two. Awareness needs to now be widely promoted and the service is subject to evaluation.     Local Area 2 Sexual Abuse and Rape Crisis service (providing ISVA)  6.23  The ISVA service became involved with Mother in August 2016 following a referral from a family member and has remained involved from that point. There have been three ISVA workers and contact with Mother has been sustained throughout albeit not always consistently. The ISVA has attended all 3 CP Conferences to support and advocate for Mother but had not been involved in the decision making process. There was effective liaison with local agencies, which included the ISVA facilitating joint visits with social workers and visits to introduce new social workers. There is an issue for the independent reviewer around the role of providers of advocacy services to parents and their role in the child protection process, which needs to be explored as a recommendation.         GP services  6.24  BR19 registered with a GP practice in April 2017 but was not seen. The GP was not informed/ invited to the initial strategy meeting in June 2017 or August 2017 or the CIN meetings and there is a different perspective on whether they were invited to the Initial CPC in September 2017. However, it is clear they are not routinely informed/ invited to review CPCs in December 2017 or May 2018 or the Multi Agency Risk Assessment Conference (MARAC) in March 2018.  There was also no contact by any other professional with the GP.    Classification: OFFICIAL SENSITIVE  15  Classification: OFFICIAL-SENSITIVE 6.25  The named GP has helpfully written to all practices to remind them of their responsibilities and to support their engagement in CP processes. However, there is clearly an issue of the system needing Children’s Social Care Services to ensure contact is made with GPs but also of the health sector and the LSCP to then support and monitor engagement of GPs in key child protection processes.   Background information provided from Local Area 3 Childrens Social Care Services/Children missing education 6.26  Local Area 2 Sexual Abuse and Rape Crisis Service referred BR19 to the Local Area 3 Childrens Social Care Services Sexual Exploitation Service in 2016 and an assessment undertaken which recognised there was evidence of BR19 associating with groups of young males and gifts of cigarettes, cannabis and alcohol. The risk was aggravated by her not being in school, the impact on her developmental needs and the amount of time available to seek relationships with those who gave her attention. The case then transferred to Local Area 1.  6.27  BR19 and Sibling 1 had first contact in May 2016 with education services and despite attempts due to Mother and BR19 missing a meeting and the local secondary school not allocating a place until a further meeting, BR19 did not actually attend school until her return to Local Area 1 in February 2017. The fact of non-school attendance and the additional risks that presented for BR19 does not appear to have been prioritised.  Background information from Local County Community Rehabilitation Company 6.28  Mother was subject to a 12 month Community Order in 2016.  There was little work undertaken with Mother during the year and a number of failed appointments and no contact for the last 2 months of the order. Probation were, however, aware of and involved with agencies in Local Area 3 in relation to BR19.   7 FINDINGS and ANALYSIS 7.1  As with any review, the process of reflection has identified some areas where the current systems and processes could be improved. All the agencies involved with BR19 and her family have identified their own learning and have captured a number of single agency improvements identified in this report and recommendations into action plans. The themes identified below set out additional learning identified by the Independent Reviewer and have resulted in fifteen recommendations.     Classification: OFFICIAL SENSITIVE  16  Classification: OFFICIAL-SENSITIVE Theme One - Multi-agency planning and analysis of risk 7.2  The Child Protection Conferences (CPCs) were initiated appropriately in response to recognition of risk but were not as effective in terms of their information sharing as key agencies were absent from the process which impacted on the quality of information shared and the analysis of ongoing risk to BR19. 7.3  All three CPCs were not attended by the GP, the Police or Housing services. This has highlighted a failure of the system whereby GPs are meant to be informed/ invited to Initial CPCs. In this case there is nothing to evidence that this took place. The Police were invited but were unable to attend the Initial CPC due to resourcing issues although they did provide a report and they are not routinely invited to review CPCs. Housing services had had involvement with the family through their Housing support, Housing allocations and ASB functions but are not routinely invited. (Recommendations 1 and 2) 7.4  Additionally, it would appear that Mother had been referred to a MARAC conference by her ISVA in March 2018 which took place in April 2018 as she had disclosed two incidences of domestic abuse from her previous partner - one which had occurred in November 2017 and one in March 2018 at which the children were present.  The outcome was a target hardening of the property and a restraining order.  However, although attended by a representative from Childrens Social Care Services and the Childrens Social Care Services IT system being updated this information was not fed into the CPC in May by any agency and did not, therefore, impact on the multi-agency assessment of risk. Practitioners felt it was important to ensure that all agencies take responsibility for sharing information into the CP process and not assume this is just for the Childrens Social Care Services practitioner in their lead role. (Recommendations 4, 6) 7.5  However, the MARAC did trigger an Initial CPC in relation to Sibling 1 which was held in April 2018.  The outcome of this conference was not to make Sibling 1 subject to a CPP but to remain as a Child in Need and essentially reflected positive reports from the school and the strong relationship between Mother and Sibling 1.  This information also did not formally feed into the CPC process for BR19. 7.6  Through the SCR process it has become clear that when additional law enforcement agencies are involved working alongside local police with a parent who is a CSE survivor their interface and role within formal child protection planning is not clear. Are they there as an agency to provide information to inform the analysis of risk to a child in strategy meetings, CP conferences and engage in the process of agreeing if the CPP threshold has been met, or are they providing basic information only? Additionally, practitioners identified that their agency recording is influenced by perceived restrictions from law enforcement agencies on confidentiality. Both these issues need to be addressed by all the  Classification: OFFICIAL SENSITIVE  17  Classification: OFFICIAL-SENSITIVE strategic safeguarding partners and a protocol agreed to ensure that agency roles are clear and the system of the protection of children is not undermined. (Recommendation 7) 7.7  It has also become clear through the SCR Process that the role of the ISVA is crucial to support the parent and often they have the strongest relationship with the parent but their advocacy role within the child protection process needs clarification. (Recommendation 7) 7.8  The CSE intelligence sharing meeting took place in January 2019 and was helpful in sharing information and identifying the potential risks. It is chaired by the Police, held weekly and involves the Police, NCA, Specialist Childrens Social Care Services team and Licensing. Practitioners at their event identified that schools were not represented at these meetings and should be aware of their existence and how they could share information into these meetings. (Recommendation 12) 7.9  An issue highlighted through the practitioners’ event related to the use of complex strategy meetings where there were a number of children involved and the need to ensure S.47 enquiries and assessments are undertaken on all the children. 7.10  The issue of minutes not being received from CPCs in a timely manner needs to be addressed by Childrens Social Care Services and escalated appropriately by other agencies. Work has been undertaken by LSCP around timescales to ensure there is a clear partnership expectation and understanding around plans and minutes being shared but this needs to be monitored.     Theme Two - Impact of CSE and Services for survivors of CSE who are parents 7.11  Mother was both a survivor of familial child sexual abuse, which led to her removal from home at the age of 10 and of child sexual exploitation once she became a Looked After Child. These adverse childhood experiences of trauma, abuse, separation and loss as well as being a young teenager at the time of BR19’s birth resulted in a profound feeling of having been let down, to be distrustful of statutory agencies which resulted in her significant lack of engagement at times with school, social workers and the police. However, she did engage positively with the MST service, which she clearly found helpful in supporting her parenting of BR19 and focused on her needs. However, this is not a therapeutic counselling service and it is clear that a timely targeted service would have been helpful to Mother. She was referred by her ISVA twice to Adult Mental Health Services and although she mainly didn’t engage, she was seen on one occasion by a triage service and her need recognised. She was referred on to the specialist service however, this resulted in a 4 month gap by which time she didn’t engage again.  There were concerns that despite agencies  Classification: OFFICIAL SENSITIVE  18  Classification: OFFICIAL-SENSITIVE understanding the adverse life experiences mum had experienced and the emotional impact this continued to have on her, there was a lack of focus, other than from the ISVA service, around supporting her to access mental health support.  7.12  There was already in existence a local service to support adult victims of CSE who could not easily access therapeutic services.  This service now offers a multi-agency hub which both receives referrals and offers a wraparound service to both CSE survivor’s as individuals and as parents and their children. It offers consultation and supported access to mental health services, specialist counselling, trauma stabilisation interventions and focussed support provided by the third sector. The Service works closely with CAMHs and supports practitioners to take a family-based approach within the context of the criminal justice system.  The SCR process heard from practitioners about the potential barriers to accessing services and that access to therapeutic services could potentially impact on the evidence provided to court. This service is helping overcome these barriers. There is a need for survivors to access their therapeutic support at the right time for them and to support their parenting capacity. Practitioners were clear that there is a need for this for the survivors of CSE, particularly those who are parents. There are many parents who are survivors whose children will be subject to Child Protection Plans and this support is important so that they have the best opportunity to parent their children successfully.  (Recommendation 13)  7.13  The Child Protection Plan for BR19 also did not include an action for direct referral/access for Mother to the right form of therapeutic therapy and this should be an explicit part of the CPP.     Theme Three - Parental engagement and consent 7.14  Throughout the period under review and historically there is continued evidence of a lack of engagement with professionals by Mother and also by BR19. Although the reasons for this are understood there is an issue about how ongoing lack of engagement and the impact of this on thresholds for intervention are responded to by professionals. This must be considered as an additional risk measure in its own right especially when considering the complex issue of adolescent neglect and the risk of CSE. (Recommendation 11)  7.15  With hindsight there was probably sufficient evidence of concern to have moved into the LGPM arena earlier and for some of the interventions to be driven/ supported by the care proceedings which could have provided the boundaries. BR19 recognised that might have helped her and might also have been helpful to Mother. The Signs of Safety framework and the emphasis on safety planning  Classification: OFFICIAL SENSITIVE  19  Classification: OFFICIAL-SENSITIVE may have been helpful but Mother required help to understand how to parent her daughter and some specific focus on that was missing, although met to some extent by the MST service. This should have continued past the end of the programme and there is a question around sustaining that intervention which will be considered as part of the planned review. (Recommendation 8, 9 and 15)  Theme Four - Professional challenge and escalation  7.16  The decision at the May 2018 CPC to remove BR19 from the CPP was overly optimistic. The impact of the MST work with Mother and on her relationship with BR19 was significant but had not been completed and the evidenced progress had not been sustained. Given the known history of the family, the fragility of the relationship between Mother and daughter, the sporadic engagement with agencies by Mother and BR19 and ongoing risk of CSE to BR19 the expectation that de-escalation to a Child in Need plan would address those risks was unrealistic. In addition, key additional information on risk was not fed into the CPC from the MARAC process and Sibling 1’s initial CPP and key partners were absent. The agencies represented at the CPC were divided in their view and ultimately two agencies changed their view to agree to the cessation of the CPP. Having seen the conference minutes, it is also clear that there was no evidenced record of progress against the Child Protection Plan and no discussion on why the recommended LGPM had not been held. (Recommendation 3) 7.17  The school noted that they felt the decision was inevitable although they clearly had ongoing concerns. However, in discussion at the practitioner’s event no agency felt that the Child Protection Conference was unequal/unbalanced but recognised that all practitioners need to feel empowered to challenge views and decisions. (Recommendation 5)  Theme Five - Professional curiosity of the child’s lived experience 7.18  Throughout the SCR process, agencies themselves have recognised occasions when they could have been more professionally curious about the lived experience of BR19 and asked more questions rather than simply responding to the presenting issue. She had many adverse childhood experiences including separation from her Mother; she spent much time out of school which will have impacted on her development alongside a poor and at times violent relationship with her Mother, domestic abuse and potential substance misuse. There were numerous instances of when professionals tried and failed to engage with BR19 or her Mother. It is important for professionals to try to understand and consider the lived experience of the child on a day to day basis in terms of the support and attention received which may increase their vulnerability to exploitation and  Classification: OFFICIAL SENSITIVE  20  Classification: OFFICIAL-SENSITIVE experience of harm and the impact of non-engagement by both the parent and the child themselves on their risk of abuse/neglect. 7.19  In this case there needed to be more active consideration of adolescent neglect as an overt feature as opposed to apparent acceptance that the main risk related to the external environment. Mother was at times unable to ensure BR19 attended GP and dental appointments which clearly meant that BR19 was not accessing services to meet her health needs and not able to maintain boundaries to ensure BR19 responded more to the “pull” of home. (Recommendation 10)    Theme six - Contextual safeguarding and perception of sexual activity between teenagers being consensual 7.20  This was an issue when BR19 at the age of 13 visited a Sexual Health clinic in Local Area 3 and was given contraception to prevent pregnancy. She said she had one episode of unprotected sex with her teenage boyfriend.  The SCR was assured that this would now result in a different pro-active response by sexual health services in Local Area 3 which was initiated in April 2017, which includes a formal review of all 13 year olds, but this process took place in 2015.  7.21  The second issue relates to the timeframe from November 2018 to January 2019 with the school raising concerns and sharing information with both the Police and Childrens Social Care Services they had received from other children of both genders engaging in sexual activity in the local park.  Mother and BR19 denied any involvement. The response from statutory agencies and the Police particularly - i.e. the Childrens & Young Persons Officers (CYPO) was this was normal teenage activity and there appeared no consideration of coercion or exploitation. The position changed over the next few weeks as the main evidence of abuse was then accessed and the specialist Protecting Vulnerable People (PVP) function of the Police became involved. (Recommendation 10)  8  Effective practices that had a positive impact on BR19  8.1 The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered effective and supports good outcomes for children. Good practice from professionals has been acknowledged and this includes, • Transfer of information from Local Area 3 Childrens Social Care Services to Local Area 1 Childrens Social Care Services and allocation to the Specialist Team • Effective intervention from the CSE specialist team  Classification: OFFICIAL SENSITIVE  21  Classification: OFFICIAL-SENSITIVE • Effective intervention from the ISVA service including facilitating introductory and joint visits with Childrens Social Care Services and referrals to mental health and MARAC.  • Effective multi-agency recognition of risk at initial CPC • Both the MST and the ISVA services ensured continuity of service when practitioners were off work. • Joint visit between MST practitioner and case holding social worker. • The provision of MST to Mother was helpful in addressing her concerns and supported her parenting of BR19 and appeared an effective intervention. • The proactive response of the local secondary school. • The multi-agency response from January 2019, which was felt to be robust and cohesive.  9 Recommendations 9.1  The Review concludes with recommendations to the newly created Local Area 1 Safeguarding Children Partnership (LSCP), which build on the recommendations and actions already identified for learning by single agencies during the process of researching their involvement in this case. In a number of cases, actions have already been taken to improve arrangements/systems.  9.2 The following additional  actions are provided under overall themes to ensure that LSCP and its partner agencies are confident that any other areas are addressed and that the LSCP is able to monitor progress. Theme A - Strengthening multiagency decision making and practice in relation to child protection processes   1 LSCP to agree that routine invitations to CPCs are undertaken in all cases to GPs and any known to Housing service. LSCP to request Local County Police and GPs ensure that if they don’t attend Review CPPs that they provide a report with updated information.  2 LSCP to request regular reports/undertake audits to monitor the engagement of key agencies in the CP process including attendance/provision of reports. 3 Local Authority 1 to ensure Child Protection Conference chairs ensure Review Conferences evidence progress against the action plan before removal from a CPP and that this is included in the LSCP audit programme. 4 LSCP to request Local Authority 1 and Local County Police review and consider the effectiveness of information sharing between the two processes of MARAC and Child Protection when there are children involved with Childrens Social Care Services.  Classification: OFFICIAL SENSITIVE  22  Classification: OFFICIAL-SENSITIVE 5 LSCP continue to promote and support professional challenge and escalation by practitioners through the escalation protocol and deliver specific training on developing professional curiosity of the child’s lived experience. 6 LSCP ensures training on understanding multi-agency practitioner’s roles and responsibilities in child protection processes is embedded in core safeguarding training. 7 LSCP to request services including commissioners of ISVA services and policing work with Local Authority 1 to develop protocols, which clarifies issues around their role in the Child Protection process and information sharing. 8 LSCP considers the wider roll out of training on Signs of Safety to multi-agency front line practitioners. 9 LSCP to request Local Authority 1 report on their review/evaluation of the MST service and how it interfaces most effectively with other Childrens Social Care Services functions. Theme B - Understanding and responding to the link between adolescent neglect, CSE and contextual safeguarding  10 LSCP continue to promote awareness and understanding of contextual safeguarding and adolescent neglect to all practitioners, particularly police colleagues, and consider the most effective interventions. 11 LSCP to consider providing specific multi-agency training around issues of parental and child non engagement with services and the impact on safety planning. 12 Local authority1 to ensure the dissemination and awareness raising with all schools of the process to share information in the CSE intelligence sharing meetings. Theme C - Understanding the impact of traumatic adverse life experiences on parenting through partnership assessments  13 LSCP acknowledges that the support service for adult victims of CSE is evaluated annually, this evaluation is reported to the partnership, the commissioners and regulators. This should continue with a view to identifying and addressing any barriers to timely access to therapeutic support for survivors of CSE.  14 LSCP to deliver training on the impact of CSA and CSE on parenting capacity as part of its core delivery offer.  Alex Walters  11/8/2020 