Sexual exploitation of a 14-year-old girl from September 2016 to March 2018. Katie lived with her mother, step-father and their children. Family known to Family Support Service and children's services. Katie lived with her father briefly before moving to foster care. She had a history of going missing, smoking and taking drugs and first disclosed sexual activity with an older male in September 2016. Ethnicity of the family not specified. Learning: use of language by some practitioners from a range of agencies in a number of settings to describe typical behaviours of young people experiencing child sexual exploitation (CSE) suggest understanding the dynamics of CSE requires a step change; impact of neglect and emotional abuse on adolescents is often underestimated; more robust connections need to be made between CSE and other forms of criminal exploitation, e.g. drug use; taking personal and professional responsibility to ensure the system is working for every child. Uses the Significant Incident Learning Process (SILP) model which focuses on why those involved acted as they did at the time. Recommendations: to ensure that there is a 'golden thread' that links strategy, policy and practice and that practitioners are competent in working with children who are potentially or actually victims of CSE; consider the value of applying a 'contextual safeguarding' approach to safeguarding adolescents taking into account the influence of peers, school and community; check that practitioners understand their responsibilities to relentlessly pursue any concerns that the system is not working for the child.
      
    Serious Case Review No: 2019/C7695   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.     1                                                           SERIOUS CASE REVIEW   Katie      Accepted by the Local Safeguarding Children Board on 15 January 2019      Report Author - Karen Perry   This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with the Local Safeguarding Children Board prior to publication. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved in the LSCB  2 CONTENTS  1. Introduction and process of the Serious Case Review  page  2 2. Details of the family and case context                     page  4 3. Key Episodes        page  4 4. Thematic analysis       page 10 5. Good Practice       page 21 6. Conclusions and Recommendations    page  22  INTRODUCTION AND PROCESS OF THE SERIOUS CASE REVIEW 1.1. This Serious Case Review (SCR) is in respect of Katie who was significantly harmed by sexual exploitation from the age of 14 years, starting when she was living at home and continuing when she was in the care of the local authority.1   1.2. Working Together 2015 states SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings.   The LSCB agreed to undertake this review using the Significant Incident Learning Process (SILP). SILP is a learning model which, having received a chronology and agency reports,  strongly focuses on engaging frontline staff and their managers2 to review practice in this case, focussing on why those involved acted as they did at the time. Family members and the foster carer who knew her well were also offered the opportunity to speak to the author. Father and the foster carer agreed to meet with the author and their comments are included at the relevant point in the report. 1.3. This SCR takes into account multi-agency involvement from July 2015, (when the family were receiving intensive “Early Help” before Katie came into care), until April 2018 when she moved into a specialist residential placement.   It only includes the case information that is required to understand how the learning has been identified.  1.4. Individual agency reports were completed which considered and analysed practice and any systemic issues and identified the learning from the case by their agency. Subsequently a large number of practitioners, managers and agency safeguarding leads came together for learning and recall events in September and October 2018 respectively. All agency reports were shared in advance and the perspectives and opinions of all those involved at                                             1 Relevant guidance at the time (Working Together 2015)  states a serious case review should be held for every case where abuse or neglect is known or suspected and either a child dies or is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.  2 Two events were held in July and Sept 2018. The lead reviewers are Karen Perry and Nicki Pettitt, both SILP associate reviewers who are independent of the LSCB and its partner agencies.     3 the time are discussed at the event. Everyone involved in the review made an invaluable contribution to the learning and conclusions, including commenting on draft version of the report. The recommendations were made in collaboration with the SCR group of the LSCB.   1.5. The areas of learning identified include the following;  Child Sexual Exploitation; recognition, understanding, protection and support    Use of language by some practitioners from a range of agencies in a number of settings to describe typical behaviours of young people experiencing CSE suggest understanding of the dynamics of CSE requires a step change   When CSE has been identified for one child in the family, consideration should be given to the current and future vulnerability of siblings   When children become looked after, placements should not be made without consideration of the “match” with any other child in placement, and an understanding of any heightened risks associated with the local area  Roles and arrangements for seeking and sharing information about potential perpetrators of CSE individual children should be explicitly agreed amongst practitioners and agencies at risk management meetings and kept under review. This is especially important where there are cross-border issues  Effective co-ordination of services for children at risk of or experiencing CSE  requires good quality risk assessments which are regularly reviewed and risk management meetings planned as a sequence, not as isolated events  All practitioners need to understand the links between going missing and CSE, and assess these for cumulative as well as incident related risk.  Agencies need to ensure their arrangements to identify, record, and share information about all missing episodes are effective  Responses to disclosures should include consideration of all relevant legal remedies; phones and computers should be examined when perpetrators are using social media to contact their victims  Responses to adolescents may be more effective if approaches to intervention take into account the likely higher relative weight of influence of the young person’s networks outside the home; peer; school and community  Assessment of neglect and parenting capacity    The impact of neglect and emotional abuse on adolescents is often underestimated  Attempts to keep “troublesome teenagers” out of care should be based on comprehensive assessment of vulnerability, risk and parenting capacity. Multi-agency chronologies are helpful in achieving this   All practitioners have a responsibility to ensure they make a contribution to assessments and ensure consideration of vulnerability takes into account a child’s age  Assessments need to consider history and parenting capacity, especially when problems are chronic and a parent taking on care of a child has not had experience of doing so for some time   4  Transition,  whether due to change of legal status, departure of staff, or change of service, increases an individual young person’s vulnerability through disruption of relationships; these occasions need to be managed collectively as well as by individual staff/agencies  Meeting the health and education needs of looked after children    Multi-agency meetings must be convened in ways that enable the contribution of all practitioners working with a child, whether this is in person or in writing    More robust connections need to be made between CSE and other forms of criminal exploitation e.g. drug use   Taking personal and professional responsibility to ensure the system is working for every child     Where individual practitioners lack confidence in raising a different professional perspective, or where they feel concerns raised have not been addressed either by their agency or by another agency, more consideration could be given to “testing out” discussions with other practitioners or the relevant agency designated professional, raising issues jointly with other professionals and/or use of the relevant LSCB procedures  2. DETAILS OF THE FAMILY 2.1. Katie has older and younger siblings.  Katie’s parents are referred to as Mother and Father. Other family members will be referred to by their family relationship e.g. Stepfather  3. KEY EPISODES 3.1. Katie and her family received intensive support from the Family Support Service (FSS) since the middle of 2015. Mother and Stepfather were having significant difficulty managing the behaviour firstly of an older sibling, and then subsequently of Katie once sibling became “looked after”.3 Practitioners observed that both teenagers seemed to be treated less well than Mother and Stepfather’s children; a particular example of this would be the family’s solution to overcrowding, which was for Katie and her sibling to live in a caravan in the garden, with no access to the home.   3.2. Due to concerns at the lack of progress and fears that Katie would follow in her older sibling’s footsteps; i.e. going missing and being vulnerable to Child Sexual Exploitation (CSE) and needing to become looked after, the FSS made two referrals to the MASH during this period; in October 2015 and in February 2016. In February the school was also sufficiently concerned to make a referral at the same time.  An Initial Assessment in October 2015 resulted in continued support from the FSS only.4 A Core Assessment in March 2016                                             3     A child who has been in the care of their local authority for more than 24 hours is known as a looked after child. For Katie’s this was initially at the request of her parents under section 20 of the Children Act 1989, until care proceedings were commenced.  4 Children’s Social Care were receiving high numbers of referrals during 2015 and had high numbers of social worker vacancies    5 identified that Katie was a “child in need”5, which meant that a social worker became involved to co-ordinate the work. A referral was made to the Edge of Care team. By July 2016 agency records indicate that Katie was so unhappy at home that she was threatening to self-harm if she were not taken into care.   Key Episode 1: from when Katie moves to live with her father until she becomes “Looked After” in a long term placement (September 2016- November 2016)  3.3. At the beginning of September Katie went missing for two days.  Whilst it was clear she had smoked cannabis and was at risk of CSE from the older male she had stayed with, she did not disclose sexual activity until some weeks later.  The first of three CSE risk assessments during the period of the review was completed. This concluded Katie was at low/medium risk of CSE.   3.4. Around the same time Stepfather contacted Father to care for Katie.  Father’s accommodation was far from ideal, being a room in a house shared with other men.  Nonetheless Katie preferred this; she had told the police she was going missing deliberately because she was scared of Stepfather and did not like living in the caravan.  Father and Katie were advised to seek help from the council homelessness service.    3.5. In mid-September, a child protection strategy meeting6 was held; Katie had gone missing three times since April 2016.  This is the first of nine such strategy meetings held over the period covered by the review.  Participants agreed that the CSE pathway was a more appropriate approach than child protection enquiries, and that a Core Assessment should be completed. A referral was made to the specialist Barnardo’s CSE team.  3.6. At the end of September Katie disclosed sexual activity with the older male to a teacher . The police investigated promptly and initial attempts were made for her contraceptive and sexual health needs to be addressed.    3.7. In mid-October Katie was made subject to a 3 day fixed term exclusion (FTE) from school due to “persistent defiance”, smoking on the school site, and being “verbally abusive” to staff. This was not the first exclusion for poor behaviour and, as she was also one of a group which trespassed on the school site and stole £600 worth of items, the school decided to pursue a “managed move” to a Pupil Referral Unit (PRU) as an alternative to permanent exclusion.  3.8. At a family meeting convened by the social worker it became clear that Katie had no-where to go during the exclusion; Father’s landlord would not permit her to stay in his accommodation when Father was at work and Mother would not have her at home. Senior managers in the local authority were reluctant to “absolve parents of their responsibilities” by accommodating Katie; however after another missing episode at the end of October, when no family member would agree to care for her after she had been                                             5 A Core Assessment is a detailed assessment to establish whether a child is in need of local authority services (under section 17 of the Children Act 1989) to achieve or maintain a reasonable standard of health or development or to prevent significant or further harm to health or development 6 As part of the local authority’s duty to investigate under section 47 of the Children Act 1989, multi-agency strategy meetings should be held where there is reasonable cause to believe a child may be suffering or have suffered significant harm   6 located, the Police used their powers of protection.7 A legal gateway meeting8 agreed that the threshold for care proceedings was not currently met and accommodation on a voluntary basis was appropriate; a review was intended in 6 weeks.9  3.9. Over the next few weeks Katie had four temporary placements due to challenges finding a foster carer who could meet her needs; difficulties included stealing from the foster home, going missing and getting her up in the morning.  Katie was also moved from one of the placements after it was recognised that the other child in placement was also at risk of CSE and that they had some associates in common. Katie remained in touch with this child; she was still going missing with her over 12 months later.   Key Episode 2: From when Katie moved to a long term placement until she was discharged from care by Father (November 2016-September 2017)  3.10. In November 2016 Katie moved to a foster placement in Local area 4 with an experienced single carer. This placement lasted 10 months10 before she was discharged from care at Fathers request.   3.11. At the point of placement the care plan was for reunification with Father in early 2017. There is no record of enquiries being made with Local area 4 before placement, as they should have been,11 about the appropriateness of placing Katie in the locality. There is no record of any notifications to Local area 4 agencies that Katie was placed in their area.12   3.12. In early December 2016 Katie received an Initial Health Assessment.13 Recommendations of the first statutory review14 held shortly after included that the Core Assessment should be updated.   3.13. Katie did not begin attendance at the PRU until April 2017. This was because, although school 1 had made a successful referral before Christmas 2016, Father refused to sign the forms as both he and Katie initially wanted her to go to another mainstream school near where Father was likely to be re-housed.  In the meantime the Designated Teacher continued to offer daily provision, despite pressure from other staff for permanent exclusion due to continued poor behaviour. From early on in the placement the foster carer was reporting difficulties in getting Katie up to go to school; a contributory cause was thought to be the effects of regular cannabis use. Personal Education Plans (PEPs)15 should be drawn up by the social worker in liaison with the school within 4 weeks of a child becoming                                             7 Section 46 Children Act 1989 8 Legal Gateway Meetings are convened by the local authority to make a decision as to whether the criteria are met for the issue of court proceedings. This will include whether the case will proceed through the pre-proceedings checklists of the Public Law Outline , or whether the case requires the immediate issue of proceedings. 9 This review never took place at this time; reasons are not known 10 This placement was initially intended only to be for 6 weeks,  but the foster carer quickly came to feel that she could offer Katie a longer term placement.  11 Children Act 1989 regulations and guidance; Volume 2;care planning, placement and review (2015) Para 3.34 12 Children Act 1989 regulations and guidance; Volume 2;care planning, placement and review (2015) Para 3.40  13 These should be offered to all looked after children within 4 weeks of coming into care  14 A first statutory reviews should be held within 4 weeks of a child becoming looked after, the second review after 4 months and then at minimum intervals of 6 months or when a significant change of circumstances is proposed or has happened 15 A Personal Education Plan (PEP) is a document held by schools and colleges which relates to a particular child and sets out their educational targets for attainment and achievement, and recommends how this will be done.   7 looked after; because of an understandable view that a PEP would best be done in the new school, plans to complete one were delayed; in fact  no PEP was undertaken until April 2017.   3.14. Katie’s first Barnardo’s worker sent monthly reports summarising the direct work done during weekly sessions by email  on four occasions to the social worker and the CSE co-ordinator.  These are difficult to find in CSC records due to no agreed procedures on how they should be stored. In March 2017 Katie was allocated another Barnardo’s worker due to it becoming clear that she was not responding to the more structured risk focused approach of the first practitioner.  No further monthly reports were supplied, despite this being raised by the CSE co-ordinator, until seven retrospective reports were provided in March 2018.   3.15. During this period there were five missing episodes, February, March, May and twice in July 2017, plus an incident of trespass and burglary in a barn involving other young people. All of these incidents involved drugs and potential or actual sexual exploitation by older males or peers.   3.16. The incident in February 2017 took place in the local area 3 police area and involved the friend from whom she had been separated. The foster carer took Katie to the GP because of her feeling “spaced out” and having superficial self-harm cuts. The GP conducted a comprehensive examination, including advice about contraception and sexually transmitted infections. The GP was tenacious in making several phone calls over the next few days to ensure he spoke directly to Katie’s social worker about his concerns.   3.17. A strategy meeting resulted in a risk management meeting which involved Katie and most of the appropriate professionals but not Local area 4 police or Barnardo’s. The CSE risk assessment was updated and risk rating revised to high.    3.18. In March 2017, Katie spent three days with Father, after which he withdrew his request for reunification apparently because he felt could not keep his job and manage her behaviour at the same time. The first of four legal gateway meetings during this key episode had been held in February. This agreed that the Public Law Outline16 should be commenced.  Despite the failed reunification attempt and a recommendation of the second statutory review in March, the first PLO meeting was not held until the very end of May 2017, when father indicated that he and Katie wanted her to return to his care. The social worker agreed to create a brief rehabilitation plan to commence at the beginning of June. By early June there had been another missing incident and Father changed his mind about Katie returning to his care. After seeking legal advice, Father and subsequently Mother, were informed that care proceedings would be issued.   3.19.  A recent significant change in the previous foster carer’s personal circumstances had meant that she was not well placed to care for Katie; In June 2017 the local authority placement panel agreed for an external search for another foster carer. The social worker’s request for a therapeutic residential placement was not agreed.                                               16 Public Law Outline is a process of assessing whether parents can be supported to improve the care of protection of their child without  the immediate issue of proceedings.   8 3.20. The foster carer continued to have difficulties getting Katie up for school due to the impact of her cannabis use. The only additional support the foster carer was provided with was a few days respite in July. The third statutory review made a range of appropriate recommendations including requesting pursuit of alternative placement, clarity as to the timeliness and frequency of risk management meetings and the convening of another legal gateway meeting to consider whether threshold was met for care proceedings. This legal gateway meeting concluded the threshold was not met because the case was subject to PLO. It did not consider the effectiveness of the PLO and whether there were grounds for care proceedings, as has since been recognised as appropriate practice in Local area 1.17  3.21.  An alternative foster placement was finally found towards the end of August. However this placement was not taken up; Father decided to discharge her from care in early September, as he was entitled to do as the local authority had not issued care proceedings.   3.22. Children’s Social Care managers decided to offer support in the community to Father and Katie rather than commence care proceedings. This decision did not appear to take into account the two recent very short-lived instances of attempted reunification. Despite the length of time that Katie had been looked after, and the two previous short-lived and unsuccessful attempts at reunification there still had been no assessment of Father’s capacity to meet Katie’s needs or keep her safe. No written plan was completed as it should have been18 and the IRO was not notified of Katie returning to her Father’s care.  A written support plan, based on a holistic assessment would have been particularly helpful to make more visible and mitigate the fragility and loss of key relationships for Katie at this time; having a new social worker, not attending school regularly, loss of IRO due to ceasing being looked after and the Barnardo’s worker being off sick.19  Key Episode 3: Living with Father, becoming subject to a Child Protection plan and coming back into care. (September 2017-January 2018)    3.23. A local authority solicitor challenged the decision not to issue care proceedings asking what had changed to make social care staff think Father could keep Katie safe. They also cited the view by a local judge on another case that a child’s wishes not to be subject to care proceedings should be over ridden given the risks posed to them and the lack of opportunity otherwise to have a separate voice (and legal representation).   3.24. Katie’s attendance at school continued to be poor during this episode, despite the Virtual Head providing a taxi to support Father in getting her there.   3.25. At the beginning of October school staff informed Father and the social worker that Katie was planning to hold a party during the weekend when he was away on a fishing trip. Father assured the social worker that he would make arrangements (which he did not                                             17 Legal gateway meetings have  been replaced by Alternative to Care panel which sets timescales for issuing care proceedings and tracks progress of agreed actions; membership includes HOS and AD. 18 Children Act 1989 regulations and guidance; Volume 2;care planning, placement and review (2015) Para 5.5 19 The previous social worker had left the employ of the council and the Barnardo’s worker was off sick from between mid-November 2017 and mid-January 2018.    9 specify) for Katie to be supervised. This turned out to involve relatives calling round periodically.  This did not prevent a 14 year old girl (the child from whom Katie had been separated about 12 months previously) and two males, one of a similar age and one of 22 years old, staying overnight and smoking cannabis. The police came to the house on the second day to retrieve the girl who was a missing person. They did not enter the house where the two males were hiding. They spoke to Father by phone, who confirmed he was in Devon; they did not clarify who was acting as a responsible adult in his absence.  3.26. This incident resulted in the convening of an Initial Child Protection Conference (ICPC) in November where Katie was made subject to a Child Protection Plan (CPP) under the category of neglect. The multi-agency CPP was detailed and comprehensive, although it assumed in error that Barnardo’s and sexual health services were actively involved at the time. In early December a legal gateway meeting concluded that the threshold for care proceedings was not met.  The first Core Group meeting to review progress in implementing the child protection plan met promptly.20 The second one was cancelled because the social worker was due in court; it is not known why this was not rearranged before Katie became looked after again.   3.27. Just after Christmas Father reported to the police that an older sibling had told him Katie had been meeting a 26 year old man who had had sex with her. In early January Katie went missing overnight; Father did not report this promptly as he was trying to deal with this himself. Two days later Katie disclosed to her social worker that: she had been raped during this missing episode; that she had been raped by another man earlier in the year and that she had “had sex” with several adult males since Christmas.    3.28. A legal gateway meeting in mid-January 2018 later agreed that the threshold for care proceedings was met; Katie became looked after again on a voluntary basis pending commencement of care proceedings.   Key Episode 4: Katie’s experience in care and the commencement of care proceedings (January-March 2018)  3.29. At the end of January 2018 Father assaulted Katie causing minor bruising in the course of attempting to get her to come home from a relative’s after a missing episode. The following day Katie sought out the school nurse to ask for a sexual health check to be arranged. She also gave a little more detail about the disclosure she had made to the social worker.  3.30. In early February Katie was placed with an intensive placement support foster carer21 and a LAC review was held. Recommendations included that CSE co-ordinator assist the foster carer in drawing up a risk management plan and that Barnardo’s be contacted to draw up a support package;  Katie had expressed a wish to get back in touch with the worker who had returned from sick leave.                                               20 Core groups should be held at minimum intervals of 4 weeks 21  Intensive placement support  provides a therapeutic fostering service; a team of professionals from psychology, education, social care, fostering and youth work backgrounds provide support to the placement. Placements are made on a planned (rather than emergency) basis   10 3.31. During this key episode Katie’s attendance at school continued to be poor; by early March this had reduced to 50%, due to a “falling out” with other pupils.   3.32. During February Katie went missing from foster care eight times for periods ranging from a couple of hours to a couple of days. No systematic activity was undertaken by the police to identify the males involved or serve them with CAWNs22 despite a number of discussions about this.   3.33. At the end of February, six weeks after the legal gateway meeting, an application for an Interim Care Order was made to the court. After reviewing the application the CAFCASS Family Court Advisor recommended to the social worker that a referral to the LSCB should be made to consider whether a SCR should be undertaken.23  Social care managers made a referral to the Serious Case Review subgroup of  the LSCB a few weeks later suggesting that a learning lessons review was conducted. The JCR requested further information from Local area 4 police and the sexual health service and the Chair of the LSCB then agreed that the criteria for conducting a Serious Case Review was met.  3.34. In mid-March 2018 agreement is given by placement panel to seek a specialist residential placement for Katie.   4. THEMATIC ANALYSIS   4.1. The learning from this review was identified from information and opinions provided in the agency reports and at the learning events.  The themes are:    Child Sexual Exploitation; recognition, understanding, protection and support  Assessment of neglect and parenting capacity  Meeting the health and education needs of looked after children   Taking personal and professional responsibility to ensure the system is working for every child    Theme; Child Sexual Exploitation; recognition, understanding, protection and support   4.2. Firstly it is important to understand the context of Child Sexual Exploitation (CSE) in Local area 1.  From the evidence of known cases, Local area 1 is not seeing men operating as a gang or grooming activity being used for financial gain. The picture appears to be more young people involved in inappropriate relationships with older men, with elements of the “party model” in as much as groups come together where alcohol often forms the context for young people being exploited. Katie’s experience is therefore representative of the usual form of exploitation currently identified as prevalent in Local area 1.   4.3. The national guidance on CSE, current for the period of the review, was published in 200924 and 2017 respectively.25 The 2009 guidance represented a significant shift in the expected                                             22 Child Abduction Warning Notice; Child Abduction act 1984 23 This should have been passed to the CAFCASS manager to raise as per procedures 24 Safeguarding children and young people from sexual exploitation (2009) 25https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/591903/CSE_Guidance_Core_Document_13.02.2017.pdf   11 strategic and operational response to CSE.26 However a triennial review of SCRs27 published between 2011 and 2014 and an Ofsted thematic inspection conducted in 201428  both identified patchy progress nationally, partly because CSE was still not consistently being recognised as an issue meriting a strategic focus by LSCBs.29 The triennial review found that challenging behaviour from young people could be misinterpreted by both family and practitioners, resulting in them underestimating or misconstruing the vulnerability of the young person. In addition SCR reports included victim blaming language; e.g suggestions that young people were putting themselves at risk and a lack of understanding of the grooming process and dynamics involved in CSE.    4.4. A joint targeted inspection conducted in 201630 in a small number of local authority areas concluded that there had been progress, with some evidence of good practice. However Ofsted also found: that the strategies in place were not necessarily effective; that although the operational response had improved there were some children who did not receive a co-ordinated response; and some professionals still had a poor understanding of CSE, including use of inappropriate language. The report also emphasised the importance of young people developing a close confiding relationship with one trusted individual. The issues described above are relevant to this case.   4.5. Practitioners at the learning events confirmed the evidence a number of agency authors identified in case records; that inappropriate language was being used about Katie’s behaviour implying  she was to blame for her exploitation. Examples include references to her as “placing herself at risk” and “engaging in  risky behaviours”,  “knowing her current lifestyle was wrong”, (strategy meeting, child protection conference minutes, core assessment, school records) and “having consensual sex with a 22 year old male”, (child protection conference minutes). Other comments which described her as “ offering sex for drugs”, (risk management and strategy  meetings), “going missing of her own free will” (Local area 4 police records), being “threatened” with secure accommodation (strategy discussion) suggest some practitioners had a poor understanding of the dynamics of CSE. Practitioners at the learning events felt use of inappropriate language about potential or actual victims of CSE was fairly widespread in Local area 1. One participant drew the review’s attention to some useful guidance produced for practitioners by the Children’s Society and the National Police Chief’s Council on appropriate language.31  4.6. The Triennial Review of SCRs identified a number of risk factors that increase young people’s vulnerability to CSE; “Experience of neglect, parental failure to protect, and time                                             26 The previous guidance published in 2000 was titled “Safeguarding children involved in Prostitution”  27 Sidebotham P et al (2016) Pathways to protection a triennial analysis of Serious Case Review 2011-14 Department for Education  28 Ofsted (2014) ‘The sexual exploitation of children: it couldn't happen here, could it?’ www.gov.uk/government/publications/sexual-exploitation-of-children-ofsted-thematic-report. 29 The LSCB established a multi-agency CSE & Missing Sub Group in 2015.  The CSE Strategy and Action Plan were signed off by the Board in July 2015.  A dataset was agreed and a comprehensive score card, along with a targeted auditing programme.  CSE risk assessments were adopted in Oct 2015 but without written guidance on their use. A CSE co-ordinator was appointed in January 2016. Pathways for referring and responding to cases of CSE, a checklist for early identification and a revised CSE  Risk assessment tool were implemented from January 2017.  30 f Ofsted, Care Quality Commission, HM Inspectorate of Constabulary and HM Inspectorate of Probation (2016) ‘Time to listen’: a joined up response to child sexual exploitation’  [London]: Ofsted  31 Appropriate language child sexual and/or criminal exploitation; guidance for professionals, no date https://www.csepoliceandprevention.org.uk/sites/default/files/Guidance%20App%20Language%20Toolkit.pdf   12 spent in care feature strongly, as do emotional and behavioural difficulties, school disruption, going missing from home, school and care, substance misuse, low levels of self-esteem and seeking affection and approval often in risky places.”32 These factors all have relevance to Katie’s circumstances.   4.7. It is clear that Katie was less favoured than her younger siblings by Mother and Stepfather. She also felt envious of the support that Father gave older sibling. After the failed attempts at rehabilitation to Father she felt rejected by both parents.   4.8. The most striking example of parental neglect was Mother and Stepfather’s solution to the overcrowding in the family home; that Katie and sibling should live in the caravan in the garden. The girls had neither access to a toilet nor a key to the house. This was still the case when Katie was living in the caravan on her own, age 13 years, after her sibling had become looked after. Notwithstanding attempts to modify the risks by the Family Support Service (FSS) e.g. by encouraging the building of a fence and Katie being provided with a phone, this should have been construed as neglect and prompted a more robust assessment of parenting capacity by Children’s Social Care.   4.9. It was not until April 2016 that a Child In Need33 plan was put into place. The referral from FSS had described the lack of progress delivering an effective parenting programme. This was due to the reluctance of Mother and Stepfather to engage consistently/at all and use the strategies taught, and lack of success in improving the quality of Mother and Katie’s relationship. However the main component of the CIN plan was involvement of the Edge of Care service, with a request for the same kind of work which had already been done by the FSS. The primary focus of the work seemed to be on keeping the family together and addressing the overcrowding/getting Katie back into the family home, rather than consideration of neglect and risks.      4.10. Once Mother and Stepfather were no longer willing to accept any responsibility for caring for Katie, Father seemed more motivated to care for and try to protect her.  However he was not well placed to do so through lack of suitable accommodation, unwillingness to prioritise Katie’s needs over his pursuit of leisure activities and, like many parents whose children are victims of CSE, inability to understand and overcome the dynamics of CSE.    4.11. Becoming looked after is a risk factor for CSE due to: the common emotional characteristics (e.g lack of self-esteem, craving for affection) that make young people vulnerable; being seen as targets by perpetrators; and  being more likely to come into contact with other young people who are actual or potential victims of CSE.  When children become looked after they should be placed with carers who can meet their needs, with consideration to the “match” with any other child in placement. In her first placement Katie was placed with someone who was also a victim of CSE and with whom she was still in touch and going missing over 12 months later.34 Katie’s longest placement                                             32 Sidebotham P et al (2016) Pathways to protection a triennial analysis of Serious Case Review 2011-14 Department for Education. Page 119  33 Section 17 Children Act 1989 34 As a result of this case ensuring compatibility of looked after children before placing them together is part of the CSC single agency action plan.      13 was with an experienced carer but in an area known to be a “hotspot” for CSE.35 Whilst this should not be an automatic barrier to placement, there was no expectation to do checks which would have enabled that circumstance to be taken into account either in considering the suitability of the placement, or updating the risk assessment.    4.12. Disengagement from education, including going missing from school, is also a risk factor for CSE. Initial concerns about education were more about Katie’s behaviour than truanting; however her attendance at school got steadily worse over the period covered by the review. The difficulties in achieving the “managed move” resulted in a part-time timetable for several months; part-time timetables for teenagers increase vulnerability to CSE since they spend less time in supervised activity.   4.13. Both Ofsted and the Triennial Review comment on the importance of young people developing a close confiding relationship with one trusted individual. The FSS recognised this by allocating a separate worker for Katie as well as one for the family. The Barnardo’s manager also understood this; by promptly allocating another worker with a different style when Katie no longer wanted to engage with the first worker. There is some evidence that Katie had a trusting relationship with a number of people in particular the Edge of Care worker, the designated teacher at school 1, the second Barnardo’s worker, the foster carer and the IRO.  Whilst there was no one consistent person to whom she could turn to over the whole period, it appears likely she did feel that there was always someone she could turn to for emotional support and practical/protective help.   4.14. Some recent research on “Contextual Safeguarding”36 provides a useful perspective on this case. Contextual safeguarding  is an approach arising from the knowledge that as children move into and through adolescence, not only are they spending increasing amounts of time away from their families, they are influenced increasingly more by peer relationships. This means that if they form friendships with others living in anti-social or unsafe contexts, whether physical or virtual (i.e social media and internet) they are likely to adopt those norms of behaviour. Risks can be amplified for children who have been abused because they may have already internalised harmful social norms and may also avoid their own homes altogether. Whilst Firmin’s research focused specifically on peer on peer abuse the findings generalise to sexual exploitation by older males too. What she found was that typical safeguarding approaches which focus primarily on home and family relationships are undermined by the weight of influence of peers and other environments important to young people; for example their schools and communities. Her model of intervention therefore advocates an analysis which involves the assessment of the relative weight of influence of four networks on the young person: home; peer; school and community.  4.15. In terms of CSE, the “push” factors as they relate to Katie have been described above.  Her “pull” factors relate to peer and community. For example: continuing to go missing with a                                             35 The CSE co-ordinator confirmed that, had she been asked before Katie was placed, she would have stated that the particular part of Local area 4 was a CSE “hot spot”. By August 2018 it was  an expectation that the CSE co-ordinator is contacted before placements are made out of county; however by October 2018 no request had yet been made and there has been no monitoring activity to check whether the procedure is being followed  36 Firmin (2017) Contextual Safeguarding: an overview of the operational strategic and conceptual framework  University of Bedfordshire   14 girl she met soon after becoming looked after, with whom she had a number of associates in common; being placed in an area known to be a “hot spot” for sexual exploitation; and use of social media by males to contact her. Although the precipitating event for the child protection conference was Father’s lack of supervision over the weekend in October 2017, looked at through the lens of Firmin’s research, the category of neglect (as opposed to sexual abuse) is controversial as it implies his parenting was the problem rather than the (dynamics of) sexual exploitation. The category focuses attention on working with Father rather than disruption of the perpetrators. Father told this review that while he accepted he had been naïve in thinking the level of supervision he had arranged was adequate he did not feel he had been neglectful.   4.16. Tackling CSE requires a co-ordinated systematic multi-agency approach involving timely sharing of information. There were some organisational challenges for key specialist personnel involved in leading the CSE arrangements during the period of the review. In 2016 the specialist CSE police response for the local area 1  was a joint service with local area 2  located in local area 2 which was managed by a Detective Inspector who worked from a 3rd area until April 2017. This diluted a local focus on Local area 1 and posed practical difficulties for officers in attending meetings, especially at short notice. Local area 1 did not get a dedicated post until mid-2017, however there continues to be no specific provision to cover holidays or sickness. Barnardo’s was also a jointly commissioned service involving two staff based in Local area 2 who faced similar challenges to the police.  4.17. Notwithstanding the organisational challenges, CSE risk assessments and risk management meetings/strategy meetings could have been used more effectively. The first risk CSE assessment was conducted in September 2016. The assessment included relevant information about current concerns, but the low/medium outcome37 of the assessment did not reflect the severity of the concerns described. The risk assessment does not seem to have been updated until March 2017, and then not again until August 2017.  This is not in line with the required 4 weekly timescales. This was raised repeatedly with the social worker by the CSE co-ordinator, to no avail.  Each of the risk assessment meetings appears to have been done in isolation rather than as part of a planned sequence, and not all the key people were invited, for example Barnardo’s and Local area 4 police.    4.18. Arrangements for effective information gathering/sharing about the males who were exploiting Katie were not in place and no detailed chronology of CSE risks was compiled until Feb 2018. At one point three different police forces were involved;38 No joint arrangements were made between them to collate and share information. Also Local area 4 police did not consistently share all the information they had about the people Katie was associating with and the level of risk. Perpetrators of sexual exploitation are very adept at grooming their victims through a mixture of affection and/or threats coupled with offering drugs to promote compliance. This means that typically young people either do not see their experience as abuse or are reluctant or frightened to report it. This underlines the                                             37 At the time there were only two possible ratings; low/medium or high. Since January 2017 risk management meetings are convened for cases rated as high and medium, the old system which underplayed the needs for co-ordinated services for children where risk was medium. 38 Local area 1 relating to the responsible CSC authority, Local Area 4 where Katie was placed and local area 3 where an offence was alleged to have taken place   15 necessity of regular and frequent contact and painstaking work to build relationships of trust so that young people feel able to share their actual experiences and get support. Also, if they and others are to be protected, sufficient details about the perpetrators are needed so that they can be identified and stopped.  Successful approaches in other parts of the country have been based on identifying one person, usually a specialist worker, to take the lead in this activity. This does not seem to have happened for Katie. One logical choice would have been the Barnardo’s worker. However they do not seem to have been given that role explicitly and they were not encouraged to share information in the most effective way (eg by being invited to risk management meetings).  In addition information about key incidents and risks was not consistently shared with them.   4.19. Effective disruption of CSE requires prompt and thorough responses to disclosures and use of the legal remedies available; for example use of legislation under the Child Abduction Act and investigation and prosecution of crimes. During the period there were five occasions when a Child Abduction Warning Notice (CAWN) could have been issued. On three of these it is not clear why they were not issued, on a fourth, there was a mistaken belief on a police officer’s part that a CAWN was issued for an address (which was not known) rather than an individual. On a fifth, there was a delay of about a month due to the delay in CSC providing the required statement from someone with parental responsibility.39  4.20. In early 2018, Katie made two allegations of rape, one relating to several months ago. Prompt efforts were made to follow up these allegations although, as is not unusual for CSE, Katie declined to be formally interviewed. The foster carer told this review that there was one particular older male who telephoned Katie very frequently over a lengthy period.  In addition there were two specific occasions (October 2016 and February 2017) where the examination of Katie’s phone and or computer might have provided useful intelligence about potential perpetrators and crimes being committed against her or others; on the first occasion seizing these does not appear to have been considered and on the second CSC secured the items but it is unclear whether or not they were passed to local area 3 police for examination.   There also seems to have been some inconclusive discussion during at least one strategy meeting of the merits or otherwise of putting a tracker on her mobile phone. Practitioners told this review that one of the barriers in collecting evidence from electronic devices was the capacity of specialist staff to examine devices forensically. Father told this review that such an examination might have revealed information about the men who he knew were contacting Katie on social media and by phone.   4.21. The national Ofsted Inspection in 2016 referred to previously found that the responses to missing children required further development in most of the areas visited. Many of the incidents in Local area 4 were not recorded by the police as Missing episodes. This was sometimes influenced by the foster carer who told this review that she had acted on the advice of Katie’s  social worker in giving her half an hour leeway before reporting her missing to the police, when she asked  that they hold off active efforts to locate her for two hours.  The police logs suggest a lack of understanding of the relationship between going                                             39 Practitioners told this review that Father was reluctant to make such a statement for fear of upsetting Katie. Father does not recall this   16 missing and CSE.40 This meant there was no automatic notification to the local CSC, in this case Local area 4, who did pass on to Local area 1 CSC those missing episodes they knew about. This also meant that Local area 4 police did not recognise when triggers relating to three missing episodes were met, which should have generated more focused scrutiny.   4.22. As Katie was looked after, then Local area 1 knew about the missing episodes via her foster carer; Return Home Interviews were done on the three occasions in 2017 that Katie was located in Local area 1 but there is no evidence they were shared with Local area 4 police. As no notification was made to Local area 4 agencies about Katie being placed then the police only had the information they recorded; no request was made to local area 4 police to attend any meetings about Katie. The commencement of the dedicated Local area 1 police post covering CSE and Missing Children in 2017 had facilitated the provision of information about missing episodes to CSE Risk Management meetings in general, unfortunately, due to capacity of work, the remit and responsibility for Missing Children has been passed back to Local area 2.    Summary of learning:   Use of inappropriate language by some practitioners from a range of agencies in a number of settings to describe typical behaviours of young people experiencing CSE suggest understanding of the dynamics of CSE requires a step change   When CSE has been identified for one child in the family consideration should be given to the current and future vulnerability of siblings   When children become looked after placements should not be made without consideration of the “match” with any other child in placement, and an understanding of any heightened risk associated with the local area  Roles and arrangements for seeking and sharing information about potential perpetrators of CSE individual children should be explicitly agreed amongst practitioners and agencies at risk management meetings and kept under review. This is especially important where there are cross-border issues  Effective co-ordination of services for children at risk of or experiencing CSE  requires good quality risks assessments which are regularly reviewed  and risk management meetings planned as a sequence, not as isolated events  All practitioners need to understand the links between going missing and CSE, and assess these for cumulative as well as incident related risk.  Agencies need to ensure their arrangements to identify record and share information about all episodes are effective.   Responses to disclosures should include consideration of all relevant legal remedies; phones and computers should be examined when perpetrators are using social media to contact their victims  Responses to adolescents may be more effective if approaches to intervention take into account the likely higher relative weight of influence of the young person’s networks outside the home; peer; school and community.    See recommendations 1 and 2                                             40 Since 2017 improvements in monitoring and safeguarding missing children arrangements have been made by Local area 4 police    17  Assessment of neglect and parenting capacity  4.23. The two most recent Triennial analyses of the findings from Serious Case Reviews show a high proportion of cases (approximately 60%) include neglect.41 Yet at the same time research shows that emotional abuse and neglect of adolescents is often either not recognised by practitioners or not taken sufficiently seriously.42 This is partly because young people tend to be seen as more resilient than young children. This belief persists although the research evidence does not support the theory that the impact of neglect is less for adolescents.43 A study involving practitioners and young people from 12 areas in England identified that this was due to a combination of factors all of which have some relevance in Katie’s case. These were young people  being perceived as; able to escape the situation (including self-refer); more able to cope than younger children; contributing to or exacerbating the problems through their own behaviour for example through conflict with parents or resisting attempts at supervision and putting themselves at risk.44  In September/October 2016 there appeared to be a view in Children’s Social Care that the parents should be encouraged to accept their responsibilities to avoid Katie being looked after; Katie was seen as troublesome rather than vulnerable.   4.24. Challenges for intervention in adolescent neglect include the elusiveness of a definition given the importance of considering a young person’s age and capabilities and the lack of appropriate tools for practice which tend to be focused on the needs of younger children.45 Social workers who responded in the earlier study had reservations about the effectiveness of child protection processes for adolescents and favoured use of Child in Need or Early Help processes.46 This may partially explain why Katie living in caravan in 2015/6 was not conceptualised at the time as neglect requiring protective action.    4.25. Assessments need to give specific consideration to parenting capacity and seek and include relevant information from other agencies.   When Katie was living with Mother and Stepfather no-one contacted the GP; had they done so they would have discovered Mother had a chronic health condition whose impact on her parenting should have been considered. Although Mother and Stepfather were primary carers up until September 2016, Father’s role did not feature in the three assessments that were completed by social workers before then. A detailed assessment of Father’s ability to care for Katie and, in particular keep her safe given her level of vulnerability, was not always done at points where Father taking over primary carer’s responsibilities was proposed or happened.                                               41 Sidebotham P et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 DfE page 43 42 NSPCC (2014) Core info; Neglect or emotional abuse in teenagers aged 13-18 43 Ibid and Raws P (2017) Thinking about  adolescent neglect; A review of research on adolescent neglect focusing  on identification, assessment and intervention Children’s Society 44 Rees G et al (2010) Safeguarding  Young People: Responding to young  people aged 11 to 17  who are maltreated Children’s Society & NSPCC 45 Ibid 46 Rees G et al (2010)   18 4.26. The conclusion of the Core Assessment in autumn 2016 was also heavily influenced by Katie’s views that she had a good relationship with her Father, felt safe with him and wished to live with him. Whilst children and young people’s views should be taken into account, the assessment did not include a detailed focus on Father’s capacity to meet her needs nor on what support he might need. For example, despite his application for housing being accepted as priority, he was not rehoused until January 201747; this had an impact on Katie’s education since the lack of permanent accommodation influenced Father’s reluctance to agree to an alternative school for her. Father told this review there was no serious attempt to explore how he might be supported to obtain alternatives to social housing e.g. privately rented accommodation.  There is also no evidence of any serious attempt to explore with him how he might manage missing incidents and evidence of sexual exploitation until after Katie was made subject to a child protection plan.  Father told this review that whilst he had a good relationship generally with the social worker, with whom he could have a robust exchange of views, he felt he had never received any realistic advice on how to keep Katie safe, and that out of office hours there was no-one to turn to apart from the police whose response did not make him feel his concerns were being taken seriously.   4.27. Once Katie became looked after, the assessment was not reviewed, despite this being a recommendation of the statutory review in December 2016, and despite the plan being for her to return to live with Father.  In September 2017, when Father discharged Katie from care, no assessment was completed. Whilst his request was somewhat unexpected at the time, the on-going debate about whether or not the threshold for care proceedings was met should have meant that an assessment should have been already underway.   4.28. Had a thorough assessment of parenting capacity been done, taking into account all the history, perhaps evidence might have been available as early as 2016 to demonstrate that the threshold for care proceedings was met. It might still have been difficult to protect Katie from CSE, however the incidents of her being exploited while left alone at home by Father and his assaulting her due to frustration at not being able to control her behaviour might have been avoided.   4.29. Practitioners at the learning events told this review that the failure to issue care proceedings in mid-2017 after informing parents of an intention to do so was probably due to the pressures of managing day to day issues coupled with a lack of robust management oversight.48 Better management oversight might also have identified the lack of an up to date and sufficiently comprehensive assessment.    4.30. Katie was in placement with one carer for ten months. This placement lasted this length of time mainly because of the high level of commitment of the carer who had a good relationship with her fostering social worker (who offered regular supervision) and with Father.  However there was no evidence of proactive consideration of additional planned respite which is particularly relevant for single carers vulnerable to exhaustion when caring                                             47 Families are all treated as high priority by the social housing provider, however there are no additional considerations for reuniting looked after children, and there is a severe shortage of suitable properties.  Father told this review he felt more should be done to prioritise getting children out of care.  48 There was a high turnover of social work team managers during the period under review    19 for young people who go missing regularly.  Strains on the carer’s ability to keep Katie safe and get her to attend school were already evident prior to Father deciding that reunification was not possible in June 2017. Subsequent pressures on the carer were compounded by a significant change in her personal circumstances.  There is no evidence to indicate that any additional support and resources were offered in recognition of this and the increasing risks; a lot of responsibility for keeping Katie safe rested with the foster carer.   4.31. There are a number of examples where agencies or individuals went the extra mile to provide support; for example the allocation of two Family support workers while Katie was living with Mother and Stepfather, the efforts by the sexual health service to ensure she had a termination by the least invasive method and the efforts by the designated teacher in school 1 to ensure she received some education pending a move to another school.   Summary of learning from this theme:   The impact of neglect and emotional abuse on adolescents is often underestimated  Attempts to keep “troublesome teenagers” out of care should be based on comprehensive assessment of vulnerability, risk and parenting capacity. Multi-agency chronologies are helpful in achieving this.    All practitioners have a responsibility to ensure they make a contribution to assessments and ensure considerations of vulnerability takes into account a child’s age  Assessments need to consider history and parenting capacity, especially when problems are chronic or a parent taking on care of a child has not had experience of doing so for some time.   Transition,  whether due to change of legal status, departure of staff or change of service, increases individual young people’s vulnerability through disruption of relationships; these occasions need to be managed collectively as well as by individual staff/agencies  See recommendation 3  Meeting the health and education needs of looked after children  4.32. Research over the last 20 years has repeatedly demonstrated that looked after children often have significant health and education needs, and statutory guidance has become increasingly detailed about how these should be met, with particular responsibilities for local authorities and health agencies. Despite pockets of good practice there were significant deficits in the service received by Katie. Her first health assessment upon becoming looked after was very delayed and it did not consider substance and alcohol misuse or sexual health needs, as it should have done.  Practitioners had concerns about drug use, initially mostly cannabis, but also other substances; on at least one occasion Katie did not know what she had been given. Despite discussion with her social worker, the Barnardo’s worker and in risk management meetings, Katie did not see the need for any help regarding substance misuse. In addition the focus by practitioners generally seems to have been more about the impact on Katie’s ability to get up for school rather than the risks to her health and the criminal activities involved in supply and use of substances.   20 Practitioners told this review that they found it difficult to find ways of disrupting the supply of drugs to young people without the support of a pathway to tackle this.    4.33. Whilst it is often difficult to get young people, especially those being sexually exploited, to see the value of engaging with sexual health services, this appears not to have been consistently encouraged by the social worker. The communication between sexual health and social worker was good from October 2016 onwards and the sexual health nurse was persistent in ultimately unsuccessful attempts to get Katie to engage further. The alternative (also unsuccessful) strategy suggested by the social worker of delivery of 1:1 sessions by the school nurse was a good idea.    4.34. There were four statutory reviews held during the period for Katie; in December 2016, March and July 2017 and February 2018. The current format for presenting draft Care Plans for approval at reviews does not give adequate scope for social worker to present all the relevant progress information. The Virtual Head49 was not invited to the first two, and no health professional was invited to the first three.  Whilst it is recognised that children and young people should be consulted about who they want to attend and that many young people will only want a small number of people they know well to attend, the statutory guidance50 suggests that a series of meetings can be an effective way to ensure all relevant people are invited.  This could have been negotiated with Katie, who may have chosen not to be present for some meetings. Whilst social workers should update practitioners who do not attend, recommendations are more likely to be effectively implemented if the relevant practitioner is there to contribute to the discussion and influence the content of recommendations. The Virtual Head was not made aware of a recommendation they should become involved to tackle the delays in achieving a change of school. The delay in change of school meant there was no PEP in place for several months after Katie became looked after.   Summary of learning from this theme   Multi-agency meetings must be convened in ways that enable the contribution of all practitioners working with child, whether this is in person or in writing    More robust connections need to be made between CSE and other forms of criminal exploitation for example the use of drugs or alcohol to facilitate exploitation.  See recommendation 4  Theme: taking personal and professional responsibility to ensure the focus is on the child and the system is working for every child  4.35. Healthy professional networks are able to debate issues and resolve them. This is not the same as everyone necessarily agreeing; individual agencies have different statutory responsibilities, so will have the final say in certain circumstances. However where a                                             49 A Virtual School Head is responsible for ensuring that arrangements are in place to improve the educational experiences and outcomes of the authority’s looked after children, including those placed outside the caring authority’s boundaries 50 Independent Reviewing Officer’s handbook para 3.10    21 practitioner has a strong view that a decision is not in a child’s best interests, especially if they believe a child needs (more) protection or the child is looked after (when all practitioners should behave as “corporate parents”51), they should raise and, if necessary, escalate their concerns.   4.36. There were a number of occasions where attempts were made to raise or escalate concerns either within or between agencies. Successful attempts include a request by legal for assessments to be updated prior to care proceedings being issued. The CAFCASS guardian attempt to ensure consideration was given to the need for a SCR was not initially successful, although her case analysis drew this to the attention of the judge that oversaw the care proceedings. The school making a referral to MASH added weight to that made by the FSS.    4.37. Less successful examples of raising concerns or escalation include:   The CSE co-ordinators attempts to get risk review meetings reconvened to  update CSE risk assessments   The CSE’s co-ordinator’s attempts to get monthly reports from Barnardo’s  Barnardo’s attempts to get invites to all meetings about Katie  The local authority solicitor challenging the decision not to issue care proceedings asking what had changed to make social care staff think Father could keep Katie safe (no-one else challenged this decision)   Lack of review of core assessment after LAC review  IRO’s concerns that Katie needed more support than Father could provide52  Change in registration to a local GP which never happened  Speed of move to school two  School’s concerns about the ability of foster carer to get Katie to school   4.38. Practitioners told this review that there were a range of barriers to raising, pursuing and escalating professional disputes. These include: becoming desensitised to ongoing concerns; being aware of capacity pressures on colleagues or other agencies; assuming that others who have been involved for longer or who are more experienced or who have lead roles or specialist expertise must “know better”; being unable to get support for escalation from line managers;  not knowing the procedure.   4.39. Every agency involved in this case has internal mechanisms, including policies on supervision and/or seeking advice on safeguarding issues for staff to raise single agency concerns.  The LSCB also had a dispute resolution procedure which practitioners involved in a previous SCR published in December 2016 stated was not easy to use. This procedure53  was not updated until April 2018, i.e. just after the period covered by this review. The LSCB accepted a recommendation from the previous SCR that a                                             51 “Treating children and young people who are in our care as if they  were our own”  52  Since May 2018 IRO’s are being encouraged by senior managers in Children’s Social Care to make more proactive and robust use of the dispute resolution procedures  53 Resolution of professional disagreement about a safeguarding children response     22 mechanism be agreed to ensure that the board was kept informed of the number of professional disagreements, understanding the themes and monitoring the outcomes.    Summary of learning from this theme   Where individual practitioners lack confidence in raising a different professional perspective, or where they feel concerns raised have not been addressed either by their agency or by another agency, more consideration could be given to “testing out” discussions with other practitioners or the relevant agency designated professional, and/or use of the relevant LSCB procedures  See recommendation 4  5. GOOD PRACTICE  5.1 When undertaking a review, it is important to also consider any good practice undertaken on the case. A number of positive interventions were noted above and it is important to highlight them again here. They include:   School 1 took steps to ensure she was provided with an education while a managed move to another school was arranged  Development by the CSE co-ordinator of new practice tools for  early identification of  risk  The GP made a referral  and subsequently shared further information with Children’s Social Care regarding concerns about CSE  When the friend from whom Katie had been separated went to the same site of the PRU, arrangements were put in place to minimise contact through separate timetables.  Change of Barnardo’s worker to ensure Katie continued to access the service  Foster carer taking Katie to the GP when concerned about the effects of drugs  The tenacity of staff in the sexual health service to ensure that Katie was offered a flexible and timely service.  Persistence of school nurse in trying to engage Katie to provide 1: 1 support regarding sexual health at the social workers suggestion. This  resulted in Katie seeking her out when she needed a referral for sexual health screening  Provision by Virtual Head of taxi to get Katie to school   Effective challenge from the legal service to get assessments updated  and application made for care proceedings  Recognition by CAFCASS that Katie had suffered significant harm and that the criteria for a SCR might be met  Continuity of case oversight in Children Social Care; Katie had the same IRO for 16 months, who has now become her SW team manager. As there had been a recent change of social worker this IRO also got directly involved to provide support to Katie at a particularly difficult time.  A number of practitioners develop strong relationships with Katie which she valued  SW undertaking care proceedings quickly grasped the key elements of the case and persuaded the local authority to provide a specialist residential placement   23  The time and thought put into providing support for Katie and her family by the Family support workers  6. CONCLUSIONS AND RECOMMENDATIONS  6.1 Although there are a number of examples of good practice, overall the picture is of a reactive rather than proactive approach, which was not effectively co-ordinated.  This was especially the case for CSE but also for care planning.  A number of practitioners made attempts to raise or escalate their concerns about both aspects, but these efforts were generally unsuccessful. There is no evidence that anyone invoked any formal procedure to resolve a professional disagreement. The consequence was that practitioners didn’t fully understand the seriousness of the harm Katie was experiencing.   6.2 The individual agency reports have made single agency recommendations. Local area 1 Safeguarding Board has accepted these and will ensure their implementation is monitored. To address the multi-agency learning, this Serious Case Review identified the following recommendations for Local area 1 Safeguarding Board (LSCB): 1. That the LSCB consider how best to ensure that there is a “golden thread” that links strategy, policy and practice and that practitioners are competent in working with children who are potentially or actually victims of CSE, so that they:   have a detailed knowledge of the dynamics of CSE;   use appropriate language to describe behaviour;   recognise the links between CSE and “going missing” and criminal exploitation  give attention to the potential vulnerability of younger siblings;   agree arrangements regarding individual children to ensure information about alleged perpetrators  is gathered and shared;   make effective use of risk management meetings and risk assessments to  understand cumulative risks  2. That the LSCB consider the value of applying a “contextual safeguarding” approach to safeguarding adolescents which takes into account the likely higher relative weight of influence of the young person’s networks outside the home; peer; school and community. 3. The LSCB should take steps to encourage partner agencies to develop appropriate systems for working together collectively to tackle multiple forms of exploitation and neglect and ensure that practitioners have the knowledge, skills, tools and support to identify and tackle exploitation and neglect.  4. That the LSCB takes steps to ensure partner agencies; a. check that practitioners understand their responsibilities to relentlessly pursue  any concerns that the system is not working for the child b. check that practitioners understand how to apply the multi-agency procedure for resolving professional disagreements and feel supported to use it   24 c. contribute to ensuring arrangements are in place to monitor the effectiveness of the escalation arrangements   