Sexual abuse of several children over a period of time. The perpetrator was found guilty of numerous offences of child sexual abuse against known and unknown children and given a sentence of life imprisonment with a minimum term of 25 years in prison. Learning includes: think the unthinkable and maintain professional curiosity in work with children and families; reflect on cases to fully explore and understand what is happening within a family rather than make assumptions or accept the situation that is being presented. Identifies a number of strengths in multi-agency responses where the children were already known to services, including good record keeping, information sharing and communication; and evidence of children's voices being sought and listened to. Makes no recommendations but the learning has been embedded in the local safeguarding children partnership child sexual abuse strategy.
      
    Serious Case Review No: 2022/C9337  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.      Case H Local Child Safeguarding Practice Review (LCSPR)      Page 1 of 2  Case Summary A Local Child Safeguarding Practice Review (LCSPR) was commissioned to consider a case where several children had been sexually abused over a period of time. The Perpetrator was resident in the same area as the children. Following a police investigation and examination of extensive evidence, the perpetrator was found guilty of numerous offences of child sexual abuse against known and unknown children and given a sentence of life imprisonment with a minimum term of 25 years in prison.  There were a number of identified strengths in multi-agency responses where the children were already known to services: • Good record keeping and information sharing between agencies was in evidence. • Good general communication between agencies and no identified barriers.  • Evidence of children’s voices were in general being sought and listened to. • Evidence of CAMHS, non-statutory counselling services and school raising and reporting safeguarding concerns appropriately.  The reviewer found that no agency either separately or together made any judgements or actions in this case that would generate recommendations for action, and the multi-agency panel were unanimous in agreeing with this finding. Individual practice decisions were carefully considered and, in some cases, questioned as part of the review, however there were no indicators of systems failures and there were no deficits in multi-agency working which might otherwise have exposed the abuse. When any sequence of events is forensically examined, areas of deficit in best practice will be found. The agencies where improvements in practice were identified had already recognised and addressed them.  The Police recognised a need to review their responses when attending domestic incidents to remain open to possible child safeguarding issues and action has been taken to bring about changes which have been reviewed in subsequent inspections of the service.  Social Care recognised that staff must maintain professional curiosity, to contextualise information received with prior knowledge, and be prepared to think the unthinkable. Reflections on cases reviewed across the country as well as the briefing on the theme of Child Sexual Abuse held on the NSPCC website will be incorporated into the existing local safeguarding training offer and reflected in the local SCP Child Sexual Abuse Strategy. Training is already in development to support procedures including reminders for practitioners of the need to think the unthinkable and retain professional curiosity at all times. Agencies may also wish to assure themselves through existing internal audit frameworks, that there are no systemic issues present, that staff are professionally curious, and that management oversight and safeguarding supervision enables reflection on cases and prior case knowledge, encouraging practitioners to ‘think the unthinkable’. Themes in common with other reviews  The NSPCC holds a range of case review reports from across the country with the theme of Child Sexual Abuse. In 2020 they considered case reviews published since 2017, where children experienced sexual abuse and they produced a briefing paper. Case H does have an area in common with the other reviews around the need to maintain a respectful uncertainty and professional curiosity at all times to guard against accepting alternative explanations for sexual abuse. This is particularly applicable to more vulnerable children. Professionals should challenge one another through positive, robust questioning of child protection decisions, practices, and actions.    Case H Local Child Safeguarding Practice Review (LCSPR)      Page 2 of 2  “The learning from these case reviews highlights that professionals must be able to recognise and respond to sexual abuse. Professionals need to be able to work effectively within multi-agency frameworks to ensure all information is shared and acted upon via suitable processes and in a timely manner. Professional curiosity should be displayed in interactions with families, carers and other practitioners to ensure that the child’s safety remain the focus and are appropriately addressed.”                                                                                                                                                                           (NSPCC 2020) If you do one thing take the time to….. Think the unthinkable and maintain professional curiosity in your work with children and families, reflect on cases to fully explore and understand what is happening within a family rather than make assumptions, or accept the situation you are being presented with.  How this learning was achieved  The review was commissioned by the SCP and an external reviewer was appointed. The terms of references for the review included the following lines of enquiry: • Were the decisions and actions taken by agencies reasonable and proportionate in the circumstances? • Were there any other actions that should have been taken? • Were there any gaps in information sharing within and between agencies that could have informed ongoing work and assessment?  • Are there lessons to be learnt that would inhibit such offences being committed in the future? • Was the voice of the child sought, and acted upon appropriately? • Was there sufficient professional curiosity and / or professional challenge in this case? • Were there any missed opportunities for single or multi-agency working in this case? The reviewer was given access to scoping information and a combined chronology.   The reviewer met with practitioners and managers via Microsoft Teams (due to pandemic restrictions) from across a range of agencies.  The reviewer wrote to the families involved to explain the purpose and scope of the review and to offer an opportunity if they wished to contribute to the review, or had anything they wished to say, but they all declined the offer. The reviewer wrote to the perpetrator to offer an opportunity for them to contribute to the review which they accepted and subsequently the reviewer met with them in prison. This meeting did not add anything new to the review since the perpetrator was either unwilling or unable to assist, minimising and now partly denying their offending, though they did acknowledge harming the children emotionally. Training and resources The SCP already offers a variety of face to face and online training courses for the children’s workforce including elements of child sexual abuse. The SCP will shortly publish a Child Sexual Abuse Strategy, toolkit, and training to support existing procedures and resources. The SCP maintains a policies and procedures website which includes information on child sexual abuse published reports on the theme of child sexual abuse can be found on the NSPCC website. 