Child sexual exploitation of three girls by a young adult female who was involved in sexual activity with them and additionally recruited them in abusive sexual behaviours by a number of older adult males between January 2013 and August 2015. All girls had complex needs and missing from home episodes. Hannah had a history of self-harm, alcohol and substance misuse and may have been involved in grooming other young people herself. She was on the Child Sexual Exploitation (CSE) list and was a Child in Need. Samantha was added to CSE list following her mother's concern about her relationship with a 26 year old man, which resulted in a police referral to children's social care. Lauren was looked after by her grandparents from 2011 who struggled to manage her behaviour. The police were involved following a violent incident by her grandfather and a Section 47 enquiry began. She was in foster care for short periods and a Care Order was discussed. The alleged perpetrator was relatively young and had been a vulnerable child; in tandem with Hannah on occasions, she was part of a wider network of predominantly male operatives. Issues identified include: the difficulty in identifying the alleged perpetrator as a risk to children; the need for services to work with parents to strengthen parental confidence as perpetrators set out to deliberately drive a wedge between child and family; importance of early intervention in responding to sexual exploitation; the need to understand children as victims without choice or informed consent. Uses narrative stories for each of the children as the basis for identifying emergent themes and the Review Panel worked collaboratively to identify critical pathways, points of learning and to focus on thematic issues. Makes recommendations to introduce a process for responding to vulnerable children/young people which incorporates child sexual exploitation, in particular identifying and minimising risk from a non-familial source, build on factors that increase resilience, facilitate a multi-agency team around the child and facilitate partnership with key people in the life of the young person. Also recommends the LSCB is regularly kept abreast of information relating to sexual exploitation and missing from home incidents. Please note that this report was written in September 2016 but was published in April 2017.
      
    Serious Case Review No: 2017/C6379   Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.                                   Serious Case Review       SEPTEMBER 2016      Considering Child Sexual Exploitation         Contents                                                                                                                                                    Page no. 1. Introduction   1 2. Membership and Conduct of the Serious Case Review Panel                                    2 3. Methodology and Family Involvement                                                                                                          2 4. The National and Local Context                                                                                                                      5 5. Key Lines of Enquiry                                                                                                                                          10 6. Analysis     11 7. Learning Outcomes                                                                                                                                            34 8. Agency Reflections and Service Improvements                                                                          36 9. Recommendations 41 10. Glossary of Terms 42                                                                                            1    1.         Introduction  1.1. This Serious Case Review has been commissioned by the Local Safeguarding Children Board (LSCB) and examines the approach taken regarding Child Sexual Exploitation, between January 2013 and August 2015, by agencies represented on the LSCB. The Review uses the experiences of three (female) children known, for the purposes of this report, as Hannah, Lauren and Samantha, to inform the analysis and findings and to draw conclusions and recommendations for both improving practice and ensuring more successful outcomes for children and young people.   1.2. A less common feature of this review is that the alleged perpetrator was a young adult female, who had herself experienced a disruptive childhood. There was intelligence and information to suggest that she had been involved in sexual activity with Hannah, Lauren and Samantha and had additionally recruited them for involvement in abusive sexual behaviours by a number of older adult males. During the Review the alleged perpetrator had been subject to ongoing Police enquiries and has now been charged with a number of offences.  1.3. In this regard and given the context, the alleged perpetrator’s actions, both in respect of recruitment and actual abusive behaviours, have to be located in a much broader context of power, coercion and control which ultimately originate with a number of male perpetrators.  1.4. The Review is thematic rather than individual to each child and whilst drawing on the experiences of all three children and where possible, their parents, carers and family members, it both explores and analyses information in relation to a number of distinct, but interconnected key lines of enquiry.   1.5. The Overview Report is not constituted as three separate reviews, however a substantial amount of information regarding all three children is considered. The narrative experiences of the children are blended, both to inform the thematic analysis but also to provide some understanding from the children’s perspective regarding their experiences.  1.6. The Review references the national initiatives and reporting and considers the extent to which these have influenced local developments, as part of the drive to both understand and respond to Child Sexual Exploitation (CSE) in the LSCB Area.  1.7. The commissioning of this Review, whilst not a mandatory requirement under statutory guidance, is evidence of a willingness to achieve a deeper understanding regarding the issue of sexual exploitation across the LSCB area and to develop and improve local responses for children and young people.  2   2.       Membership and Conduct of the Serious Case Review Panel  2.1 The LSCB appointed two independent Reviewers to facilitate the Review. Neither Reviewer has had any professional contact with any of the agencies involved and both have previous experience in undertaking Serious Case Reviews.   In order to oversee the conduct of the Review and co-ordinate the involvement of agencies, a Panel was formulated which comprised of the following senior staff:    Associate Director of Nursing,  Mental Health Trust  Senior Inclusion Manager, Education  Safeguarding Officer, Education  Principal Inclusion Manager, Services to Schools  Senior Manager, Clinical Commissioning Group  Service Manager for Review and Inspection, Local Authority   Independent Single Agency Author, Local Authority  Head of Nursing-Safeguarding, NHS Foundation Trust  Detective Chief Inspector, Police  Clinical Manager, Sexual Health Services  Team Manager,  Drug and Alcohol Support Services  Managing Director,  Local Therapeutic Services  Assistant Director Children’s Services, Barnardo’s  2.3 The panel met on seven occasions and developed the key lines of enquiry for the review and co-ordinated all agency contributions. There was an authentic desire to use this Review to learn from and enhance local multi-agency working in order to develop practice and responses to children at risk of CSE.  3. Methodology and Family Involvement  3.1       Working Together 2013, the version applicable during the start of the Review, requires that Serious Case Reviews are conducted in such a way which:     Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight;  Is transparent about the way that data is collected and analysed, and  Makes use of relevant research and case evidence to inform the findings.    3  3.2 All agencies completed individual chronologies and analyses of agency involvement detailing what was known regarding the three children. The agency reports addressed the following questions:    What is your analysis of your agency involvement with the subject child during this period?  Were any assessments undertaken?   Were services delivered appropriately according to organisational/statutory guidance?  Were there any indicators of concerns for the child and how were these responded to? To specifically include indicators of emotional vulnerability and child sexual exploitation.     Are there any factors that should be taken into account that impacted upon organisation/team/individual practice ?    How satisfied is your agency that judgements in respect of safeguarding and promoting the welfare of children were sound and supported by firm evidence?  Was risk to children sufficiently identified and acted upon?  Are you satisfied by the management oversight?   Did workers have access to reflective supervision?     Was information shared across agencies at appropriate points? If not, what do you think may have prevented this from happening?    Is there any organisational learning that you can identify for your agency from the information available to you?    In respect of sexual exploitation:    Does the agency/service consider itself to have sufficient knowledge   and skills to identify and respond to CSE?     Are there any gaps in knowledge that need addressing?    The reports were completed thoroughly; they were analytical and demonstrated a robust and reflective approach to judgements of practice.   3.3 The timescale for the Review was determined as 1st January 2013 to the 3rd August 2015. It was agreed that this would provide scope to include historical events which were relevant, allowing for a greater understanding regarding more recent interventions and decision making.   3.4 The timelines and agency analyses were condensed into three narrative stories for each of the children and these were presented to the Panel Meeting in December 2015. These narrative stories provided the basis for identifying the emergent themes which the Review Panel believed were key.  4  In this respect the Review Panel worked collaboratively to identify critical pathways, points of learning and to focus on thematic issues.  3.5  A multi-agency practitioner meeting took place with practitioners and first line managers to consider the emerging themes and their relevance to wider and current practice.  3.6 The views of the children and their parents and carers were also sought.  Ongoing investigations and a period of change limited the ability of the Review Team to explore perspectives of Lauren at an early stage.  Shortly after the review was presented to the Board Lauren expressed a desire to contribute to the Review and a meeting was arranged with the Board Business Manager and Reviewer.  Lauren was an extremely articulate young person, she spoke candidly of her need for nurture, acceptance and belonging and how initially this is what she truly believed the alleged perpetrator was offering her.  Lauren explained that she would deliberately deceive professionals when she perceived them as threat to developing this relationship, but that she liked most of the professionals who worked with her. Lauren believed that protection should have been implemented whilst she lived with her mother and that greater controls should have been achieved for her during her adolescent years.  Significantly, Lauren described that she enjoyed the controls imposed by her current carer, and how she will ask to push a boundary simply because hearing the word no makes her feel cared for.  Lauren urged professionals to think beyond the obvious, to consider the role of adults in the children’s lives and how they may be connected.  Lauren singled out the local mental health service as one which provided consistency and emotional support, and also stated that the two significant social workers had shown her care and concern.   3.7 The Mother of Hannah was spoken with and provided useful insights regarding the experiences of both herself and her daughter; however Hannah was clear that she did not want to contribute to the Review. Attempts were also made to contact Samantha and her family, however no response was received from Samantha and family members were unable to contribute because of other commitments.  3.8 The majority of the source information for this Review has come from the agencies’ own internal reports, contributions and analysis. Accounts of any deficits in performance have come from the agencies themselves and reflected an honesty, willingness and open minded approach to learning.  This culture of transparency has enabled the Panel to have genuinely challenging discussions about how local systems can be adapted to better meet the needs of children at risk or exposed to child sexual exploitation.   3.9 The review reflected on a process of developing awareness and consequent improvement of services that have emerged in the LSCB area over the past 3 years in relation to Child Sexual Exploitation.  5  4.         The National and Local Context  4.1      Child Sexual Exploitation is now recognised as a crime against a child that has far reaching consequences for the child’s life, the family and Society as a whole.  The Children’s Society publication “Old Enough to Know Better” (November 2015) outlined that until relatively recently children were being exploited and then criminalised for their involvement in commercial exploitation. Only in 2015 was the law changed, which means that it is no longer possible to prosecute a child under the age of 18 for involvement in their own sexual exploitation. The language of ‘child prostitution’ has also been renamed as what it really is: Child Sexual Exploitation.  Given that this Review is in relation to Child Sexual Exploitation, the working definition as described by government and adopted by the Review is as follows:   Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability.”   (National Working Group for Sexually Exploited Children and Young People and Working Together to Safeguard Children, 2015).   4.2 The following national, enquiries, research and inspection have all been published during the time frame for this Review:    The See Me, Hear Me Framework, published in January 2014 was an inquiry into Child Sexual Exploitation in Gangs and Groups published by the Office of the Children’s Commissioner.   The Jay Report, an Independent Inquiry in to Child Sexual Exploitation in Rotherham 1997-2013, by Professor Alexis Jay, which identified a range of factors at both managerial and practitioner Level, which created the conditions within which long standing and large scale sexual abuse of children in the community took place.    OfSTED Thematic Inspection: The Sexual Exploitation of Children: “It Couldn’t Happen Here, Could it?” published in November 2014 identified  6  a number of findings from Practice which impacted upon successful outcomes for young people at risk of CSE.  Real Voices, an Independent Report by MP Ann Coffey, examining responses to sexual exploitation in Greater Manchester in 2014 and drawing on events in Rochdale, emphasised the need to listen carefully and seriously to children and young people.  Threat Assessment of Child Sexual Exploitation and Abuse: the Child Exploitation and Online Protection Centre (CEOP), published July 2013, which highlights that approximately 5% of UK children suffer contact sexual abuse at some point in childhood. Between 2011/12 and 2013/14, 90% of all Local Authorities have seen rises in Police recorded child sex offences with Police Forces nationally identifying a 40% increase in the recording of Child Sexual Exploitation Offences.  4.3 The Review recognised that these national initiatives had influenced much policy formulation, service delivery and practice in the LSCB area.   4.4 The LSCB area has a less urban and smaller minority ethnic demographic from many other areas where Child Sexual Exploitation has been linked to gang culture and particular issues regarding ethnicity. The recognition of Child Sexual Exploitation in the area has been a developing and emergent process and agencies have demonstrated a real desire to both comprehend and respond to, in a more effective way, an issue which has become more of a reality for the area, particularly over the past three years.  4.5 The commissioning of this Serious Case Review, whilst not mandatory in respect of national guidance, has also evidenced a strong multi-agency commitment to recognising and responding to the issue more effectively. This is further evidenced in local reporting and the number of local initiatives which have reflected this development as awareness of the extent and nature of the problem has grown. It was also evident from discussions with Panel members and practitioners that within the time of the review, particularly during its early stages, less was known about Child Sexual Exploitation.   4.6 Responses to Child Sexual Exploitation have also taken place within a changing landscape regarding the reorganisation and reshaping of Children’s Services. The introduction of the single assessment, the implementation of the revised version of Working Together (2015), the response to the publication of the Munro Report and changes to the commissioning of School Nursing services, which has impacted on recruitment and retention, have all been significant issues.  4.7 A recent Elected Member Briefing Paper in respect of Child Sexual Exploitation has identified key issues for the area such as:   7   Increased awareness of Child Sexual Exploitation and the consequent demand for services and impact on agencies.  The need to ensure that robust early intervention and preventative services are in place.  The need for effective information sharing between partner agencies and the Voluntary Sector and effective cross referencing of information and softer intelligence.  The need for the effective disruption of offending  behaviours.  The need for ongoing awareness raising regarding Child Sexual Exploitation, particularly in Education settings and with  parents, carers and families.  4.8 In order to respond to these issues the following services are available in the area:   Barnardo’s Services, including both local and national initiatives.  Independent Sexual Violence Advocate Service (ISVA), working with children and young people who have experienced sexual violence.  Awareness raising with licensing and night workers in respect of protecting children from Child Sexual Exploitation.  Missing from Home: allows early identification of risk and ensures a consistent approach to Return Interviews and referrals to support services where appropriate.  Youth Workers: includes the delivery of Risk Taking Roadshows to all secondary schools across the LSCB area and the delivery of tailored Child Sexual Exploitation group work and individual one-to-one work with young people.  4.9 The LSCB leads the governance arrangements for Child Sexual Exploitation Services within the area and in collaboration with other LSCBs has performance management systems and reporting arrangements in place.  4.10 The  Sub Regional Strategic  CSE Group provides strategic direction across the wider sub regional area for agencies working with children and young people who may be at risk of, or vulnerable to exploitation. The Strategic Group also provides a forum for sharing good practice and intelligence across the sub regional Local Safeguarding Children Board Sub Groups and is chaired by a Police Superintendent.  The Sub Regional Group has also taken the lead to deliver a preventative initiative, which aims to raise awareness and offer advice to small businesses such as taxi firms, hotels and fast food outlets, regarding the prevalence of Child Sexual Exploitation. The group has also taken the lead to deliver a major publicity campaign which provides information for children, families and professionals regarding signs and symptoms, advice and guidance.  4.11 The LSCB, CSE Sub Group, aims to strengthen the identification of young people who are vulnerable, exploited, missing or trafficked and to ensure  8  robust and effective safeguarding processes are in place in the area. The Group holds responsibility for the Strategy and Work Plan and oversees the CSE Practitioners Group. The Work Plan of the Group reinforces the four priorities of the Sub Regional Strategic CSE Group which mirror the themes of the See Me Hear Me Framework;   Preventing, identification of those most at risk and ensure focussed early intervention.  Protecting, to offer support and the provision of services to young people who are at risk of sexual exploitation.  Prosecuting, to proactively identify perpetrators of Child Sexual Exploitation and to disrupt offending behaviour.   Publicising, the promotion of awareness of Child Sexual Exploitation through schools, agencies, families and communities.  4.12 The  CSE Practitioners Group  works collaboratively to safeguard children and young people by sharing intelligence, interrogating data relating to possible perpetrators and locations of concern and examining new referrals and historical information.  4.13 The LSCB undertakes quarterly audits of randomly selected Child Sexual Exploitation cases, the findings of which are reported to the LSCB and are used to inform service improvement and delivery.  4.14 The following training and awareness raising programmes have also been delivered in LSCB area:   Child Sexual Exploitation Drop in Sessions, which are available to Elected Members, Officers and partner organisations, including voluntary, statutory and community groups and which can be accessed through the LSCB Training Programme;  Safeguarding Children from Sexual Exploitation, a one day training session available to Elected Members, Officers and partner organisations, including voluntary, statutory and community groups through the LSCB;  Chelsea’s Choice, an awareness raising theatre production, commissioned by the LSCB for all secondary schools, which has currently reached a significant number of pupils, practitioners and parents;  E-Learning Accredited Awareness Raising Programme, which reflects current research, government guidance and best practice;  A Safeguarding Conference, facilitated by the LSCB which included contributions from Barnardo’s, Chelsea’s Choice and young people from the area.  4.15 A review of these developments clearly indicates a purposeful multi-agency recognition that Child Sexual Exploitation does exist within the sub regional area and that young people, both male and female are being groomed by a number of perpetrators. It is also unlikely however, that available intelligence  9  and data reflects the full scale of the issues as sexual exploitation and trafficking, in particular, are offences which involve silent victims, who may not have identified themselves as a victim of exploitation. Children may be deterred from reporting due to fear, intimidation, manipulation, control, embarrassment, self blame or mistrust of professional agencies. In the LSCB area there has also been a rise in Child Sexual Exploitation cases, in line with the national average noted above, with victims being predominantly female and white European. Offenders are predominantly male and the highest number of victims are aged between 14 and 15 years closely followed by those aged 16 or 17 years .  4.16 The local Police force has established a specialist unit specifically for gathering and managing Child Sexual Exploitation intelligence. Progress with regard to investigations is also shared at a strategic level with Directors of Children’s Services, Chairs of LSCBs and Senior Officers.  4.17  There is therefore, a set of robust initiatives, responses and developments which reflect a commitment from Statutory and Voluntary agencies to respond to Child Sexual Exploitation, raise awareness, improve outcomes for children and young people via robust safeguarding arrangements and to enable the effective prosecution of offenders. This was clearly reflected in both the commitment of the Serious Case Review Panel and the openness, honesty and commitment to learning by Practitioners and Managers who participated in the Practitioners Event and Briefing. In this respect the culture demonstrated by the representative agencies was positive, open to challenge, learning and reflective.   5.          Key Lines of Enquiry  5.1 Whilst an initial Terms of Reference and scope regarding the Review were agreed at the Panel Meeting of the 19th October 2015, these were developed and amended into Key Lines of Enquiry. The Initial Terms of Reference were in respect of;   The experience of the young people involved and whether agencies maintained a focus on the young person.  A consideration of the actions of the agencies and individuals in relation to who knew what when and was this knowledge understood in relation to sexual exploitation.  What factors militated against the early recognition of the risk of sexual exploitation.  Whether procedures were correct and were applied consistently.  Interagency information sharing.  Supervision and support arrangements for staff.  Training of staff in understanding and recognising sexual exploitation.   10  5.2 The Key Lines of Enquiry which were identified by the Review Panel as being of critical importance, followed the production of the children’s narrative stories and developed the original Terms of Reference into what the Panel believed were the critical factors which required exploration and analysis. These were in respect of:   Thresholds: what factors influenced decision making regarding interventions, what tools and models were used to inform decision making and how effectively were safeguarding procedures utilised?  Joint Working: how effective were relationships between the Police and Children’s Social Care and how effective were the relationships between the CSE Strategic Groups and Operational Practice?   Multi agency working: how effective were responses to Missing from Home episodes, how effective was the multi agency planning process, how well understood were common language and processes and how effective was professional challenge?  Vulnerability Factors: what were the specific vulnerability factors for Hanna, Lauren and Samantha and how effectively were these factors considered in any assessment, planning and interventions for these children? Also, how common were these vulnerability factors for all three children?  Role of Parents and Carers: what were the specific issues for practitioners in respect of working with the parents and carers of the three children? How were the children assessed in the context of these relationships? Were parents and carers assessed as protective or harmful and what were the common features for these three children regarding their family backgrounds?  The Child’s Voice: how were the voices of children heard and how did this influence any decision making and interventions?   Understanding Child Sexual Exploitation: namely when or how was Child Sexual Exploitation identified and what were the implications for practitioners regarding skills, knowledge or resources?   6.          Analysis        All agencies provided comprehensive timelines, chronologies and analyses regarding involvement for all three children. These contributions, in addition to contributions made by practitioners and managers, provided the sources for the analysis in respect of the key lines of enquiry. This was assisted by contributions from Panel Members as well as the Independent Reviewers.   6.1 Thresholds of Intervention  6.1.1 The LSCB area have established robust safeguarding procedures, underpinned by a Child Concern Model. This approach enables practitioners to locate interventions in a consistent, targeted and systemic manner.  11  Contributions from Panel members and practitioners indicated a general consensus that Safeguarding processes often work well, particularly for younger children. For older children and teenagers such as Hannah, Lauren and Samantha there were perceived deficits regarding the appropriateness of child protection systems which may have precluded their application when responding to those young people who are at risk of sexual exploitation. Review participants recognised that Child Protection systems are more often used for younger children or when risk is perceived to originate from parents or care givers, rather than from an external source in the community.  6.1.2 For Hannah, there were specific concerns which included ongoing associations with the alleged perpetrator, a number of missing from home episodes and a previous history of self harm, alcohol and substance misuse. There was also resistance from both parents to agency intervention and support, including assertions from Hannah’s father that her relationship with the alleged perpetrator was a positive one. This hindered engagement with the family and created difficulties in assessing risk of harm to Hannah.  6.1.3  There was also emerging intelligence that Hannah may also have been involved in grooming other young people, warranting consideration at the CSE meetings. Additionally, there was a significant volume of concerning photographic data which was recovered by Police, describing sexual relationships between Hannah and at least two males over twenty years of age. Hannah had described to her Social Worker intimidation by the alleged perpetrator and her associates and there was Police Intelligence to suggest that Hannah was associating with at least 2 males, about whom significant safeguarding concerns had been expressed.   6.1.4 This information and intelligence emerged over time during the Review period and interventions whilst provided initially on an Early Help basis then continued on a Child in Need basis. A first referral was made to Children’s Social Care by school in April 2014, regarding Hannah’s relationship with the alleged perpetrator and significant drug and alcohol misuse. The outcome of the referral concluded that outreach support would be provided. Hannah’s father at this point had also been described as rejecting of support, refusing any interventions and had attempted to minimise the risks to Hannah. Later that month, Hannah was admitted to hospital following a paracetamol overdose, which Hannah described as a suicide attempt and self harm lacerations. In June 2014, because of concerns raised by Police and the NSPCC regarding Hannah’s associations, Hannah was added to the CSE list. This included  children considered at the CSE Practitioners group and the process was considering the circumstances of up to 60 children at any one time.   6.1.5 In August 2014, Hannah was found by Police in the early hours of the morning with the alleged perpetrator and a male about whom there were serious concerns regarding the exploitation of children.  Following this it was  12  agreed that a Common Assessment Framework (CAF) would be completed on Hannah’s return to school. This response did not comply with the threshold criteria and reflected a much lower response than was necessary.  By October 2014 there was evidence of interagency challenge when concerns were expressed by the Police regarding the level of social work intervention. Police intelligence suggested that Hannah had been attending an address where drug and alcohol use was taking place and where the alleged perpetrator was attending, along with older adults. It was agreed that a Social Care Assessment would be completed and Hannah’s Social Worker was directed to complete an assessment.  6.1.6 The Chair of the CSE Practitioners meeting also raised a concern that responses to Hannah should be treated as a Child Protection/Safeguarding issue, not as a Child in Need intervention. The Chair requested an immediate Strategy Meeting as she believed that Hannah was being sexually exploited and that Hannah’s parents were not engaging with the Social Worker. This incidence provides evidence of oversight and challenge but, given the subsequent actions, no effective feedback loop, as no assessment was completed for four months which again concluded a need for Child In Need services. A new, specifically chosen Social Worker was appointed to impress upon Hannah’s parents that there was reliable information to suggest that Hannah was being exploited. In November 2014 a significant volume of photographic material was recovered from Hannah’s phone and she reported to her Social Worker that she was in a relationship with a male who posed a risk to children. Hannah’s parents were again described at this time as hostile and intimidating to receiving this information. The conclusion of the assessment resulted in a referral to local Barnardo’s services, and whilst this was an appropriate referral, Hannah remained defined as a Child In Need throughout the Review period.   6.1.7 For Samantha, her involvement with Children’s Social Care prior to 2014 was limited to the provision of equipment and signposting to other services. It is well documented that Samantha’s mother found her behaviour to be challenging and difficult to manage. In March and June 2014 there were Missing From Home (MFH) episodes and concerns reported by Samantha’s mother, that Samantha was in a sexual relationship with a 26 year old man and that Samantha was at the address of the alleged perpetrator. In June 2014, on the date of the 2nd MFH episode, it was indicated that Samantha had been assaulted by her Grandmother and again later the same evening by a member of the public. On this occasion Samantha was reported as heavily intoxicated and in the presence of a 26 year old male, about whom there were significant safeguarding concerns. Whilst the first missing incident was not shared by the Police, later in June the Police did make a referral to Children’s Social Care which stated that Samantha had been in a sexual relationship with an older male and was associating with the alleged perpetrator. The outcome of that referral was that the Early Help Service would continue to support Samantha, with no indication that a further  13  assessment was necessary. This would suggest that the key indicators of CSE such as association with older males and missing from home were not sufficiently understood as risk factors at that time. In October 2014, Samantha was added to the CSE list for consideration at the Practitioners Group.   6.1.8 Using a locally agreed  referral tool, the Police made a further referral to Children’s Social Care in April 2015, this was recorded as a contact when it should have been treated as a referral and the Police were informed that Early Help had been offered to Samantha.  The Police had also provided additional information that multiple males had been contacting Samantha via Facebook, in relation to sex and drug use. At this point the Assistant Director for Children’s Social Care, following concerns expressed by the Police, requested that this be progressed to a referral and an appropriate Assessment. This again indicated appropriate challenge by the police. The subsequent assessment led to a referral to local Barnardo’s services in July 2015 which did result in significant attempts to engage her by the allocated worker, although Samantha was inconsistent in her responses and engagement.   6.1.9 For Lauren the interventions follow a different pathway. Lauren had been living with her grandparents since 2011 and they were struggling to manage her behaviours. Grandmother was concerned that Lauren had been missing on at least one occasion and that she had been uploading photographs of herself kissing boys on social media sites. In February 2013 Police were called to the Grandparents home, as it had been reported that Lauren had been refusing to comply with boundaries and was being restrained on the floor. Lauren disclosed that her Grandfather had head butted her and a Section 47 Enquiry commenced. Lauren was accommodated but returned to her Grandparents home after 11 days in foster care, at which time the Police Investigation was incomplete and her grandfather had not been spoken to regarding the incident.   6.1.10 Within a short space of time, the situation deteriorated to the point that a tent had been erected in the garden for Lauren to sleep in.  This resulted in Lauren being accommodated in July 2013 for a second time and she returned back to her Grandparents care in November 2013, at Grandmother’s request and following Lauren’s wishes. It was clear that the Children’s Social Care Team had reservations, but felt powerless to direct any other option. This decision for Lauren to return home was not however underpinned by an assessment of the risks and there was no risk management process put in place.  There were continued reports of Lauren being missing from home, at one point for four times during one week and a further allegation that her Grandfather had head butted her. Whilst the relationship between Lauren and her Grandfather had been acknowledged as a volatile one, with reports of Lauren attacking both her siblings and her Grandparents, interventions remained on a Child in Need basis.   14   6.1.11 In May 2014, Lauren was accommodated for a third time following a further Section 47 Enquiry and this time the application of the Public Law Outline (PLO) was considered. The Section 47 Enquiry also concluded that Lauren should remain in Foster Care. Information provided to the review indicated that an application for a Care Order was discussed with Lauren by the Independent Reviewing Officer, but that Lauren was adamant that she did not want this to happen. Further discussions took place but ultimately a decision was made not to initiate care proceedings.   6.1.12 There are a number of issues which flow from the narrative stories of the three children. Firstly, that that application of thresholds did not sufficiently identify risk of CSE and consequently utilised Child in Need or Common Assessment Framework (CAF) Protocols without consideration of child protection procedures associated with higher levels of risk.  Secondly, for all the children there were points which clearly evidenced increased risk of significant harm but which did not result in a review of how thresholds were being applied.  In attempting to understand why more formal safeguarding systems had not been applied, a number of themes emerge. Practitioners and managers raised the issue that child protection procedures and Conference are seen as a forum where risk is presented solely from within the structure of the family rather than from the community. This may have been a factor which precluded the application of child protection processes, as the major source of risk for all three children was their association with the alleged perpetrator and a number of older males. The application of the Child Protection Plan also carries with it the inference that any safeguards that parents or carers may be providing are inadequate, leading to an overall assessment of continuing risk of significant harm, where parents and carers are a significant risk factor.  6.1.13 Practitioners also described some of the difficulties in applying a protective system where there are ambivalent, resistant or challenging behaviours exhibited by the young people. Throughout the process Hannah consistently denied any sexual involvement with the adults who posed a risk of harm, whilst Lauren indicated that she did not want to be subject to Care Proceedings, stating that there were too many people in her life and that she did not want any further involvement. The perceived effectiveness of safeguarding systems for hard to engage young people was therefore a consideration. For Samantha, there were misplaced assumptions regarding her capacity to consent based on her chronological, rather than her functioning age, alongside a poor understanding of  an ability to exercise choice in an abusive situation,  which then influenced decision making.  6.1.14 There may also have been a reticence to use what has traditionally been seem as a more adversarial system, in the desire to achieve a greater level of  engagement with family. The resistant and sometimes hostile stance of Hannah’s parents in particular demonstrate this, as practitioners clearly  15  wanted to engage more positively with Hannah’s parents to enhance her protection. For Lauren, violence had become part of the family dynamics, with Lauren herself often being violent towards her Grandparents and siblings and it was difficult for practitioners to differentiate between victim and perpetrator, particularly with regards to the violent episodes in the home. There was however, sufficient evidence to indicate that the actions of Lauren’s carers were both emotionally and physically harmful to her. If the practitioners had been more minded with regard to sexual exploitation, they may have given greater consideration to the damaging effects of this behaviour on Lauren’s self-esteem and how this could have increased her vulnerability to exploitation. For Hannah, the resistant and minimising stance of her parents was clearly a concerning enough risk factor.   6.1.15 Whilst practitioner perspectives regarding the appropriateness of child protection systems have been noted, there were issues for all three children, regarding some level of risk posed by their parents and carers. Whilst Lauren’s experience was different, in that she was accommodated several times, there was evidence that at least one Section 47 enquiry remained incomplete and that Lauren moved back to her Grandparents a number of times without a good enough assessment of risk or a risk management plan. For Lauren there were two broad levels of intervention, Accommodation as a Looked After Child, or interventions on an Early Help or Child in Need basis. Whilst an application for Care Proceedings for Lauren was considered and recommended by the Social Worker, this was not progressed and a number of practitioners described this as a missed opportunity.   6.1.16 Whilst it may be that the Board does need to consider more innovative ways of identifying and managing risk and vulnerability for older children and young people, particularly in the area of Child Sexual Exploitation, there was sufficient information to suggest that Safeguarding Procedures may have been a more appropriate response in all these cases. Practitioners and Managers described the use and value of an agreed diagnostic tool which assisted decisions regarding where interventions are to be located, yet analysis indicated that this was not used either consistently or appropriately in all the cases. It was difficult to get a sense of transition from Early Help via Common Assessment Processes to Child in Need and then Child Protection levels as events unfolded.   6.1.17 In terms of the unusual circumstances regarding the gender of the alleged perpetrator, the following issues emerged. The alleged perpetrator was a relatively young female who had herself been a vulnerable child.  This may have hampered the ability to recognise that essentially what was taking place was the sexual abuse of children by an adult. Powerful normative societal values perceive women as nurturers and sexual abuse as a feature connected to male dominance and power.  Although statistically sexual offenders are in the vast majority male, there are many examples of women who operate as sexual abusers alone and within a partnership. In the context of Child Sexual  16  Exploitation, the recruitment of other young people by a peer is also a common feature. This will have been compounded by the age of the alleged perpetrator. Assessing circumstances whereby a young person is considered a victim as well as perpetrator is a particularly challenging aspect of sexual abuse. The alleged perpetrator, in tandem with Hannah on occasion, was part of a wider network of predominantly male operatives, whom this review has not considered and as one practitioner stated ‘we have been looking [criminally] at the wrong people.    Finding:   Assessing risk of sexual exploitation must be embedded into early help services.   Thresholds need to be applied at a level consistent with risk.  Social work assessments need to be applied in a timely manner.   Looked After Children care planning needs to focus on security and permanence.    6.2      Joint Working  6.2.1 The Review acknowledged both the commitment to joint working evidenced by Panel Members and also the clear protocols which are in place governing joint working in the area. However, analysis of information presented to the review indicated a variable picture, with evidence of good practice, challenge and timely interventions but with some evidence of weaker responses.   6.2.2 Consideration of the responses to Missing from Home episodes presents variable, but often less than satisfactory responses. In Hannah’s case, her parents did not always report her missing. Hannah’s mother informed the review that they wanted to address the issue themselves and evidence suggests that there was a level of parental resistance and hostility, particularly regarding Police involvement. This clearly limited the ability of agencies to respond to events as they were unfolding. In some instances there was a delay in information sharing, which hindered the effectiveness and agility of responses and concerns were expressed by Police regarding delay and the quality of joint working during the investigative process regarding Hannah.   6.2.3 On occasions when Missing from Home incidents were responded to by the Police, there is evidence to suggest that information was not always shared with Children’s Social Care. In Samantha’s case there were two Missing from Home episodes, one which took place in March and the second in June 2014. No referral specifically followed either incident. The incident in June ended when Samantha was found by Police Officers with a much older male who was supplying her with alcohol. This episode was not subject to any Police  17  investigation and no referral information was communicated to Children’s Social Care regarding this incident.  Information was also conveyed by Samantha’s mother to Police Officers at the time, regarding her daughter’s complex needs, developmental functioning and her vulnerability to sexual exploitation. The Police analysis acknowledges that whilst Samantha was located and advice provided, no offences were recorded and the alleged assault by her grandmother was not mentioned and not crimed. This is also the case with regard to an allegation, made at the same time by Samantha’s mother that her daughter was in a relationship with a 26 year old male. In addition, no checks were undertaken regarding Samantha’s Aunt, with whom she then went to stay until the volatile situation that the Police were responding to had calmed down. The subsequent referral was recorded as a contact only, and it was noted that, as Samantha was shortly due to move out of the area to be with her mother, the risk was diminished.   6.2.4 Information from Lauren in June 2014 suggested that she had witnessed sexual activity between Samantha and an older male, although it was not until October 2014 that Samantha was referred to the CSE Practitioners Group. In February 2015 at 3am, Samantha contacted the Police requesting assistance as she was concerned and frightened regarding the actions and behaviour of a male who was intoxicated and behaving aggressively. Police attended, although it is recorded that Samantha was with another female who took Samantha to another address. No details were recorded of who the other female was, who Samantha was left with and whether this was either suitable or appropriate. There was also no referral attached to the event which suggested again that information was not shared with Children’s Social Care. The absence of referrals beyond the Police appeared to relate to officers not contextualising or understanding what might have been taking place due to a lack of knowledge regarding the signs and symptoms of exploitation and the specific risks faced by the child, even though she had already been considered at the CSE meeting.  6.2.5 The issue of Hannah’s parents non-reporting of missing episodes has already been described and this in itself was a significant risk factor which should have been clearly identified as a safeguarding concern within the family. However, Hannah disclosed that on occasion she had been picked up, sometimes as late as at 4am by the Police, without any other agency being made aware that she was missing.   6.2.6 There are a number of examples of good practice with the Social Worker for Hannah responding to police information in a timely way and attempting to engage her parents. Recording for Hannah was detailed and thorough.  6.2.7 Lauren had no missing episodes recorded until January 2014 when there were at least 6 episodes recorded during the month. Recording for Lauren is patchy by Children’s Social Care, which makes it difficult to understand some of the responses. In June 2014 the school expressed concern about Lauren  18  being missing, although it was subsequently recorded during a meeting at school a few days later, that there were no safeguarding concerns for Lauren. There were however, instances of good practice and clear evidence of more appropriate responses regarding missing episodes for Lauren whilst she was in Foster Care. Thee responses were robust and appropriate, indicating that Looked After Children processes were in place and joint working between Police and Children’s Social Care was better supported.   6.2.8 There were some practical considerations which impacted on the effectiveness of joint working, such as a lack of notice being given regarding key meetings, which hindered the ability of key officers to attend. This was evident in exchanges between the Police and Children’s Social Care (CSC) regarding Hannah in September 2014, where Police information indicated that they understood there was no social work activity and insufficient contact between the Police and CSC regarding safeguarding Hannah. However records indicate that a Social Work service was being provided at this time along with support offered by a local Drug and Alcohol service for Young People regarding Hannah’s alcohol use.  6.2.9 The analysis of joint working indicates a varied picture, with some instances of positive and timely practice and other indications that key information was not always communicated, particularly between Police and Children’s Social Care. Information also suggests that there were examples of misunderstandings, such as the assumption made by Police that there had been no Social Work involvement for Hannah during the summer of 2014, when a number of services were being provided.  When some referrals were made by Police to Children’s Social Care, such as in the case of Samantha, they were not always responded to in a robust manner. For Police Officers who may have been relatively inexperienced, or who lacked a knowledge base regarding the dynamics and complexities of Sexual exploitation, this raised the importance of training, development and access to guidance and information which impacted on the quality of response.  Practitioners also described uncertainty about what information could be shared, particularly with parents, and which information could be legitimately shared with professionals, all of which impacted on a shared understanding of the children and risks they were facing. Information from the Practitioner Event suggested that Police Officers responding to missing episodes were not always sufficiently knowledgeable about signs and symptoms of sexual exploitation and that intelligence systems did not always reflect children about whom there were specific concerns. Whilst the lack of an application of a more appropriate safeguarding system will have undoubtedly contributed to this issue, a more systemic approach to the recording and administration of information about specific children may have improved the ability of officers to identify and share indicators regarding ongoing risk.     19  Finding:    Quality of information is significant, particularly when sharing across agencies.  Uniformed police officers need to have sufficient knowledge of sexual exploitation to deploy safeguarding responses.    Missing from home is a key indicator and needs a consistent and coherent multi-agency response.    6.3     Multi Agency Working   6.3.1 The Review acknowledged the willingness of multi-agency partners to work together in the area and this was evidenced during the Review by the agencies represented. The Independent Reviewers observed a culture that was constructively challenging and open to learning, with agencies demonstrating a strong commitment to both understand the nature of what had been taking place and to develop local solutions and responses. There is a strong foundation for multi-agency working which is supported by comprehensive policies and procedures.  6.3.1 There were a considerable number of agencies involved with the three children, particularly for Hannah and Lauren, to the point where Lauren believed she was overwhelmed with services and consequently expressed frustration at having to repeat her story to so many professionals. Whilst these local agencies were providing valuable therapeutic and support services, the absence of a more focussed planning process was noticeable and this was an issue raised by the mother of Hannah during the Review.  This absence of a structured approach to multi-agency planning and review also contributed to some practitioners feeling like they were working in the dark. Whilst this was due in part to the developing and emerging awareness of the nature of sexual exploitation, practitioners described a lack of clarity and explicitness regarding the issue which would have been assisted by a better defined and sharper focus on multi-agency planning and review. There were however, some good examples of effective informal communications between practitioners and this may have compensated for the overarching weaknesses.   6.3.2 The perceived weaknesses in the child protection system, to respond effectively to high levels of risk and vulnerability outside of the family, influenced and impacted on the quality of multi-agency working. It is also true however, that whilst Child in Need and Early Help models were utilised, because they were perceived as being far more co-operative and consensual, there remained an absence of a multi-agency infrastructure regarding children’s plans, meeting and reviews. Consequently, all of the interventions for the children, particularly Samantha and Hannah, were not structured around an individual child’s plan.  Practitioners and managers described how  20  Child In Need and Early Help arrangements are not always perceived as statutory in the way accepted for child protection processes, which has a limiting effect on activity and attendance at meetings, which can often be resource led and therefore inconsistent. Whilst Lauren’s views regarding the need for Care Proceedings have been noted, there is a question as whether this was allowed to override what was in her best interests. Although Lauren’s home life was chaotic, leading to regular family breakdown, no firmer or more decisive action was taken and Lauren needed to be subject to a more rigorous risk management approach. These findings are consistent with the Ofsted Thematic inspection published in November 2014 which identified the following similar themes:    That Local authorities and police are not always following formal child protection procedures with children and young people at risk of child sexual exploitation.  Screening and assessment tools, where they exist, are not well or consistently used in some local authorities to identify or protect children and young people from sexual exploitation.  Plans of how local authorities and their partners are going to support individual children and young people at risk of, or who have been sexually exploited, are not robust.   Local authorities are not keeping plans for Children in Need under robust review. This leaves some children in a very vulnerable position without an independent review of their changing circumstances and needs.  Management oversight of cases is inconsistent and is not strong enough to ensure that cases are always being properly progressed or monitored in line with the plan.   6.3.3 The infrastructure regarding the arrangements of the CSE meetings has been described under the section on Local Context, yet analysis of how these systems operated indicated a number of issues. Firstly, decisions and information were shared at a strategic level but there was a concern from practitioners that this was not sufficiently cascaded down to operational activity or case management.  Secondly, feedback from Practitioners suggested that because the Police did not issue information for a number of weeks, other professionals were not always aware of the salient issues at a point when they could take action. Consequently practitioners described some uncertainty and ambivalence regarding what they were responding to, and how timelines impacted upon their options.  A striking message which emerged during the Practitioner Event was the description of sexual exploitation in these cases as a ‘Guarded Secret’. This will have undoubtedly influenced and contributed towards a limitation in recognising what is essentially sexual abuse of children and will have contributed to a lack of clarity regarding decision making. Thirdly, and connected to this point, the relationship between the Strategic and Practitioner CSE Groups was not always clear and information flow was not efficient, timely or agile. Recommendations from CSE meetings were not always actioned and there  21  was no feedback to ensure this occurred. The Jay Report (2014) emphasised the absence of risk assessment and risk management as part of an environment that left risks badly managed.   6.3.4 Comprehensive information was supplied by the schools, certainly in Hannah’s case regarding concerns about her relationship with the alleged perpetrator.  The concern about how and where softer information and intelligence could be shared without the knowledge of family meant that in many instances, agencies did not have common knowledge. This was compounded by the use of Child in Need or Early Help multi-agency approaches where service provision and interventions are based around parental/young person consent regarding information sharing and communications. The use of the Child Protection Conference, with a facility for confidential intelligence sharing and discussion may have assisted with this, particularly in respect of concerns regarding the children’s associations and networks.  6.3.5 The issue of capacity and resources does merit some consideration. A common theme emerging from the Practitioner Event was that working with children and young people at risk of sexual exploitation is both time and resource intensive, in terms of recognition and response, building trust and relationships and multi-agency working. A number of practitioners raised the issue of capacity in this respect and also suggested that whilst interventions for much younger children are extremely robust in the LSCB area, there is a need to remain equally focussed on the vulnerability of teenagers. This is a message supported by the Children’s Society publication, Old Enough to Know Better which illustrates the particular vulnerabilities of 16 and 17 years olds to sexual exploitation, and in particular how the law offers less protection to a child of this age. This includes the fact that a child at 16 is of a legal age to consent without any clear definition of consent and is often seen as no longer a child despite the provisions of the Children Act 1989. The child is unprotected through the disruption of offenders by means of Child Abduction Warning Notices, which only apply to children under 16.   6.3.6 Practitioners reported a culture that supported challenge, and this is evidenced specifically through this Review. In the case of Samantha, intervention by the Assistant Director for Social Care following an alert from the Police did lead to an assessment being completed in place of the already existing CAF. However, in the case of Hannah, concerns reported by the CSE chair did not generate a more robust safeguarding response. In this sense therefore, the evidence from the Review regarding the effectiveness of professional challenge is mixed. There are examples of leadership challenge but this was weaker in follow up. Officers suggested that a more practitioner inclusive multi-agency approach to audit could offer a way forward in enabling a greater understanding of where weaknesses occur in multi-agency working,  as well an opportunity to undertake reflective practice in a multi-agency context.   22   6.3.7 Practitioners received professional supervision, but the sole focus remained a single agency approach, which is open to the charge of being narrow in focus, particularly when responding to some of the complexities regarding sexual exploitation. In this respect it was felt that the development of a model of professional thinking time would be welcomed, in the context of facilitated, purposeful, professional only meetings. In evaluating whether a culture of curiosity was embedded within agencies, the evidence again suggested a mixed picture. It was clear that the foster carer caring for Lauren was both tenacious and determined in attempting to establish whether Lauren was having contact with the alleged perpetrator. This resulted in the foster carer following her to school on a number of occasions and reporting her concerns to the Fostering Agency which in turn were shared with the Local Authority.  Both Hannah’s parents and Lauren described the involvement of one particular member of school staff who communicated well with the children, their carers and agencies on a regular basis and whom Lauren reported as being only one of two individuals that she could trust.   6.3.8 By contrast, when Samantha attended the Urgent Care Centre in February 2014, reporting that she had been kicked in the arm, there are no enquiries with regard to what had happened. Whilst there were additional concerns in relation to her complex needs, challenging behaviours, sensory impairments and deteriorating family dynamics, there were no referrals to Children’s Social Care from key agencies who had been involved with her in the early stages of the Review. At a multi agency meeting in March 2014 it is recorded that the medical specialist had planned to contact agencies in the area local to where Samantha was living with her mother, yet there is no indication in any records that this took place.  Similarly, when Samantha moved area for a short time to be with her mother, the minutes of the CSE meeting (December 2014) recommended that the Police must share information with local Policing in the area Samantha had move to. However, Samantha is not mentioned in the minutes of the CSE Meeting in February 2015 and no indication is given that this recommendation had been actioned. When Samantha moved back to the LSCB area and was seen by the Education Psychology Service it was then concluded that Samantha’s particular combination of difficulties would make her very susceptible to exploitation.   6.3.9 Hannah had considerable contact with CAMHS in 2013 in relation to concerns regarding low self esteem, deliberate self harming, relationship difficulties, familial mental health issues, challenging behaviours, learning difficulties and an inability to engage with services. Whilst these signs and symptoms in themselves are not necessarily an indication of or susceptibility to sexual exploitation, they do point to significant vulnerability. In early March 2014 a referral was made to Children’s Social Care regarding Hannah’s relationship with the alleged perpetrator and alcohol and possible cocaine use, in late March, Hannah attended hospital following an overdose where it was noted that she had lacerations to her arm and there were concerns noted regarding  23  her low mood, lack of friends, parental resistance and a lack of school support. Hannah was admitted to hospital approximately 3 weeks later, following a missing episode and an episode of self harm using a pencil sharpener blade. She was 14 at this time, and no enquiries or communications took place with Children’s Social Care, regarding her vulnerabilities.     6.3.10 Practitioners had raised the issue of lack of knowledge, uncertainty regarding when sexual exploitation needed to be considered and stereotypical assumptions regarding gender roles in Child Sexual Exploitation as being a hindrance in recognising exploitation.  The Rule of Optimism (Dingwall, Eekelaar and Murray 1983) was also recognised as a possible rationale for understanding how professionals process and rationalise certain indicators and events, limiting the ability to identify safeguarding concerns. The consistent use of Early Help or Child in Need Systems will have reinforced this pattern of thinking. Recognising the significance of inhibitors is critical in developing a more effective culture of curiosity or respectful uncertainty. Conformational bias, the tendency to see what already supports rather than what challenges our views is a dangerous pitfall for professionals, and one which needs skill, critical thinking and a reflective and challenging working environment to mitigate against.   Finding:   There is a strong commitment and desire to work together and a culture of willingness, transparency and challenge.  Multi-agency structures across all the continuum of need are necessary to underpin communication and safer outcomes.  Children’s Plans need to be underpinned by accurate assessment of risk and need.    6.4     Vulnerability Factors:   6.4.1 In examining the particular vulnerability factors for the three children a number of common themes emerge.  There were social histories which include the absence of parental figures, particularly mothers. This was the case for both Lauren, who had not had contact with her mother for a number of years and Samantha whose mother was living a significant distance away during the period of Review. This also extended to fathers, so that whilst Hannah’s mother was present, her father was reported to work for significant periods of time away from the family home. Lauren, who was living with her grandparents, had not any contact with her birth father for a number of years and there are no records of Samantha’s birth father.  6.4.2 Histories of abuse and family dysfunction were evident. This was particularly the case for Lauren who had experienced physical violence including  24  exposure to domestic violence at home, her mother and mother’s partner’s substance addiction and prolonged experience of caring for her younger siblings. The CAMHS summary of January 2013 records,  a girl who has been abandoned by her mother who is a current heroin user, who has a history of family breakdown, hostile or rejecting relationships, being bullied at school by other children, communication difficulties, tells lies and displays anger and aggression. These circumstances also appear to be replicated, at least in part, in the family setting of her Grandparent’s home. For Samantha, there was involvement by additional agencies as far back as 2006 regarding support around boundaries, challenging behaviours, the provision of aids and adaptations and a referral to CAMHS, which followed concerns regarding sexual activity with 2 boys when she was 8 years old. Samantha had a sensory impairment and learning difficulties, a diagnosis of Attention Deficit Hyperactive Disorder (ADHD) and functioned well below her developmental age. These elements were insufficiently considered in relation to her susceptibility to sexual exploitation. For Hannah there were concerns regarding low self-esteem, self-harm, relationship difficulties, the prevalence of mental health issues within the family, challenging behaviours and low mood.  6.4.3 For all the children, the interventions would have been better progressed through comprehensive and robust assessments of risk. These early indicators of vulnerability should have influenced to a greater extent the decision making around thresholds of interventions, in accordance with the LSCB threshold document. Lauren was consistently reminded by her Grandparents that she was worthless and they often conveyed messages that suggested to her that she was evil and unwanted. The incident whereby a tent was put up in the garden for Lauren to sleep in is almost beyond comprehension and will have conveyed a profoundly negative and corrosive message regarding her self worth, self esteem and intrinsic value. In this respect the significance of low warmth/high criticism environments with regard to the assessment of vulnerability and risk, as referenced in Messages from Research (1995), is particularly applicable.   6.4.4 A related issue for all three children was their regular use of social media sites which was influencing their responses and behaviours and whilst this is a more complex issue to analyse, for these children it provided a form of communication and networking that increased, rather than minimised their vulnerability. The only evidence of any attempt to manage this was by the foster carer for Lauren, who attempted to limit the use of the internet and i-pad and provided appropriate parental/adult oversight. The need for e-safety knowledge is a significant one for parents, carers and practitioners, as in general terms, adults are often less knowledgeable than children about the changing pace of technology.   6.4.5 For all the children there were also indications that drug and alcohol dependency, risk taking behaviours, episodes of missing from home, issues of  25  abandonment and loss, dependencies on the alleged perpetrator and associations with a number of males who posed a risk, were also all prevalent. As all the children at some point, displayed some significantly challenging  and ambivalent behaviours, the Review considered how much this influenced an assessment of vulnerability, rather than an assessment of the children as being challenging or difficult. This was raised by practitioners as possibly lessening an assessment of vulnerability and awareness of abusive contexts, increasing the assumption that children and young people are therefore self determining or making active choices. Whilst the Review did not find any evidence of concerning practice in this regard, there was an acknowledgement that challenging behaviours can often be conceptualised as a problem for or within the child, rather than a symptom of vulnerability.  6.4.6 There was certainly recognition at the Practitioner Event, that the characteristics described will have increased susceptibility to sexual exploitation and that the inconsistent use of screening tools and the lateness regarding social work assessments, particularly for Hannah and Samantha will have prevented an early and more holistic analysis of vulnerability. This will have impacted on both awareness and recognition of risk. The vulnerability and risk factors described above were consistently acknowledged by practitioners as concerning, providing evidence that collective and organisational thinking had developed beyond the Review Period.  Whilst it was also acknowledged that some of these features in themselves do not definitively predict the presence of, or susceptibility to sexual exploitation, there was certainly some recognition that the prevalence of such a number of these factors increased vulnerability significantly. To this end, there is a need to ensure that Early Help organisations have a firm understanding of sexual exploitation with comprehensive guidelines and for social work assessments to be analytical rather than descriptive.    Finding:   Attachment and loss are highly significant vulnerability factors.   Complex needs such as disability, mental health, drugs and alcohol need to be considered as part of assessment and risk assessment.   Long standing family dysfunction compounds the potential for successful interventions.    6.5 Role of Parents and Carers    6.5.1 Policy, Procedures and Practice in the LSCB area are strongly orientated towards developing meaningful and outcome focussed partnerships with parents, family members and carers. This is evidenced by the use of the holistic approach in the area and the various tools which aim to capture the views, wishes and feelings of parents and carers at all stages of interventions.   26  6.5.2 An analysis of the role of parents and carers in these three cases indicated several common themes, some of which have been described earlier. For Lauren, who had not had contact with her mother for a number of years and about whom there was some evidence of idealised thinking by the child, the relationship was characterised by ambivalence, broken promises regarding contact and a consistent awareness of her mother’s inability to break free from significant drug dependency. A dysfunctional dynamic was also present in the relationship between Lauren’s mother and her Grandparents with evidence to suggest that Lauren’s mother exacerbated some of the difficulties that Lauren was experiencing with her Grandparents. In March 2013, Lauren’s mother had not fulfilled a promised commitment to have contact with Lauren; this was highly distressing for Lauren, particularly as her mother requested an assessment as a carer when she was accommodated. Whilst this was appropriately not progressed, it will have created confusion and ambivalence for Lauren. Again, as before these messages will have had a corrosive impact on Lauren’s emotional well being, in addition to the negative behaviours of her Grandparents which have been described above and which indicate poor attachment and greater vulnerability. Of particular concern were events in September 2013, where Lauren’s birth father, with whom she had not been having contact, resumed a relationship with her and contact between Lauren and her birth father began to take place. This broke down quickly and will have undoubtedly created additional rejection and distress for Lauren, increasing her emotional fragility and vulnerability, particularly in respect of her need for acceptance and belonging.  6.5.3 For Hannah, the role of parents differed markedly. There was evidence of an ambivalent relationship between Hannah and her mother.  There are a number of occasions where Hannah’s father is noted as being rejecting of support, requesting that agencies leave Hannah alone and that Social Work involvement would be professional overload. There are also occasions when Hannah’s mother indicated that she was displeased with the service and there was a belief by professionals that the parents were obstructing access to their daughter. For much of this time interventions were provided for Hannah on an Early Help and Common Assessment Framework (CAF) basis, and even up to November 2014 there are indications that the CAF had still not been completed. As described earlier, the chair of the CSE Practitioners Group raised concerns regarding the lack of a Child Protection focus and concerns were also expressed in October 2014 that the parents were minimising concerns. The lack of co-operation, and potential for collusion from Hannah’s parents was not sufficiently assessed as a risk factor which increased Hannah’s vulnerabilities and susceptibility to further exploitation.   6.5.4 Hannah’s mother stated to the Review that whilst Hannah was sneaking out at night, both parents had wanted to protect her without agency involvement. When asked about the hostile stance that both parents had taken with agencies, particularly the Police, Hannah’s mother reported that on one occasion the Police had raided and searched the house, had  27  threatened to “drag” Hannah down the stairs and accused her father of being a “poor” father. Hannah’s mother also reported that whilst Hannah was unwell in  bed, officers had arrived in a number of vehicles, had demanded her phone and also took items that the Police did not have authorisation to take, such as an i-pad, as the warrant was only in respect of the phone. In this respect Hannah’s mother reported that the manner and demeanour of officers was intimidating and threatening. This suggested that even at this late stage, the gravity of the concerns regarding the images or data that Hannah may have been in possession of, was not fully appreciated or understood by her parents.  6.5.5 For Samantha, there were significant issues regarding her Grandmother that were not adequately assessed. The incident in June 2014 where the alleged perpetrator reported to Samantha’s mother over the telephone, that her Grandmother had physically assaulted Samantha, was never addressed. Neither was the connection between Samantha’s mother and the alleged perpetrator sufficiently explored. Similarly, the apparently volatile relationship between Samantha and her Grandmother was not sufficiently explored or addressed in any assessment, which is particularly pertinent given Samantha’s complex needs. Interventions progressed on an Early Help basis until May 2015 when the Assistant Director for Children’s Social Care instructed that a Children and Families Assessment was to be undertaken.   6.5.6 There is a significant amount of information to suggest that parental factors were not sufficiently addressed as part of an assessment of risk or vulnerability. For Samantha and Hannah, the resultant assessments were undertaken at a late stage and only after direction from senior management in Children’s Social Care and challenge by the Police. The absence of a risk management approach indicated that issues of risk due to parental or carer behaviours were not taken seriously enough.   6.5.7 A further question for the Review was in relation to how Parents were assessed, in terms of either partnership or risk. Given that professionals expressed a concern regarding a lack of information, there is no doubt this was also mirrored with the parents/carers. A publication by PACE (Parents against Child Sexual Exploitation) in 2014 states that ‘families are often traumatised twice over – firstly by the horror of witnessing their child suffer, and the impact of that on themselves and their family, and secondly, by the way they can be treated by agencies who seek to safeguard the affected child. All too often, parents are side-lined and either ignored as ‘forgotten safe guarders’ or deemed ‘failed carers’.   In many situations, a strong approach to parental partnership can be a     determining factor in promoting resilience and building self-esteem for children affected by sexual exploitation. The extent to which parental partnership is achievable however will be determined by a number of factors:   28   Whether there is a concern that the sexual exploitation is being facilitated by the child’s parent.   Whether there is concern that the sexual exploitation is facilitated by the child’s parent failing to protect.  Whether there are other related or non- related concerns present.   These questions need to be assessed within any assessment of sexual exploitation. This is in addition to responding to the reaction of parents/carers, in respect of being able to emotionally cope with the presence of sexual exploitation, to determine how well they are able to meet the immediate needs of their child.   6.5.8 The discussion and considerations about how to best structure work with parents and carers in relation to sexual exploitation is considered in the recommendations.       Finding:   Assessing parental potential for partnership is an important component of a Child and Family assessment.   Parents and carers should be engaged as safeguarding partners  as far as is possible.    Practitioners are not confident that existing multi-agency processes fit well with responding to sexual exploitation.    6.6     The Child’s Voice  6.6.1 The Review acknowledged that there are a number of policy, procedural and practice initiatives in the LSCB area which assist professionals to capture the views, wishes and feelings of children and young people. This indicated a strong commitment across the multi-agency partnership to the importance of the voice of the child. Child Protection Conferences and Looked after Children’s processes routinely use tools to establish the child’s wishes and feelings. The involvement of young people in recruitment and selection is further evidence of a commitment to the voices of children and young people. There is also a quarterly audit on Children and Young People’s Views which is part of the Local Safeguarding Board Performance Management Framework. Case recording systems in Children’s Social Care consistently prompt practitioners to record children’s contributions via comment boxes. Review participants did point to the importance of a coherent analysis of this data and recognised that a critical element was how this information is used to shape and deliver services.  6.6.2 The children considered during this Review remind us that children’s voices come in many guises. There was significant evidence to suggest high levels of distress, anxiety and aggression, even at an early stage. For Hannah this  29  manifested itself in deliberate self harming, low mood, anxiety, poor self esteem and challenging behaviours. There were also instances of suicidal ideation and relationship difficulties which were impacting on her ability to function appropriately at a number of levels. Poor relationships with her parents and reports of anxiety and panic were also evident. Whilst Hannah had initially denied any sexual activity with either the alleged perpetrator or the associated males about whom there had been concerns, there was some evidence of risk taking behaviours which could have been explored in more detail from the child’s perspective. Whilst many of these behaviours could be viewed as a form of communication, there was little evidence to suggest that they were framed as such and used to inform assessment and planning. Indeed as described earlier, social work assessment was considerably late, which suggests that these features were not addressed as early as they could have been.  6.6.3 Whilst there were concerns regarding Samantha’s relationship with the alleged perpetrator, Samantha did not disclose any verbal information to suggest that this might be the case. However given Samantha’s complex learning needs it would have been important to have had a more critical approach to communication and reaching an understanding of her world. For Lauren who became Looked After, there were also similar indicators of distress and anxiety, particularly regarding the relationship with her family members. Lauren was posting pictures of herself on the internet, along with personal contact information, conveying powerful messages connected to approval, acceptance and worth. There are also instances where Lauren was reported to be taking her clothes from her Grandparents never to be seen again or returned in a poor state. Again, whilst these instances relate to behavioural rather than verbal responses, they do indicate the presence of powerful and complex emotions and thoughts which did not receive the attention, analysis and exploration that may have informed the assessment and planning process.   6.6.4 In June 2014 witnesses disclosed that Lauren had been engaging in sexual activity with the alleged perpetrator, although this was denied by Lauren at the time. It was also recorded that due to the volume of work the investigation was not formally handed to the Senior Investigating Police Officer until the end of September 2014. In October 2014, Lauren provided a full and frank account of grooming and sexual abuse and in March 2015, she disclosed to the Barnardo’s Worker that she had been locked in a room by the alleged perpetrator and that an older man had then arrived and raped her. This information was reported to the Police and Children’s Social Care. It was not until February 2015 that Lauren disclosed to her therapeutic practitioner the extent of her feelings about herself, her feelings about her mother, her experiences of being sexually exploited and her experience of significant abuse and neglect when she was younger and living with her mother and siblings. These disclosures are both profoundly distressing to read and highly informative regarding Lauren’s vulnerability and history.  30  Lauren also described her feelings of shame associated with the town and disclosed information to suggest that both the alleged perpetrator and Hannah were both recruiters in a wider ring of sexual exploitation who facilitated meetings with various older men. Lauren reported that it was the alleged perpetrator who made her feel wanted at a time in her life when no one enabled her to feel valued or important. Lauren also described her fear of the alleged perpetrator being angry if she said no to the men who had abused her which indicated her exploitation and powerlessness but also control and domination by the alleged perpetrator.  This is a view which was echoed by the mother of Hannah, when describing the relationship that her daughter had with the alleged perpetrator.   6.6.5 The work which was undertaken with Lauren by a local therapeutic service was one of the most insightful, informative and thoughtful episodes recorded during the Review period and illustrated both the critical importance of listening carefully to the child’s narrative and also the time and resource intense nature of this therapeutic work. It was a theme that was articulated several times by practitioners and indicated the crucial importance of time, acceptance, relationship building, trust (and therefore organisational capacity) when working with children and young people who are at risk of sexual exploitation.  6.6.6 For all these children there were issues relating to attachment and loss and the importance of associations and peer groups with regard to belonging. There were also issues relating to how non-verbal communications, in the form of behavioural or emotional responses, could be understood and articulated. This analysis was lacking in assessment and when assessments did take place there appeared to be a lack of attention given to the children themselves and the world seen through their eyes. One of the points raised by practitioners was the importance of understanding why young people gravitated towards certain hotpots in the local area.   6.6.7 There was some evidence to suggest that, at times, the behavioural issues were seen as the problem and this raised a question of how agencies both conceptualise and respond to children who exhibit some challenging behaviours in the context of sexual exploitation concerns. For Samantha, the most striking feature regarding fixed thinking around behaviours was in respect of an assertion that, because Samantha was 17 years old, the situation was considered ‘difficult’ and she was ‘not breaking the law’. This failed to take into account her complex needs, learning difficulties, developmental functioning and therefore her vulnerability. This statement also rested on an assumption, at least in part, that Samantha had the capacity and cognitive understanding to be making an informed choice about the abuse she was experiencing, mistakenly locating it in a framework of consent. It failed to take into account issues of power and vulnerability and therefore her susceptibility to exploitation. Whilst this illustrates some of the complexities regarding informed consent, it also raises a question of how  31  best to protect older, but still very vulnerable young people, particularly when legal provisions such as the Child Abduction Order, served on the alleged perpetrator in respect of Lauren, only apply for children up to 16 years of age.  6.6.8 The Children’s Commissioner publication Protecting Children from Harm: A Critical Assessment of Child Sexual Abuse in the Family Network in England and Priorities for Action (November 2015) notes that there is an over-reliance on children disclosing abuse to statutory services and that refocusing is required so that professionals are attuned to changes in the behaviour of children and their emotional responses, ultimately enabling them to talk about their experiences.   Finding:   Non-verbal communications are as significant as verbal communications.  Consistency of professionals is significant regarding the child’s ability to engage.  Disclosure should not be considered as a defining criteria for assessment of sexual abuse/ exploitation.   Access to therapeutic services is critical.    6.7     Understanding Child Sexual Exploitation  6.7.1 As indicated, awareness and understanding of Child Sexual Exploitation has been an emergent and developing issue in the LSCB area, which has been shaped by national responses and a strong multi agency commitment to identify and respond to the problem locally. The Review also acknowledged that this has taken place within a rapidly changing public service landscape which has had significant implications regarding organisational capacity and the allocation of resources. The Review acknowledged that responding to Child Sexual Exploitation and working with young people is both time and resource intensive. It is dependent upon the ability of professionals and practitioners to form meaningful, safe and trusting relationships with young people over time, enabling them to disclose, share and confide in the individuals who are working with them.  6.7.2 Understanding this form of abuse is also dependent upon professionals having access to comprehensive information which forms the multi-agency policy framework. This particularly relates to information and procedures regarding signs and symptoms and how to seek advice and consultation if professionals are concerned. Responding at the earliest opportunity is key to redirecting the critical pathway for a child. For Hannah there were observations made by the school in March 2014 regarding both threatening and intimidating behaviour by the alleged perpetrator towards pupils, regarding the interactions and relationships with Hannah. This was early  32  evidence of a possible controlling relationship followed by concerns expressed by the Police that Hannah and the alleged perpetrator were observed being intimate together, with the alleged perpetrator describing Hannah as her girlfriend. This resulted in a detailed referral to Children’s Social Care. The concerns in respect of Hannah’s vulnerability, self harm and her relationship with the alleged perpetrator are acknowledged by Children’s Social Care, however, it is agreed that only outreach work will be provided with no case manager. Over the next 2 months there are continuing reports of Hannah self harming, misusing alcohol and being missing from home which did not result in a review of the suitability of the response.   6.7.3 During May 2014 the Police reported to Children’s Social Care that Hannah had been associating with a male who had conditions not to be in the presence of under 16s. Whilst Hannah was interviewed as part of ongoing Police enquiries and further concerns were reported by the Police regarding Hannah’s associations, interventions continue to be provided under Early Help. In September 2014, it is reported in the CSE minutes that Hannah is grooming and being groomed. In this case, there was clearly recognition of exploitation as early as March 2014, however it was the robustness of the responses that were weak and this is evident in the concerns raised by the Chair of the CSE Meeting and the Police regarding the appropriateness of interventions to Hannah.   6.7.4 For Samantha, the first indication that she may have been sexually exploited was also in March 2014, at the point where she was first reported as missing from home.  Her Grandmother provided information that she was drinking with a 25 year old male and expressed concerns regarding her vulnerability. In June 2014, Samantha was reported missing from home for a second time and her Mother reported that Samantha was having sex with a 26 year old man and being pressured to do so. Police information also confirmed that Samantha and an older male were in a sexual relationship and that they had both been found intoxicated. Police intelligence indicated that Samantha had been frequenting the alleged perpetrators flat and was found to be there. There is however no explicit recorded recognition by agencies that Samantha may have been sexually exploited. Further concerns were reported regarding Samantha associating with the alleged perpetrator and other older males yet interventions continue on an Early Help basis. It is only in October 2014 when Samantha was referred to the CSE Practitioners Meeting that there was an indication that ‘she may have been subject to sexual exploitation’. As described earlier, a Children and Family Assessment was not undertaken until May 2015.   6.7.5 There is also no evidence which suggests the consistent use of any screening tools, other than the referral tool completed by the Police in April 2015, which resulted in the Assistant Director for Children’s Social Care directing that the contact should be progressed to a referral and a subsequent assessment regarding Samantha. An earlier and more consistent approach  33  regarding the use of screening tools, in all of the above cases, may have helped to crystallise thinking and form a sharper response at an earlier stage.   6.7.6 For Lauren there were some indications as early as January 2013, yet no concerns were reported or recorded regarding possible sexual exploitation until a referral was made to Barnardo’s in July 2013 although the rationale for this was not recorded.  It is not until May 2014 that concerns were reported to Children’s Social Care by the Police, in respect of Lauren being in a sexual relationship with the alleged perpetrator and it was at this point that a CSE referral was completed. In the same month, and as a result of discussions at the CSE Practitioners Group, concerns are discussed regarding Lauren’s associations with the alleged perpetrator and the controlling and coercive nature of the relationship. As with Samantha and Hannah, the first recorded indication of the possible sexual exploitation of Lauren was in May 2014, despite the earlier presence of some sexual exploitation indicators. The recording in respect of Lauren was patchy and incomplete in places. Similarly, there is no evidence of the use of screening tools at an early stage which may have provided for a more informed response.  6.7.7 The recognition and response raises some common issues. The consistent use of screening tools, combined with a methodical use of the LSCB threshold document as a diagnostic tool to locate appropriate interventions should have assisted a more appropriate set of responses. Screening tools regarding Child Sexual Exploitation were not utilised at an early stage, particularly in respect of CAMHS and Sexual Health Services. Although there was some recognition that Child Sexual Exploitation was a possibility, it was not explicitly recorded and there appeared to be some hesitance around recognition. This does resonate with a consistent theme raised by practitioners that there was a guarded secret surrounding this issue. This may well be linked to confidence for practitioners in respect of recognition and response and the significance of information, training and education was therefore acknowledged as a vital factor. In addition the introduction of a multi-agency model of professional thinking time and practitioner led audits will assist to develop a stronger culture of curiosity, respectful uncertainty and confidence.  6.7.8 The raising of awareness at an Early Help Stage is fundamental to earlier and more effective recognition and response. Access to consultation for practitioners was also acknowledged as critical, as not all of the signs and symptoms will necessarily indicate that sexual exploitation is occurring. Yet for all these children there were significant early indicators of vulnerability which were evident. In addition, the importance of early holistic assessment based on the Assessment Framework, particularly in respect of understanding the child’s needs, parental capacity and environmental factors, will be vital in any diagnosis or analysis of risk and vulnerability. This may well have also provided for earlier referrals to the CSE processes.   34  6.7.9  The relationships between the Strategic and Practitioner CSE processes did not always result in sharing of information effectively. Practitioners described not having enough clarity and information and that whilst there was awareness that cases were discussed at CSE meetings, there were concerns expressed that a minimum of information was reaching the operational and practice level which detracted from more effective responses.   Finding  Practitioners have developed awareness of sexual exploitation during and beyond this period of review and this continues.   The CSE process needs to be familiar to practitioners.   Professionals need time to think together to better respond to sexual exploitation.    7.          Learning Outcomes   7.1 Agencies across the area have a clearly outlined multi agency strategy to respond to Child Sexual Exploitation. The Strategy, illustrated in the CSE Work Plan broadly adopts that recommended by the See Me Hear Me Framework and outlines four key priorities:  Prosecute: Disrupting, arresting and prosecuting CSE offenders  Prevent:    Raising awareness of CSE among young people, parents, carers  and potential perpetrators  Protect:  Safeguarding young people and supporting professionals and             providing strong leadership, effective systems and working with partners to tackle CSE  Publicise:  To reflect that the community has an important part to play in responding to child sexual exploitation  7.2 In respect of prevention, a central feature of this Review was the identification of the alleged perpetrator as a risk to children.  This common thread was identified by the Police and placed into the CSE planning process to respond to the needs of the children. Although recognition of each child as a child at risk could have occurred sooner, it is important to remember that this was established through a pattern of information from police intelligence that was emerging over a period of time and was not as linear as it would appear in hindsight. There was a sense of discomfort throughout the Review, that the alleged perpetrator was herself a victim of sexual exploitation as a child and that her activity was easier to target than the older males referenced at the head of an abusive structure.    35  7.3 This Review highlights the challenge of raising awareness and the significant scope that the task covers in terms of professionals, family, young people themselves and the community. Ensuring an appropriate level of awareness for even one agency such as the Police requires a constant rolling programme reaching out to all personnel working in the community.   7.4 This Review has identified some areas of weakness in relation to the protect agenda, which are reflected in the recommendations made to the Board. There is the will and desire to improve on practice and to develop multi-agency systems in a way that best supports the risks faced by children.   7.5 While there are areas of practice that can be strengthened to better support multi-agency systems around children, perhaps the most significant issues to be addressed is how to achieve an infrastructure that recognises the limitations of the Child Protection Process for children at risk from non-familial sources, and establish a protocol that sets out a framework for responding to and managing the risks posed by the situation and actions of young people who are vulnerable to abuse or exploitation.  There are several examples of such models; commonly they feature multi-agency planning, objective and challenging review, and a lead Professional.   Whatever model is used, it is critical that assessments are comprehensive, analytical and culminate in robust assessments of risk, as without this, plans are likely to be misguided. The practitioners were keen to explore a model that better reflected the position of parents and carers of children. It is important to be ever mindful that a calculated approach by perpetrators of child sexual exploitation sets out to strip parents of their ability to fulfil their parental responsibility and that perpetrators will set out to deliberately drive a wedge between the child and their family that causes trust between parents and child to break down with the ultimate goal of estrangement. Conversely, some parents may themselves be groomed and this was an issue raised during the review. It is vital therefore that services work with parents in a way that recognises the impact on the whole family dynamics and seeks to strengthen parental confidence.   7.6 This Review provides a reminder for all professionals of how easy it is to lose sight of the child’s day to day life and how the world presents from their perspective. There remains a need to re-enforce through training understanding children as victims without choice or informed consent and to ensure that all aspects of culture reflect this value, particularly language, attitudes and decision making.  This need would also be assisted through the introduction of a model of addressing risk which recognises that children are victims without victimising their future, by enabling children to take greater control of their lives within a framework of nurture and support.   7.7 A key message through every element of enquiry is that working with children at risk of sexual exploitation is very time consuming, as well as requiring a great deal of tenacity by the practitioner. The time consuming  36  nature of the work can be a significant potential barrier to achieving success for children. Practitioners spoke about the time it takes to build up a relationship of trust with children and how the competing demands for time can make this difficult.  Given high demand on services, managers often feel under pressure to maintain very tight criteria and can close cases precipitously. The role of first line management is entirely significant to practitioners feeling supported in working in such a difficult area of work, and essentially being prepared to continue in the face of rejection by the child. The multi-agency culture must reflect that a child is a child as defined under the Children Act, and that what is often described as the wilderness years between 16 and 18 does not become a determining factor in considering vulnerability.  Lauren commented on how a secure and safe placement came late for her and that she needed to feel at a much earlier point that professionals were willing to exert a greater degree of control.  7.8 For children consistency of workers is extremely important, and in responding to sexual exploitation, the process of case allocation should be mindful of this. Working with children at risk requires extremely skilful direct work, and the Review provided an example of this. There is a relatively good range of services for direct work and allocations were timely on each occasion.  The contribution from Lauren emphasised both of these points.   7.9 As in all aspects of working with families in need, the importance of early intervention is entirely significant to later successful outcomes, and this is particularly true of children at risk of sexual exploitation. Early intervention services that educate, build up self-esteem and develop resilient characteristics in children and families are the most effective way to pre-empt and reduce risk.   8. Agency Reflections and Service Improvement  8.1 There has been significant reflection evidenced by all the agencies represented on the Panel during the review. Panel members have engaged positively with the process and there is a collective view that systems are now stronger and leaner, with many changes being driven by national guidance, inspection and enquiry.   8.2 The Review acknowledged the importance for all organisations, but particularly those such as Early Help, Sexual Health Services, CAMHS and the Police to have access to, and consistently use a coherent framework to enable an early and more effective recognition and response. Positively, agencies are responding to concerns regarding sexual abuse with the numbers of children subject to Child Protection Plans in respect of Sexual Abuse at 8% of the total numbers of children subject to plans. This is slightly greater than the national average.   37  8.3 In terms of the multi agency reflection and improvements, the development of the CSE Warning signs and Vulnerabilities Checklist and its distribution to all organisations is a significant element of the CSE Work Plan. This is evidence of a greater strategic and more standardised approach to the issue of early recognition and response and will assist agencies to more consistently respond to early indicators of risk.  8.4 An initiative which has been implemented for all young people under 18 is the Spotting the Signs framework for providers of Sexual Health Services. This was recognised as being especially helpful, particularly given the particularly sensitive nature of the information shared with sexual health services.   8.5 In respect of multi-agency reflection and improvement, the importance of capturing all relevant information from young people who have been missing from home or care was identified as being of critical importance. A quarterly multi-agency audit of missing/return interviews has already been implemented, in tandem with a Service Improvement clinic, chaired by the Assistant Director for Children’s Social Care. Revised missing from home protocols have been introduced, so that all children who are reported as missing from home or care now routinely have a return interview. There have been improvements in the collection, quality and analysis of the data set. This has been implemented by the Strategic CSE and improvement has been evidenced by systematic audit. These improved performance management arrangements regarding the quality assurance of these interviews, with regular audit and feedback into practice will also enhance the effectiveness of ensuring successful prosecutions.  8.6 The Review recognised the importance of community awareness and engagement particularly in terms of understanding the factors, signs and symptoms that are evident when children and young people are at risk of sexual exploitation. The Review acknowledged the importance of comprehensive information, in the form of a media communication strategy, including warning signs and vulnerabilities, particularly for schools but also for small businesses, hotels, bed and breakfast accommodation, taxi firms and fast food outlets.  8.7 An issue recognised by the review was the importance of training, development and awareness raising initiatives, some of which have been identified earlier. Engagement with the variety of agencies that come into contact with children and young people is of critical value and the importance of this has already been raised in National Reports. The Review has both acknowledged this issue and taken significant steps to ensure that training and awareness-raising sessions, including the role and function of the CSE arrangements, are available to all practitioners, first line managers, schools, Heads of Service and Elected Members. These have been described earlier as part of the LSCB CSE Strategy and Work plan. These are;   38   Child Sexual Exploitation Drop in Sessions, which are now available to all Elected Members, Officers and partner organisations, including voluntary, statutory and community groups and which can be accessed through the LSCB Training Programme.  Safeguarding Children from Sexual Exploitation, a one day training session available to all Elected Members, Officers and partner organisations, including voluntary, statutory and community groups through the LSCB.  Chelsea’s Choice, an awareness raising theatre production, commissioned by the LSCB for all secondary schools, which has currently reached several thousand pupils and which has been re- commissioned.  E-Learning Accredited Awareness Raising Programme, which reflects current research, government guidance and best practice.  A Safeguarding Conference, facilitated by the LSCB which included contributions from Barnardo’s, Chelsea’s Choice and young people from the area.  The LSCB has also initiated work with PACE (Parents against Sexual Exploitation) to develop an on-line information package for schools and has also developed stronger links to Faith and Community Groups.   8.8 Barnardo’s have embedded in their strategic planning the requirement that practitioners capture as much relevant information as early as possible, from case histories and chronologies. There has been further reinforcement of the importance of regular and timely communication with key professionals and the high value of professional challenge regarding the best interest decisions of children. Practitioners and Managers are continuing to ensure that multi agency meetings take place in accordance with local procedures and managers and practitioners continue to attend mandatory safeguarding training. Barnardo’s also continue to deliver LSCB and single agency training and issues regarding responding to disguised compliance are being actively addressed. Managers are continuing to provide oversight and sign off to ensure case recording meets organisational standards. Reflection time and monthly clinical group supervision is also being provided to ensure critical analysis and models of best practice are being developed which incorporate the voices of children.  8.9 A specialist resource provided by Barnardo’s, in the form of a dedicated Child Exploitation Worker for children aged 5-16 years will be critical in ensuring that access to resources is timely and efficient. A dedicated Barnardo’s practitioner is located within the Social Work Team to provide a more integrated response.   8.10 For the Police Service, there has been recognition that the most appropriately trained officers must be deployed at the earliest opportunity to capture all relevant information and evidence. The development of the dedicated Police team is intended to improve operational and strategic effectiveness. The force has recognised the importance of dedicated  39  resources in his area and this will assist the consistent and regular review of cases where CSE is an issue. The Police have also developed ‘hotspot information’ regarding people and areas, to enable effective identification of perpetrator behaviour and areas of risk, with the Police holding a hotspot list which is regularly subject to review. Alerts are created if there are more than 2 repeat incidents.   8.11 The raising of awareness, particularly for Police Officers and night time economy workers, including Hotels and Bed and Breakfast accommodation, which forms part of the CSE Work Plan, are also critical moves forward.  8.12 For Looked After Children’s and Safeguarding Health Services monthly bulletins are now circulated to GP Practices across the area to highlight key issues regarding CSE. Information has been distributed to safeguarding leads regarding CSE and the Clinical Commissioning Group (CCG) are providing updates for the governing body regarding actions and learning. Any learning and development is being incorporated into training.   8.13 The NHS Foundation Trust have utilised the Department of Health, Helping School Nurses to tackle Child Sexual Exploitation (2015) and Learning Lessons from Serious Case Reviews (Brandon et al 2012) as part of training to recognise vulnerabilities at an earlier stage.   8.14 School Nursing Services have identified and used “Helping School Nurses to Tackle Child Sexual Exploitation” (DOH 2015) as a tool for identifying good practice and areas for development. Electronic Information systems have also been developed and improved to facilitate earlier and more effective identification of risk and this is being quality assured on a consistent basis. Staff are also being provided with training to improve the culture of curiosity, professional confidence and assertiveness and familiarity with signs and symptoms.   8.15 It was also acknowledged that there were effective single agency models of effective and reflective supervision in operation, enabling a much higher degree of critical thinking.  However, review members reflected on the usefulness of developing multi-agency supervision, peer challenge, and audit, utilising frameworks such as the Tony Morrison model of supervision which has already been adopted by the NHS Foundation Trust.  8.16 For schools the importance of developing lines of effective communication and information sharing, particularly in respect of mid term transfers, has been acknowledged and that early help, interventions and referrals must be in accordance with local protocols such as the LSCB threshold document. There has been the introduction of weekly inclusion meetings with key professionals and the importance of challenge has been recognised and reinforced. Training is being provided which reflects developments in responding to CSE.  40   8.17 For Children’s Social Care there has been recognition that liaison between the CSE and the key Social Worker requires improvement. Consequently the administrative process regarding CSE has been improved particularly in respect of attendance and minute distribution. The CSE Practitioners Group is now more rigorously tracking actions from meetings.  CSE processes are now incorporated into induction processes and supervision must evidence outcomes of CSE meetings where appropriate. The Barnardo’s worker located within the Social Work Team is now provided with access to relevant information systems to assist more effective communications and responses and there is now the provision of the “management tab” on the electronic case file system which will assist information sharing and sight of management decisions for practitioners. If three referrals regarding any child are made within a year, a consultation must take place with the Team Manager and a written rationale provided for any decisions made. In addition, there is now a revised risk assessment tool for CSE which was introduced in 2015  8.18 As noted in 9.5, Children who go missing are now tracked more rigorously and consistently and information is passed to relevant practitioners in a more timely way. A co-ordinator ensures that individual children have an interview, unless it is declined, and children who go missing on 3 or more occasions within a 4 week period are automatically discussed at the CSE Practitioners Group. This includes arrangements with neighbouring authorities in respect of children who are placed out of the area.  8.19 There has been acknowledgment that vulnerable children and young people need to form trusting, meaningful, sustainable and safe relationships with people who can help and support them. This, by its very nature is both time and resource intensive; therefore organisational capacity and a relevant skills and knowledge base for officers are absolutely essential. Again there has been a consistent recognition of this during the Review with a dedicated resource for Child Sexual Exploitation being provided in both Social Care and the Police.  8.20 This Review has recognised the importance of communicating that Safeguarding Children is everybody’s Responsibility. Consequently, the Sub Regional CSE Strategic Group has also taken the lead to deliver a preventative initiative, which aims to raise awareness and offer advice to small businesses such as taxi firms, hotels and fast food outlets, regarding the prevalence of Child Sexual Exploitation. The group has also taken the lead to deliver a major publicity campaign, , which provides information for children, families and professionals regarding signs and symptoms, advice and guidance. In this respect there has been a strong acknowledgement that community engagement and awareness are as vital as professional engagement and awareness. This initiative has been extended by Licensing in the LSCB area to work with taxi drivers.  41  9. Recommendations  1. That the LSCB explores the feasibility of introducing a                                  process for responding to vulnerable children/young people which incorporates child sexual exploitation and:  Identifies and minimises risk from a non-familial source;  Builds on factors that increase  resilience;  Facilitates a multi-agency team around the child;  Facilitates partnership with key people in the life of the young person.   2. Taking into account of outcome of recommendation 1, the LSCB to be satisfied that information available through the CSE strategy systemically feeds into the operational approach and response to children in need.   3. That the LSCB requests training needs analysis from partner agencies that explores the ability of professionals and agencies to identify and respond to indicators of child sexual abuse and exploitation from early help through to targeted services.   4. That the LSCB seeks assurance that each child currently identified at risk of sexual exploitation from information available through the CSE strategy has an assessment of their needs and that actions are taken accordingly.  5. That the LSCB promotes the use of purposeful professionals only meetings/thinking time to support multi-agency reflection, support and challenges in case where risk is not reducing.   6. That the LSCB is presented with key data and information at a regular frequency relating to sexual exploitation and missing from home and that this is used to monitor activity and influence resources.   7. That LSCB continue to champion the developments to address child sexual exploitation and seek data through a range of sources to evidence the impact.       42  10. Glossary of Terms   ADHD        Attention Deficit Hyperactive Disorder  CAF           Common Assessment Framework  CAMHS     Child and Adolescent Mental Health Services  CAO          Child Abduction Order  CCG           Clinical Commissioning Group  CSC           Children’s Social Care  CSE          Child Sexual Exploitation  JSNA         Joint Strategic Needs Assessment   LA            Local Authority  LSCB      Local Safeguarding Children Board  MFH          Missing From Home  NSPCC      National Society for the Prevention of Cruelty to Children  OfSTED     Office for Standards in Education  PLO           Public Law Outline  S47            Section 47 Enquiry (Section 47 Children Act 1989)  SIO             Senior Investigating Officer      