Death by suicide of a teenage girl in January 2019. A19 started self-harming in 2017 and in September 2018 mother contacted the school with concerns about A19's self-harm and suicidal thoughts. In October 2018, A19 disclosed that she had been sexually assaulted by a distant family member; school reported this to the police; A19 did not wish to support a prosecution. Towards the end of term, A19 disclosed to a teacher urges to self-harm or worse; information shared with mother who agreed to take her to a GP. In the new term, A19 messaged a former teacher disclosing self-harm the previous day and referred to the sexual assault. School was alerted; lessons included the issue of suicide that day. A19 taken to hospital later that day and died six days later. Ethnicity or nationality of A19 not stated. Learning: early help for young people suffering self-harm and/or suicidal tendencies needs development to promote multi-agency working; responses to a young person disclosing sexual abuse may be more effective if they feel included in discussions regarding decisions and potential outcomes; training required to assist social workers exercise their right to disclose information confidentially. Recommendations: to enhance the use of the self-harm referral pathway and refer young people when support is needed; to ensure similar enquiries are managed by the police in a sensitive manner when a young person feels unable to proceed with a prosecution and victims better informed if there is no intention to speak to the alleged perpetrator.
      
    Serious Case Review No:  2019/C7930  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1         Child A19 Practice Learning Review    Allison Sandiford LLB (Hons) Independent Author           2  Contents  1. Introduction ...................................................................................................................... 3 2. Brief Synopsis of Events ................................................................................................... 5 3. Practitioners’ Views / Actions ........................................................................................ 7 4. Family Views ................................................................................................................... 10 5. Analysis of the Key Lines of Enquiry ............................................................................. 12 6. Additional Analysis ........................................................................................................ 23 7. Good Practice Identified ............................................................................................. 25 8. Recommendations ....................................................................................................... 25     3  1. Introduction  Initiation of the Local Child Safeguarding Practice Review  1.1. This Local Child Safeguarding Practice Review (LCSPR) was commissioned in March 2019 by a Local Safeguarding Children Partnership (LSCP). The matter under review is the tragic death of a teenager (Child A19) having been found suspended by a ligature placed around the neck.  1.2. The LSCP concluded that the circumstances of this case meet the criteria for a LCSPR as per statutory guidance1.  The Purpose of this Review   1.3. The purpose of this review is to consider what lessons can be learned to guide future practice concerning young people who are experiencing self-harming behaviour or considering taking their own lives. The purpose of this review is not to scrutinise the actions taken; nor is it to make a judgment of whether A19’s death was predictable or preventable.  The LCSPR sought to understand  1.4. The early help offer to address Child A19’s mental health; There has been extensive learning from a previous case review that resulted in additional support to enable universal services to access emotional health and well-being provision and the creation of a self-harm referral pathway as part of the regional procedure ‘Young People and Self-Harm’. The review will investigate how learning from previous case reviews has been implemented in practice.  1.5. The closure of the Police investigation without the suspect having been formally interviewed.  1.6. The use of the Child Sex Offender Disclosure Scheme (Sarah’s Law2) to inform the suspected abuser’s partner of the allegation made against him when safeguarding procedures had already been applied.  1.7. The closure of Children’s Social Care (CSC) involvement without a comprehensive picture of Child A19’s health, particularly mental health, and the potential lack of understanding of the impact of the alleged sexual assault on Child A19 and how the family dealt with it.                                                             1 Working Together to Safeguard Children (2018) 2 The child sex offender disclosure scheme in England and Wales (also sometimes known as "Sarah's Law"), allows anyone to formally ask the police if someone with access to a child has a record for child sexual offences.  4  1.8. How the voice of the child was heard, and the daily lived experience understood, assessed and responded to by professionals.    Methodology and Agency Involvement  1.9. The review was managed by a review panel (known as the Panel) which included representation from relevant organisations within Health, Children’s Social Care, Education, the Police and representatives from the Local Safeguarding Children Partnership. Allison Sandiford, an independent reviewer (the Reviewer) was commissioned to work with the Panel and to undertake the review.   1.10. The review has been informed by:  Agency chronologies and reports Background information from agencies involved Access to key documents Panel discussion and analysis Input from practitioners via a learning event Family views and experience.  1.11. All relevant agencies reviewed their records and provided timelines of significant events. These were considered by the Panel who had the opportunity to raise questions and clarify understanding of any circumstances. The agency timelines were merged and carefully analysed by the Reviewer and areas highlighted that required further consideration.  1.12. Key practitioners were identified to attend the learning event in order to assist the Panel and Reviewer to understand the detail of agency practice in this case.  1.13. The learning event was held on 4th June 2019 and was attended by 12 professionals. Most had had direct involvement with A19 and/or the family. The Reviewer facilitated the learning event assisted by the Chair of the Panel. Further to the event and with the support of the Panel and LSCP, additional enquiries were made with professionals who had been unable to attend. This information is included in the report.  1.14. The Reviewer met with A19’s family who provided their experiences of the support and services offered to A19 and themselves.  1.15. Following the learning event and family meeting, the Reviewer gathered and analysed the learning for discussion with the Panel. The findings were re-examined, and the Panel considered what could be done differently to improve future practice.   1.16. A draft report was provided to the Case Review Panel in advance of the Safeguarding Children Executive Partnership Meeting in September 2019.  Period under Review  5   1.17. The review period commences from school’s first record of self-harm in January 2017 and ends with the Coroner’s Pre-Inquest Review Hearing on 13th March 2019.  1.18. The critical period is from the point that Child A19 disclosed the sexual assault to school in October 2018, up to and including the date of death.  Parallel Processes  1.19. The review, although an independent process undertaken on behalf of the LSCP, was thoughtful of the ongoing Coronial Inquiry and future Inquest in relation to Child A19’s death.  2. Brief Synopsis of Events  Initial Indications of A19’s Mental Health   2.1. The first reported threat of self-harm by A19 dates from early 2017; A19 threatened to self-harm if school contacted Mother regarding a disclosure of another student self-harming.   2.2. At the end of 2017 a student disclosed at school that A19 had sent a message claiming to have self-harmed. This was shared with Mother who said that A19 had been a bit down lately and was tired due to a new routine.  2.3. In September 2018 Mother contacted school stating she was worried about A19 regarding suicidal thoughts and self-harm. School spoke to A19 and self-harming behaviours were confirmed to have started when A19 was in Year 9. A19 discussed feeling relief when self-harming but did not understand why. A19 denied current self-harm and did not give any indications of future harm. A19 was informed that staff were available to talk and given support leaflets.  2.4. In the following weeks, A19 utilised the support school offered by means of attending the inclusion team3 on several occasions. A19 disclosed feeling upset around this time but did not say why.   Disclosure of Sexual Assault  2.5. In October 2018, A19 disclosed to school, inappropriate touching by a distant relative (AR). The sexual assault had occurred at the end of September (the incident post-dated Mother contacting the school with concerns of self-harming and suicidal thoughts). A19 also disclosed that AR had since sent inappropriate messages. A19’s parents were                                                            3 The Inclusion Team offers students support that may be needed for a variety of reasons.   6  recently aware as A19 had confided in a friend whose mother had told A19’s Mother. A19 had since heard Mother shouting at AR and telling him not to make any further contact.  2.6. School contacted Mother who confirmed she was aware of the allegation and had confronted AR and told him to stop all contact. Mother did not appear to be aware of all the details disclosed by A19 and she was invited into school where she was advised. Following the meeting A19 and Mother left school, but soon returned and A19 retracted some of the detail.  2.7. School reported the assault to the police and made a referral to CSC. Later that day, Police and CSC conducted a joint visit to the family home. A Police Constable spoke to A19 in the presence of Mother and Father but A19 had left the address prior to CSC attending. CSC spoke to A19 alone the following day at school. A19 reported feeling safe at home and was confident of no further contact with AR.   2.8. A few days later Mother advised the police that A19 did not wish to support a prosecution. Mother said that A19 had never envisaged the police being involved and did not want the matter to progress any further. The crime was subsequently closed as without the support of A19 there was little or no chance of a successful prosecution.  2.9. 8 days after the disclosure police, education and CSC attended a strategy meeting4 where it became clear that the police were unaware of A19’s initial disclosure to school.   2.10. In November CSC completed a C&F5 assessment. The outcome was that A19 did not wish for any support from any agency other than school and Mother and Father were confident that they could manage the situation without CSC involvement. The case was closed.   Increasing Concerns and Events Leading to A19’s Death  2.11. Towards the end of the Autumn school term A19 was found in possession of a lighter during a lesson. A19 told a teacher that the lighter was to prevent self-harm.  2.12. 2 days later A19 disclosed to a teacher a want to self-harm or worse. This information was shared with Mother and it was agreed that she would take A19 to the GP during the school holidays.  2.13. In the late afternoon of the first day of the new term A19 sent an ex-teacher a message disclosing self-harm the previous day. The message referred to the afore mentioned sexual allegation.  2.14. School was alerted to the message and A19 was spoken to the following morning. A19 denied both the message and self-harm. No other agency was made aware. School                                                            4 A strategy meeting convenes where concerns have been raised about the safety/wellbeing of a child 5 Child and Family Assessment  7  noted that throughout the morning A19 presented as usual, even when the issue of suicide was discussed in a lesson6. However, later in the day, A19 presented as tearful and attempted to speak to a member of staff but did not wait for the staff member to become available, choosing to return to class instead.  2.15. Following the end of the school day, school received a call from a concerned parent after a child had informed her of A19’s intention to end life. School contacted Mother and Father separately to alert them.  2.16. Later the same day the ambulance service reported to police that A19 had been found hanging and taken to hospital.   2.17. A19 died 6 days later.  2.18. Following an investigation, Police concluded that there was no third-party involvement or suspicious circumstances. A file was submitted to HM Coroner.  Initiation of the Review  2.19. On 7.3.19 the Rapid Review Panel Meeting decided that the threshold for a Serious Case Review had been met. Due to the process change this was progressed as a LCSPR.  2.20. On 13.3.19 the Pre-Inquest Review Hearing convened.   3. Practitioners’ Views / Actions The following observations and considerations have come from agency reports and the Practitioners who attended the Learning Event.    Education  3.1. The disclosure of sexual assault was preceded by 3 concerns of self-harm which had been raised at the school over a period of 20 months. School had communicated all concerns with Mother - the third being a concern raised by Mother herself. The information was not shared separately with Father as Mother was the first named contact for school and there was a presumption that she would share concerns. Mother engaged well with school, she would return calls and she presented as a very capable parent in control of the situation. School wasn’t ever aware of any outside support being sought by either parents or A19, but this did not heighten any concern as A19 continued to present well at school and work hard.  3.2. When a member of staff has a concern for a student a ‘Cause of Concern’ form should be completed. School identified occasions when this form had not been completed                                                            6 Suicide was discussed in a lesson as the class were studying a poem about war and the poet who wrote it later took his own life. This poem is part of the GCSE compulsory poetry anthology ‘War and Conflict’.   8  correctly or had been misplaced. To improve this process school is investing in CURA which is an electronic computer system that will allow for better communication between staff. This will prevent future forms being misplaced or incorrectly filed. Training on the detail of record keeping is regularly delivered to schools by the Local Authority and highlights the importance of clear and concise records. CURA will help school to retain their records of students’ experiences and will provide complete profiles of individuals concerns.    3.3. In the weeks prior to the disclosure, school were aware that A19 was utilising the anti-bullying room in school which gives students daily access to a quiet place and/or support for issues of peer conflict. A19 disclosed feeling upset during this time but did not explain why. School were therefore expectant of some sort of disclosure coming from A19.  3.4. When A19 did disclose the sexual assault, school rightly reported it to the police. The call taker took enough detail of the disclosure to open an incident and pass it to a radio operator for allocation to an officer. The specifics regarding A19 returning to school and changing the account were not taken at this time, but school documented this on the referral that they sent to CSC. In a strategy meeting that convened 8 days later, it transpired that the police remained unaware of the alterations to A19’s account; school recall an action of the meeting being for CSC and police to consider this information. However, school reported at the learning event that they hadn’t received the minutes of the strategy meeting and this has resulted in discrepancies between agencies’ recollections of discussions and an inability for agencies to check whether they had completed all actions assigned to them.  3.5. Following the disclosure school informally monitored A19. A19 reported being okay and not wanting to talk. It was 2 months later, just before the end of the term, when a further concern was recorded; a member of staff took a lighter from A19. A19 said the lighter was to prevent self-harming. School attempted to contact Mother but had to leave a message requesting she call them back. Contact did not happen until 2 days later by which time A19 had disclosed wanting to ‘self-harm or worse’. When school communicated the 2 new concerns to Mother, it was agreed that Mother would seek advice from the GP. School and other professionals have since questioned whether too much reliance was placed on Mother to access services to support A19.   3.6. It was the late afternoon of the first day of a new term when A19 sent a message to an ex-member of school staff reporting self-harm. This was addressed at the beginning of the following day and the message was denied by A19. A19 was asked whether Mother had spoken about visiting the GP about the self-harm during the holidays and A19 said that she had not. There was no further opportunity to discuss this with parents prior to the tragic events that followed at the end of the school day, as contact with Mother was unsuccessful.   3.7. Because A19 had participated in a class that discussed suicide on the day of the incident, school has wondered whether there should be a review of the GCSE curriculum and/or more support offered to staff re preparing learners for sensitive topics. Teachers could consider issuing a warning of a topic, prior to the lesson, that could possibly cause distress. This would give learners an opportunity to identify lessons uncomfortable to them and allow staff to adapt the content if appropriate and identify support networks to learners.    9  3.8. The school was not actively informed by any agency of A19 being in a critical condition until 10:35 hours the following day when CSC had processed the referral and clarified the information with the hospital and police. This resulted in school having to contact Mother and Father at a very difficult time to confirm the incident, after a comment had been seen on social media. School said that it would have been helpful to have had official confirmation earlier to allow school to consider how to support students and staff.   Children’s Social Care  3.9. A CSC worker and a police officer attended the family home on a joint visit following the sexual assault disclosure. A19 was not present when CSC arrived but had spoken to the police officer prior to leaving. CSC obtained details from A19’s parents of other children that AR had contact with, and referrals were made to safeguard them. This demonstrated good practice. The CSC worker considered that parents presented as shocked by the incident and were still processing the information during the visit but had demonstrated an ability to manage the situation and safeguard A19. Mother said that she did not need any further support from CSC.  3.10. A19 was spoken to alone by CSC the following day at school. A19 was described as quiet during this meeting. The importance of talking to someone about experiences was discussed with A19 and the role of Healthy Young Minds (HYM’s) was explained. A19 did pass comment that Mother did not want to talk about the incident at home but there was no commitment to the offer of any referral to HYM’s. A19 was able to identify a teacher at school as a source of support. At the end of the meeting the social worker said that she did not think CSC needed to be involved any further.  3.11. The strategy meeting was attended by CSC, school and an officer from the Public Protection Investigation Unit of the police.  The meeting determined that the threshold was not met for a section 47 assessment.   3.12. CSC completed a C&F assessment and concluded that Mother and Father were able to manage the situation. At the learning event it was discussed whether additional consideration could have been given as to whether further support is needed to be offered to parents who find themselves supporting a child following sexual abuse by a family member. However, when the case was closed it was not challenged by any other agency.  3.13. The next involvement CSC had with the family was following A19 being found in a critical condition a few months later.  Police  3.14. Prior to the sexual allegation disclosure police had not had any direct involvement with A19.    10  3.15. Following the disclosure an officer attended the home address and spoke with A19. A19 did not disclose the account that had initially been disclosed to school. The officer recorded what A19 said and this was appended to the incident log. The conversation was in the presence of parents. The only opportunity that A19 had to speak to the officer alone was in the hall of the address.  3.16. A few days later an officer spoke to Mother on the telephone in detail and explained the prosecution process including how evidence would be gathered and what support would be offered to A19. The family were given the weekend to consider their options and Mother was contacted by telephone again on the Tuesday and asked whether A19 was willing to support a prosecution. Mother said that A19 had decided not to prosecute. Mother was confident that the offender would not repeat his actions. There was no further contact with A19.  Health  3.17. The GP was unaware of A19’s self-harming or the disclosure of the sexual assault.  3.18. Upon arrival at the hospital there was evidence noted of previous healed cuts to A19’s forearms and self-harm to both wrists.  4. Family Views   4.1. Parents and sibling were invited to contribute to this review. They met with the Reviewer and provided their experiences of the support and services received by A19 and themselves. The Reviewer would like to offer the family sincere condolences and thank them for their invaluable contribution.   4.2. A19 was very much loved and parents and sibling described A19 as presenting as happy in the family home.  The family were unaware of how A19’s mood was changing, and A19’s death was a devastating shock.   4.3. The family did not recognise the initial concerns raised in 2017 of self-harming as serious. Mother was assured by A19 that there would be no further incidents and because no further marks were seen on A19’s arms which were frequently exposed, the family presumed that it had been a one-off incident.  4.4. The parents’ view is that they needed more information about self-harming behaviours and the possible risks around this time. School provided A19 with a leaflet at some point, but this did not raise parent’s awareness or improve their understanding.  Mother remembers the leaflet containing the details of different organisations to support young people with mental health and she encouraged A19 to consider them.   11  4.5. Mother commented that she wondered whether because she is a professional person, other professionals presumed that she had the understanding and knowledge to deal with the situation. Both parents would like to see an improvement in self-harming awareness being taught to all parents.  4.6. Mother began to understand the seriousness of the implications of self-harming when school raised a concern with her in December 2018. She was sufficiently concerned at this time to contact the GP surgery, but the first available appointment was the following month. Mother was asked if A19 required an emergency appointment, but she was unsure as to whether a threat to self-harm or worse would be considered an emergency and declined.   4.7. Mother and Father both agreed that school taking the choices out of their hands by making a referral to other services on their behalf would have helped the situation. Both considered that A19 would have been more receptive to attending an appointment if the suggestion had not come from parents.  4.8. Mother described being in total shock when she learned of the sexual abuse towards A19. Parents agreed that had the perpetrator not been a family member the situation would have been easier to deal with and they would have possibly encouraged A19 to support a prosecution.  4.9. Family understood that school needed to report the incident to the police, but they did not think that A19 anticipated the police becoming involved. Neither parent is unhappy with how school dealt with the incident, but both considered that extra support in the following weeks may have helped. Mother felt pulled in many directions emotionally and would have appreciated guidance. Father said that contact from school would have needed to have something to offer them; the standard response of ‘okay’ would have likely followed the question; ‘how are you all coping?’ Parents considered that guidance on how the allegation could affect A19’s mental health would have helped.  4.10. It was Mother who explained the court process to A19, and she wonders whether it may have been better if the information had come direct from someone within the police. Mother said there was a possibility that A19 may have decided not to prosecute based on how a prosecution might make Mother feel. Professional guidance for A19 would have been appreciated.  4.11. None of the family were aware that the suspect hadn’t ever been interviewed or spoken to by a police officer.  4.12. The parents view of the social care involvement at this time was that CSC attended with the police to gain details of any other children that the suspect might have contact with. Family were happy to pass this information. Parents were unaware that a C&F assessment followed. They knew that a social worker had spoken to A19 alone the following day, but they had no memory of any other contact with CSC.   12  4.13. Parents both considered that a further offer of help may have proved useful a few weeks after the disclosure, when the family had had time to process the incident. They would have appreciated someone helping them to understand the effects the assault may have on A19 and someone offering support directly to A19.   4.14. The family all described the Coronial pre-inquest review as being made more difficult by the fact that it felt as if some professionals in attendance didn’t understand what had happened and had not prepared for the day. They said that it made the process impersonal and harder to bear.  5. Analysis of the Key Lines of Enquiry The analysis is derived from the practitioners who attended the learning event and discussions with the Panel. The analysis of practice in no way seeks to apportion blame to professionals but seeks to understand what can be learnt to support professionals to develop better future safeguarding of children.  The Early Help Offer to Address A19’s Mental Health.   5.1. There is online guidance, by way of a local self-harm referral pathway, designed to help anyone working with children and young people to respond to the issue of self-harm. It contains important principles and pathways to support positive change centred around the young person at risk. Between 2016 and 2018 the Local Authority conducted intensive work to promote this early help offer by way of briefings and e-bulletins but when asked at the learning event, school staff reported being unaware of this pathway. However, whilst the school were not aware of the specifics around the referral pathway, school is very clear and confident that it knows how to access support and guidance for students who are self-harming and that it has good links with HYM’s. Several staff members were trained on the Mental Health First Aid Course and other staff members continue to be so. A few staff members have also attended general awareness courses. The paragraphs below consider the schools application of the training and their offer of low-level support to A19 who, during discussions, continued to deny any issues.   5.2. Within the timescale for this review A19 has been subject to 6 reports of concern within school which reference self-harm, 3 of which occur within the last month of life. The first concern was addressed at the beginning of 2017 and with no further concern identified for a period of 10 months and then a subsequent 11 months, it is reasonable that professionals, at this time, may have concluded that the problem had been low risk and addressed effectively.   5.3. Regardless of the level of risk, school’s initial responses to concerns remained consistent with verbal advice which included the discussion of external support networks, information leaflets and, in line with best practice, communication with Mother. This informative communication ensured that parents were in a knowledgeable position to orchestrate any further support that they considered necessary, and it is evidenced that  13  Mother felt able to seek support as she contacted the school herself with the third concern. Schools consistent communication with Mother is significant to decisions made to not refer A19 to any other services as school was in no doubt that Mother’s responses evidenced her capability of safeguarding from future harm. Mother presented as confident and able, and this was reinforced by the knowledge that she was a professional herself whose role required an understanding of safeguarding children.   5.4. Following Mother contacting school with her concerns, a member of staff spoke with A19 alone. A19 disclosed self-harming in the previous school year but denied any current harm. There was also mention of some problems between A19 and another student. School discussed the previous harm and was assured by A19 that there was no intention to harm in the future. The problem between the students was addressed by ensuring that they were kept separate and around this time, A19 began to utilise the anti-bullying quiet space. This usage was observed but although A19 admitted to being upset, the cause was not disclosed. Within weeks A19 made the disclosure of sexual abuse. The first response by school was appropriate and staff followed safeguarding guidance by listening to A19 and making it clear that they would have to share the information. Appropriate contact was made with Mother, CSC and the police and all staff involved in the disclosure made detailed statements that were attached to the referral sent to CSC. The sexual assault disclosure had the effect of becoming the focus of concern for A19 and it offered a possible explanation for A19 being upset and utilising the anti-bullying space. What does not appear to have been considered at the time was whether there was any possible link between the previous self-harming and the sexual abuse incident. If this had been deliberated there may have been some consideration following the disclosure, as to whether there was any possibility of longer-term grooming by AR. This omission is understandable as A19 made no reference to any history of abuse. However, there is indication that A19 was uncomfortable whilst discussing the incident and therefore, further disclosure would have been difficult to do. School recollect that A19 struggled to voice the account, preferring to use hand gestures and possibly as a result of subsequent miscommunication, or possibly as a result of embarrassment, A19 later retracted part of the initial disclosure. This communication difficulty is comprehensible but does mean that A19 may not have disclosed the full extent of any abuse and thus left professionals unable to respond to the full circumstances. Research7 has concluded that upon disclosure, A19 will likely have battled an extensive range of internal worries surrounding stigma, blame and shame, a worry of not being believed and fears for the consequences for the family. These concerns would have all operated to encourage silence. In the absence of obvious signs of abuse, A19 unfairly and unavoidably had the responsibility of speaking out and seeking help.  5.5. The police and CSC responded to the allegation the same day and conducted a joint visit to the home address. The police recorded a crime of Sexual Assault and CSC ensured that parents had a safeguarding plan in place.  5.6. The practitioners recall the strategy meeting being held 8 days after the disclosure, by which time the police had already closed the investigation. There is a sense at this time,                                                            7 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/UniBed_MakingNoise-20_4_17-1.pdf  14  of the assault having been minor and parents having taken control of the situation, but it cannot be disputed that the facts remained largely unknown. The only professional who had spoken to A19 alone following the disclosure was a CSC worker who A19 had no relationship with and was therefore unlikely to disclose sensitive information to.   5.7. At the strategy meeting and during the C&F assessment, Mothers voice regarding A19 being kept safe from AR in the future was taken at face value. There was no consideration of AR finding a way to reach A19 without parents being aware and as a result no recourse was offered to A19 to learn how to keep safe and understand about abuse. This is a noteworthy omission in the early help that should have been offered to A19 and could have been achieved by a referral to the multi-agency Child Sexual Exploitation team.   5.8. The self-harming and sexual assault were not considered in relation to one another even when a few months later, A19 referenced self-harming on 2 occasions within days of one another. Upon receipt of the new self-harming concerns, school continued with its starting point response of verbal advice and communication with Mother. It may have been good practice at this point, now having both familial sexual abuse and threats to self-harm disclosed, to consider whether a school nurse and/or school counsellor could have offered any support but at no point in this review has any contact been evidenced between A19 and a school nurse and/or counsellor. However, it is necessary to note that these comments were made by A19 at the very end of a school term and in practice there would have been very little time and opportunity for staff to discuss and complete referrals to a school nurse and /or counsellor within these time constraints. School should be commended for the open-door policy offered to A19 and the continual communications with parents and it is recognised that when school’s concerns did increase at the end of the term, parents were asked to consider getting advice from their GP. This advice was acted upon by Mother and appears to only have been hindered by the lack of appointments available. There has been question as to whether or not school should have over ridden parents by contacting the GP or another service and whether this would have been done if A19’s family did not have a professional background. Whilst it is true that consideration needs to be given to how practitioners work with a professional family, there is nothing to suggest that Mother and Father were not acting appropriately and safeguarding A19. Professionals are aware that the ability to be empathetic and non-patronising with parents is fundamental to working effectively with families, but this needs to be balanced against evidence that the parental actions are ensuring that the children’s needs are met. There is verification of school’s intention to do this as Mother had agreed to update school re the outcome of a GP appointment after the school holidays. Sadly school had no further opportunity to discuss what action had been taken and consider whether a referral was necessary, as upon A19’s return to school, conversations were dominated by the message referring to further self-harm sent to an ex-member of staff and contact with parents was not possible until the school had been forewarned of A19’s intention to harm.  5.9. Whatever the outcome of the attempted GP appointment, prior to the school holidays commencing, school had no reason to override parents and refer A19 to the GP. Article 8 of the European Convention of Human Rights determines the right to respect for private and family life and as school was confident that A19 was being safeguarded,  15  interference into family life of this sort would not have been considered lawful, necessary and proportionate. It could have been construed as overstepping the mark and intervening unjustifiably into the family’s private life. The decision for A19 to see a GP was one that school could reasonably expect to be made by either or both parents and there were no factors surrounding either parents’ circumstances that would have caused school to worry about the validity of the decision made.  5.10. An additional barrier to no further referrals being made was A19’s dismissal of support.  Support networks were discussed with A19 and contact details were provided by both school and CSC, but it is apparent throughout this review that A19 was consistent with the decision that further support was not needed.  5.11. Having considered the early help that was offered to A19, it is predicted that the support would not have looked very different in the event of school following the local referral policy. The difference is only that the school may have contacted HYM’s for advice as the pathway states that where a young person is expressing suicidal thoughts, the designated officer should contact Child and Adolescent Mental Health Services (now HYM’s) immediately. A19’s comments ‘self-harm or worse’ should have been construed as an expression of a suicidal thought. The effect of HYM’s having been consulted was discussed in the learning event and professionals were all in agreement that A19 would not have met the HYM’s threshold, although consultation of HYM’s can always be sought and other early help offers may subsequently be provided. It is worth noting that professionals anticipating what another service will likely conclude upon referral, could serve as a barrier to multi-agency discussions.  5.12. Research8 carried out by the GW4 partnership9 has found that ‘schools as a whole do very little work to prevent or raise awareness of self-harm’. It is therefore admirable that this school had already recognised the importance of Mental Health awareness prior to this tragic incident and started work on a new Mental Health Strategy. A place had already been secured on the ‘Trailblazer’ provision for mental health. Staff have now participated in the Mental Health Champions Senior Leadership programme and a group of students have had external training to become Mental Health Champions. It is hoped that student awareness will assist with peer support and create an environment more open to student discussions about how they feel.   5.13. The Borough’s early help offer now looks very different to how it did in January, as since the beginning of the year it has been developed and has moved towards a Neighbourhood model. This aims to improve multi-agency working and make it easier to share information when considering a child’s needs at an earlier stage. Of major significance is the Team Around the School (TAS) which is a meeting to which school can bring (with parental consent) any lower level concerns to allow interventions and actions to be agreed multi-agency.   Summary of Learning:                                                            8 clahrc-peninsula.nihr.ac.uk/research/self-harm-and-suicide-in-schools 9 GW4 is a collaboration between the University of Bath, the University of Bristol, Cardiff University & the University of Exeter.  16   • Further promotion of the local self-harm referral pathway is required to raise professionals’ awareness. • Early help for young people suffering self-harm and / or suicidal tendencies needs to be developed to promote multi-agency working. • Concerns for a young person should be escalated to allow agencies to consider other support services available. • A parent’s ability to safeguard should not override the need to educate a young person about how to keep safe.  The Closure of the Police Investigation   5.14. School reported the allegation to the police. An officer attended the home address and spoke to A19 the same day. In the presence of parents A19 recounted the incident stating that during a function AR had stroked A19’s bottom under clothing and later squeezed A19’s bottom over clothing. Over the following weeks AR sent numerous inappropriate messages by social media and as a result the officer seized A19’s mobile telephone. The police subsequently submitted a crime for a sexual assault on a child under 16. Although officers were aware of the inappropriate messages, the Home Office Counting Rules10 state that where the victim and the perpetrator are the same in allegations reported at the same time, only the most serious offence is to be recorded. The sexual assault was the most serious crime of the two as determined by the length of the maximum penalty that can be legally imposed.   5.15. Prior to the strategy meeting 8 days later, an officer had spoken to Mother on the telephone on 2 occasions and it had been confirmed that A19 did not wish to support a police investigation. Mother said that A19 hadn’t ever wanted to progress the matter to the police and had been telling a family friend who worked at the school about the incident without realising that school would inform the police. She said that A19 hadn’t ever envisaged the police becoming involved. Mother also confirmed that she had spoken to AR and he had apologised and acknowledged that he had acted inappropriately. She was certain that he wouldn’t do anything like this again. The crime was subsequently closed with the rationale that without the support of A19 ‘there is little or no chance of a successful prosecution’. Mother attended the police station a few days later and collected A19’s mobile phone. It had not been sent off for any examination due to the family not supporting the allegation.  5.16. The strategy meeting minutes indicate that school discussed the amendments made to A19’s initial account at this meeting. It is listed as an action for social care to share the additional information from school with the police, but this was not completed as the crime had already been closed. Consideration could have been given at this time to reopen the investigation but without A19 providing evidence to the police in the form of a witness                                                            10 The Home Office Counting Rules provide a national standard for the recording and counting of 'notifiable' offences recorded by police forces in England and Wales (known as 'recorded crime').  17  statement or video recorded interview, there was still very little chance of a successful prosecution.  5.17. Also prior to the crime being closed, an action had been placed on the police log to arrest the suspect. This was not executed due to A19 not supporting the prosecution and police being confident that appropriate safeguarding measures had been finalised. It has been discussed that whilst the policy in relation to the investigation being victim focussed was followed and the case closed at the family’s request, consideration could have been made to go against the family wishes. In this event, AR would not have been considered for arrest without A19 providing a video interview or witness statement, but he could have been considered for a voluntary attendance interview under caution. This approach is legally permissible but is a strain on resources that are already under pressure. It must still be considered however that if resources had allowed this depth of investigation, AR may have made an admission that could have resulted in some form of sanction. In addition, the interview of the suspect may have provided further evidential phone data as AR had sent A19 inappropriate messages via social media following the incident. But this would have been dependent upon AR volunteering the surrender of his device. Without an arrest, a warrant from a Magistrate is required to provide legal power to seize the phone. This is a further process that would have proved problematic without A19’s support in the investigation. Subsequently, in the absence of ARs device being available for examination there has not been any consideration given to pursuing the crime ‘Engaging in Sexual Communication with a Child11’. Even though there were screenshots in circulation of the messages, it would be evidentially difficult to prove that these originated from AR’s device in order to secure a prosecution. Best practice in such investigations would be to seize and examine both the senders and the recipient’s mobile handsets but again this would have required A19’s and parents’ consent.   5.18. It is imperative to remember that any further investigations may or may not have, affected the outcome that the crime was finalised for no further action.  Summary of Learning:  • Responses to a young person disclosing sexual abuse may be more effective if a young person feels included in discussions regarding decisions and potential outcomes. • No further action regarding a criminal offence should not mean no further safeguarding action. • Responses to disclosures should include the consideration of all legal remedies.  The use of the Child Sex Offender Disclosure Scheme (Sarah’s Law)   5.19. In the interest of safeguarding, CSC sought the details of all other known children that AR had contact with. This was good practice and within 2 days CSC attended the                                                            11 On the 3rd April 2017 Section 67 of The Serious Crime Act 2015 inserted a new section 15A into the Sexual Offences Act 2003 and created an offence of ‘engaging in sexual communication with a child’.  18  relevant addresses and disclosed to the carers of the children that AR was subject to an ongoing police investigation as a sexual allegation had been made against him by a minor.  5.20. CSC also advised the carers to make an application for disclosure under Sarah’s Law (the Child Sex Offender Disclosure Scheme) if more information was required. The partner of AR made this application and the police made a further disclosure. This was unnecessary as CSC already has the authority to ‘share important information about any adults with whom that child has contact, which may impact the child’s safety or welfare12’. The police disclosure did not offer any further information.  Summary of Learning:  • Further training is required to assist Social Workers to exercise their right to disclose information confidently.  The Closure of Children’s Social Care Involvement   5.21. The response to the allegation of sexual abuse by CSC was prompt. A worker attended the family in a joint visit with the police and ensured that the family had a safety plan in place. During the visit the worker obtained the details of any other children that AR had contact with a view to safeguarding others.   5.22. Concerns were raised by professionals in the subsequent C&F assessment that parents had not immediately reported the assault to the police upon it becoming known to them. Mother had become aware of AR’s behaviours 2 days prior to A19’s disclosure, when another child’s parent had sent her screenshots of conversations between her child and A19. CSC acknowledged the delay but following conversation with parents felt assured that it was due to initial shock. Mother’s first response had been to confront AR and safeguard A19 by stopping any further contact, but it is clear from discussions recorded with parents at this time that they initially struggled to come to terms with AR’s behaviours. AR was a significant person in the family who was described as always having had a good relationship with A19 and sibling and acting the fool with them.   5.23. At the end of November, the assessment concluded that because Mother and Father were safeguarding A19 and had declined support from CSC the threshold had not been met for services to be imposed upon the family. The case was to be closed to CSC and monitored by education.  5.24. It is questionable as to whether the assessment truly considered the impact that the allegation could have on a young person, in particular given that A19 had previously admitted to self-harming as a way of bringing feelings of relief and had made reference to feeling low. There is evidence that CSC had discussed support with A19 in the one to one meeting, but the evaluation appears to have lacked depth. At the time of this discussion, CSC were not aware whether A19 was intending to support a prosecution or not, but a                                                            12 Paragraph 24 Working Together to Safeguard Children 2018  19  willingness or a reluctance to support a police investigation should not influence the efforts that must be made to understand the possible impacts of familial sexual abuse on a victim and the family environment. Familial abuse is complex and subsequently professional’s response requires distinct attention to positive welfare.  The disclosure of the abuse by A19 was the beginning of a challenging process as the familial ties between A19 and AR brought unavoidable changes within the family environment. An understanding of the change and disruption that would follow the disclosure was vital in order to recognise the support that A19 undeniably would need.  5.25. The Making Noise Project13 is a study that was commissioned by the Children’s Commissioner for England and carried out in 2015/16 by staff from the International Centre: Researching Child Sexual Exploitation, Violence and Trafficking, in partnership with the NSPCC. It sought to elicit children and young people’s views and experiences of help-seeking and support after child sexual abuse in the family environment.  The study highlights the importance of acknowledging that disclosure, and the consequences that follow, can represent new risks and challenges for children and young people, which must be actively considered and addressed. While a minority of interviewees described the point of disclosure as a ‘relief’, ‘unburdening’ or the beginning of things getting better, there were also many children and young people for whom this was not the case or who described ‘things getting worse before they got better’. Following disclosure, many children described significant levels of change and disruption to multiple aspects of their lives including family relationships, living circumstances, friendships, schooling and a familiar sentiment that ‘nothing was the same ever again’.  5.26. The assessment recognised that A19 did not wish to seek support from any external agencies and preferred to talk to staff at school if required. This is not unusual for a young person who following such a disclosure may be desperately seeking some ‘normality’. The assessment also recognised that parents were able to identify necessary actions to keep A19 safe from future incidents and A19 confirmed to CSC feeling safe at home. However, A19 also expressed a desire to speak about the abuse more freely at home. This would indicate that A19 recognised the discomfort the situation was causing and would strongly suggest that A19 was aware of the emotional impact the disclosure had on the family. This would have had a significant consequence on A19’s emotional well-being within the family environment. It was therefore necessary to involve direct support for A19 from the non-abusing family members and a further home visit to help parents to understand how to respond to A19 and reduce any feelings of responsibility towards the rest of the family, may have had a positive outcome. At the very least it would have given CSC the opportunity to assess parents understanding of the emotional support that A19 would require following the disclosure. Mother is of a professional background with a job that requires an understanding of safeguarding procedures, but her knowledge should not have been taken for granted in a situation that involved her own family. Given that AR was a significant figure throughout Mother’s life any inability to detach herself from the personal situation and consider it through professional eyes is understandable.                                                             13 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/UniBed_MakingNoise-20_4_17-1.pdf   20  5.27. There may have been a number of reasons why parents felt unable to accept or ask for support with the situation, but it would be negligent to not give any thought to any disguised compliance. Especially when consideration is given to the fact that any family, but possibly more so a professional family, may not welcome CSC involvement. There is a professional need to question whether Mother could have said what she knew would need to heard to assess the risk level as low. Practitioners are aware of disguised compliance but compliance from another professional can be extremely credible. Therefore, there is a continual need to seek evidence, even from a professional parent, to corroborate what is being said. In addition, a disguised compliance is not always a conscious decision, and, in this case, the initial shock may have caused parents to play down emotions and left them unable to consider whether support would be required long term. This is a further reason why it could have proved useful if CSC had revisited the address prior to closing their involvement. It would have offered the opportunity to observe the family and reiterate what support was available and it would have also given A19 and the family more involvement in the final decision-making process.  Summary of Learning:  • There is a need for specific guidance on best practice in supporting a family following familial sexual abuse. • The impact of familial sexual abuse on a young person and within a family environment is often underestimated. • A young person’s disclosure of sexual abuse can significantly disrupt many aspects of their lives and may not instantly improve their situation. • Non-abusing family members may not understand the support an abused family member will need.  • A young person who has been sexually abused may be unaware of how it will affect them long term and may initially refuse support but need it in the future. • A professional parent may not always be able to bring their professional knowledge into a personal experience. • A final family visit prior to closing a C&F assessment could provide further opportunity for the family.  How the Voice of the Child was Heard.  5.28. A19’s voice was predominantly heard by school as A19 did not utilise support services and other agencies only became involved in times of crises. Research from previous Serious Case Reviews suggests that young people who take their own lives often decline services and the research for this review would suggest that A19 did not find it easy to seek help from professionals. A19 did communicate with staff at school but the pathway to communication had often been laid by another, with the first two concerns of self-harming behaviours being brought to staff attention by other pupils and the third being raised by Mother. In addition, A19 only discussed the sexual assault following parents being made aware by a third party.   21  5.29. The barriers to A19’s physical voice remain unknown but there is a suggestion that A19 was not always comfortable with school relaying conversations to parents. In 2017 when school reported an intention to speak to parents about a self-harm disclosure A19 showed distress by threatening to self-harm. In view of this it may have been beneficial for school to have an agreement of what information was to be shared with parents and what information, if any, could be kept confidential. This is not easy but in the absence of accepting other support A19 was left with no confidential network. A previous Serious Case Review14 has highlighted that ‘the emphasis on sharing information with parents must not override the rights of a child to privacy and the provision of a safe way to discuss their concerns with professionals.’  5.30. The disclosure of the sexual assault was discussed in detail at the learning event and it was explained how A19 struggled to verbalise the account and preferred the use of gesticulations. This led to the account being open to interpretation and the school’s interpretation was later questioned by A19 and Mother, and subsequently changed. What is unclear is whether school’s interpretation was correct and changed due to possible feelings of embarrassment on A19’s behalf or a concern for Mother’s feelings, or whether the interpretation was incorrect. A19 was spoken to again by a police officer in the presence of parents and the account given was that AR had stroked A19 on the bottom. This is distinctly different from school’s interpretation which suggested digital penetration. The true account will always remain unknown as A19 presented as reluctant to discuss it again in any detail. It is known that some children feel inhibited to talk openly about experiences in the presence of parents and the only person who spoke to A19 alone was the CSC worker. A19 had never met the worker before and was described as not wishing to discuss the incident in any detail and not seeming to want to be there.   5.31. It is often very difficult to engage a child who hasn’t met you before about such a sensitive subject and A19’s response was not out of the ordinary. Disclosure of sexual abuse is uncomfortable and often a process not a one-off event. CSC recognised this by asking who A19 could speak to and A19 identified a teacher. School were unaware of this conversation but in any case, following the disclosure, had attempted to build a pathway for further discussions by monitoring A19 and asking how things were. A19 had not wanted to talk. There is no suggestion from any agency that following events A19 presented any differently and it is easy to consider that A19, possibly by virtue of having a supportive family, had a resilience to the incident. But it is also possible that A19 was left with an unmet need of full disclosure. This is particularly plausible when you consider that 2 months later, 2 teachers reported causes of concern regarding comments of self-harming. No link was made between the comments and a possible sign of A19 being ready to talk. It would have been beneficial at this time to consider the self-harm comments in conjunction with the sexual disclosure rather than as a separate concern. If this had been done further attempts to help A19 to engage with support services could have been made. Instead the concerns were relayed to Mother and focussed on the threats to self-harm rather than identifying and considering the underlying cause.                                                             14 The voice of the child: learning lessons from serious case reviews April 2011, No. 100224  22  5.32. Following the disclosure of sexual abuse A19’s voice appears to be forgotten. A significant omission of A19’s voice is the lack of explanation for the first account noted by school being altered.  In addition, the decision not to support a prosecution has been relayed to the police by Mother and there is no reference to this decision ever being discussed directly with A19 by any professional. A19’s views upon the matter and how it was dealt with are unknown. The focus of A19’s experience became overshadowed by the family’s capability to protect and the lived-in experience of A19 has been lost. A longer-term presence of a professional working with A19 to promote knowledge of sexual abuse and keeping safe could have helped A19 to overcome the experience. It is clear from the message sent to the ex-teacher in January, that the sexual abuse was still forefront in A19’s mind.   5.33. What is evident throughout the review is that A19 was able to talk to peers. It was to friends that A19 disclosed the self-harming, the sexual assault and an intent to end life. This is understandable as A19’s life was lived within the support of friends and outside the realm of professionals.  Given the importance of this peer support, and the high level of disclosures that young people will offload to friends, it would be useful for professionals to find ways to utilise this. In addition, assistance must be given to young people to help them to respond and support one another whilst making it clear that they do not have any personal responsibility. This is important as A19 has demonstrated that it is reality that a child could be more likely to disclose self-harm and/or suicidal thoughts to another child than they would to a professional.  5.34. Although talking to friends was mainly positive for A19 the written notes imply that some peer groups were bringing additional difficulties and there may have been some experience of bullying or gossip. Bullying had been discussed at school with A19 but other than a one-off incident nothing had been disclosed. The school has an anti-bullying ambassador programme which includes an anti-bullying room being available in school for students to access for support when required. A19 utilised this room for 2 weeks prior to the sexual abuse disclosure but would not disclose what was wrong. The evening prior to the sexual disclosure A19 did disclose that some older boys had made upsetting comments but A19 had said that it could be discussed the following day. The following day the sexual disclosure took precedence and bullying was not raised again.   5.35. Towards the end of 2018, A19 expressed a want to ‘self-harm or worse’. The use of the word ‘worse’ was not explored with A19 despite research suggesting an association between self-harming behaviours and suicide15. The risk of suicide should have been discussed but there is no verification of any questions of any suicidal intent being posed to A19. Non mental-health professionals may be wary of direct questioning but there is no evidence to suggest that it will encourage a young person to pursue suicidal behaviour.  In fact, it could have the opposite effect by signalling to a young person in distress that another person cares and is willing to talk about how they feel.  5.36. It is apparent from the review that A19 was not a child who found it easy to communicate with professionals and voice worries but was articulate and vocal enough to                                                            15 https://www.nhs.uk/conditions/self-harm/  23  engage superficially. This gave professionals a sense of hearing A19’s voice but in reality, there is little evidence of professionals being able to break the surface and fully understand what A19’s concerns were. There is a rationalisation of no referrals to other services in the context that A19 was not actually self-harming, yet the hospital noted evidence of previously healed cuts to both forearms and self-harm to both wrists. Had these marks been evident during school, staff would have been able to open a conversation with A19 with a suitable challenge for a support plan being required.   5.37. In summary there were clear barriers to A19 being heard by professionals. Firstly, there was a lack of physical evidence to corroborate what A19 plainly verbalised regarding feelings of self-harm. In the absence of notable marks A19’s comments could be construed as ‘talk’. Secondly in the presence of good behaviour and a supportive family there was no indication of the complexity of emotional problems A19 was facing. The thoughts of self-harm were clear but A19’s verbal responses to professionals concerns and general behaviour, over influenced the level of risk considered.  Summary of Learning:  • Professionals should be aware that embarrassment of a young person’s sexual abuse may prevent them from disclosing all the information. • Professionals need to be aware of the connection between self-harm and suicide. • A young adolescent person could be more likely to disclose to a friend than to a professional16.  6. Additional Analysis  Coroner Experience  6.1. The pre inquest review hearing was attended by a principal general law solicitor from the Local Authority who takes the lead on inquest matters. Consideration has recently been given to identifying a lead specifically to attend child inquests and as a result a second solicitor was in attendance on this occasion to observe the process. The principle general law solicitor had not been updated of the response of the rapid review panel and it was by coincidence that the observer was able to respond to the Coroner’s queries and make telephone calls to clarify timescales etc. This unfortunately gave the impression of the representatives being unprepared but was not the case.  6.2. Further to the above, on 29 June 2018, local areas began their transition from Local Safeguarding Children Boards to the Local Safeguarding Children Partnership arrangements set out in Working Together to Safeguard Children 2018. This guidance set out the new process for Child Safeguarding Practice Reviews, replacing the previous process for                                                            16https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/07/It_Takes_a_lot_to_build_trust_EXECUTIVE_SUMMARY.pdf  24  conducting Serious Case Reviews. The Coroner was unaware that this authority had made the transition and was unfamiliar with the new terminology.  Summary of Learning: • It would be good practice to inform the Coroner of any procedural changes to the review process.  Strategy Meetings   6.3. School made an appropriate referral to CSC and contacted the police the same day that A19 disclosed the sexual abuse, but it was 8 days before the strategy meeting convened. It would have been beneficial for a strategy meeting to take place much sooner as this delay between A19’s disclosure and the multi-agency meeting meant that all of the information was not shared between the agencies now working with the family, prior to the police closing their investigation. The meeting was attended by CSC, police and education. A health representative was not present, but it is noted on the minutes that the health information was requested. This appears to have remained outstanding as it is not included within the C&F assessment. In addition, as a result of health not being in attendance, health has no record of the abuse or the concerns of self-harm ever being shared with them. Although the strategy meeting did successfully share information between the attending agencies, it failed to consider a ‘strategy’ to keep A19 safe from further harm in the event of AR not heeding Mother’s warning to stop all contact. This was particularly important as the meeting had already discussed a concern that A19’s parents had not contacted the police themselves upon learning of the abuse. The strategy meeting would have been the ideal environment for the agencies to discuss whether any work could be provided direct to A19 regarding keeping safe and understanding abuse.  6.4. The distribution of minutes was discussed at the learning event as some professionals consider that minutes are not always circulated in a timely manner.  This limits the ability of agencies to check that discussions have not been misconstrued and whether all actions have been recorded correctly. All agencies understand the importance of making their own notes and recording their own actions in emergency meetings such as a strategy meeting, but distribution of minutes ensures that each agency has a uniform record of decisions agreed by all. The Local Authorities safeguarding framework states that it is ‘the responsibility of the chair of the meeting to ensure that the decisions and agreed actions are fully recorded using an appropriate form’, and that ‘a copy should be made available immediately for all participants’.   Summary of Learning:  • Strategy meetings must convene in a timely manner and distribute minutes speedily.   25  7. Good Practice Identified Much good practice has been identified during this review by professionals at the learning event and by the Panel. Some has already been commented upon, but it is important to highlight the following as part of the review.  7.1. Following the incident, the Local Authority immediately offered school support from the Educational Psychologist team. The team provided invaluable guidance with regards to communicating information with staff, parents and pupils and they trained staff to support students. This support was offered in a timely manner and proved extremely helpful.  This was excellent practice demonstrated at a very difficult time.  7.2. School informed other schools of individual ‘Causes of Concern’ as they became aware of them following the incident. This allowed other schools to support their students promptly.  8. Recommendations In order to promote the learning from this case, the review identified the following actions for the LSCP and its member agencies:  8.1. The early help pathway to be reviewed in consideration of the number of young people self-harming and for the LSCP to (i) effectively and continually promote its use as part of the regional procedure ‘Young People and Self-Harm’. (ii) An audit should take place 12 months after part (i) is completed to compare its usage prior to and since the recommendation was made;       Proposed outcome: Knowledge and use of the self-harm referral pathway is enhanced across the authority and young people are referred when support is needed.   8.2. The Chair of the LSCP should ensure that Police are made aware of the findings of this practice review in order that any relevant areas for development can be identified regarding the force’s involvement with allegations of sexual abuse involving a young person suffering with their mental health. Specifically, how they communicate information to victims as to how the alleged perpetrator has been dealt with;    Proposed outcome: The Police will be able to identify learning points from the investigation regarding A19 and the wider family and take appropriate action. This will ensure other similar enquiries are managed in a sensitive manner when a young person feels unable to proceed with a prosecution and victims will be better informed if there is no intention to speak with the alleged perpetrator.  8.3. The LSCP to audit the timeliness of strategy meetings and the distribution of their minutes to ensure that the local safeguarding framework is being adhered to. Proposed outcome: Strategy meetings will be effective, and attendees will have a uniform record of discussions and actions.  26  8.4. The LSCP to ensure that agencies have training available for professionals, to help them to understand when and how to share information regarding a person who is a risk to children. Professionals should be encouraged to seek legal advice when in doubt.   Proposed outcome: Risks to children who have unsupervised contact with a suspect will be managed more effectively  8.5. The LSCP to review their processes in how and when they communicate the commission of a LCSPR to parents and their families.   Proposed outcome: Parents and families will be informed of the review process in a timely manner.       