Chronic neglect and intrafamilial child sexual abuse of male and female children, who were aged between 3-9-years-old at the time abuse was first reported. Mother and her male partner were subsequently convicted of multiple offences of sexual abuse. Family were known to multi agency services, and had period of child protection planning under the category of neglect, later stepped down to child in need plans. Concerns re-emerged and children were removed from the family home, on an interim basis, into care. Shortly after the children were removed they made disclosures about their previous home life and of being sexually abused. Ethnicity or nationality not stated. Learning includes: information exchange between professionals must be comprehensive and timely; professionals need to recognise the different indicators of possible child sexual abuse so that potential indicators are not misunderstood, dismissed or ignored; professionals need to use curiosity, hypothesising and a critical analytical mindset throughout the risk assessment process; if an agency decides not to implement an important case conference recommendation, the relevant agency professional must notify the case conference chair with reasons. Uses the Significant Incident Learning Process (SILP). Recommendations include: professionals must have knowledge to enable them to identify and respond effectively to children who are or who may be at risk of suffering multiple categories of abuse; professionals must have knowledge of child sexual abuse, including female perpetrator behaviours; Achieving Best Evidence (ABE) interviews and medical examinations must be child centred and undertaken in a timely way; effective management and multi-agency oversight must be child focused, analytical and reflective.
      
    Serious Case Review No:  2020/C8469  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.                                                              Final version  – September 2020 1    Executive Summary – September 2020 Family G     Contents  Subject    Page  1. Background to this Serious Case Review.   2 2. Scope of the review   2 3. The views of the family  2 4. Objectives of the review  3 5. Brief Summary of analysis related to key learning areas  3 6. Activity undertaken to date  5 7. Lessons Learned  6 8. Recommendations  8 Appendix A: Independence; methodology; key issues and bibliography    9                                                                      Final version  – September 2020 2   1. Background to this Serious Case Review  1.1 This Serious Case Review (SCR) is conducted under the statutory guidance of Working Together to Safeguard Children 2015. The purpose of a serious case review is to conduct “a rigorous, objective analysis of what happened and why, so that important lessons can be learned, and services improved to reduce the risk of future harm to children,” (WTSC 2015, page 72). 1.2 This SCR concerns a family comprised of both male and female children who experienced chronic neglect and intrafamilial child sexual abuse.  1.3 The family were well known to multi agency services. The children had a lengthy period of child protection planning under the category of neglect. This was stepped down to child in need plans and the case was later closed. Concerns began to re-emerge shortly after the closure of the child in need plans. This resulted in a second period of child protection planning, again under the primary category of neglect and a secondary category of emotional abuse. Legal proceedings commenced and the children were removed, on an interim basis, into care. Shortly after the children were removed from the family home, they began to talk to care givers and professionals about their previous home life and of being sexually abused. Their mother and her male partner were subsequently convicted of multiple offences of sexual abuse relating to all the children.   2. Scope of the review     The review covered a 7-year period due to: (i) the length of time the children were known to service providers (ii) the protracted criminal proceedings.   3. The views of the family  Services supporting the children will work together to agree how and when to share this review’s findings with them. Relevant adults did not contribute to this review due in part to unforeseen circumstances. Continuing efforts will be made as appropriate to share the review findings and seek their feedback at this, the final stage of the review process.                                                                 Final version  – September 2020 3  4. Objectives of the review  The terms of reference were wide ranging including an overview of systems, how agencies and organisations worked together to safeguard the children, information sharing and management oversight/supervision.  The review commissioners considered that the exceptionally young ages of the children and the extensive abuse they suffered, in conjunction with the co-occurrence of abuse committed by a female perpetrator, were areas of new learning across the local authority area. The children’s ages ranged from 3-9 years at the time child sexual abuse (CSA) was first reported. The review also focussed on the extent to which indicators of CSA may have been missed prior to the children’s disclosures.  The terms of reference prepared by the review commissioners also asked the independent reviewer to assess whether the support given to the children, once taken into care, was appropriate and sufficient, given the very lengthy delays in bringing the case to charge, trial and conviction.   5. Brief Summary of analysis related to key learning areas The independent review author explored the motivation of perpetrators of sexual abuse within a familial setting.  Whilst it is acknowledged that extensive research into male perpetrators of CSA is in existence this is not the case for female perpetrators. There was no evidence to say that the mother, who was known to have perpetrated acts of abuse in her own right, was manipulated or targeted and  “groomed” by the perpetrator. Nor could this hypothesis be discounted as she was a woman with significant vulnerabilities who lacked the capability and, at times, the capacity to adequately care for and safeguard her children. In short, the motivation for committing CSA and who was the instigator of this category of abuse remain unknown.  The review author noted that indicators of child sexual abuse are known to be wide and varied and can encompass physical, behavioural and emotional indicators, including how children relate to others and parental behaviours. They are not always ‘sexual’ in their manifestation.  They can be explicit or subtle, long or short term and understood in the context of a child’s development. Just because children have not verbally disclosed the abuse, does not mean they have not disclosed.  Many children do not “tell” in a straightforward way; rather, their behaviour and demeanour or the characteristics or behaviour of caregivers indicates that something is wrong. There were examples of behaviour from all children, and one child in particular, which raised concerns for the                                                            Final version  – September 2020 4  children’s wellbeing. These agency concerns were identified, assessed and evaluated through the multi-agency child protection and child in need planning processes; however, this did not always lead to effective assessment or clear analysis, evaluation and robust intervention.  Research confirms that susceptibility to sexual abuse is known to co-exist with neglect and other forms of child abuse. Using a holistic assessment would have placed the focus on the needs of the children. A child centred approach places an emphasis on decisions being made in the child’s best interests which could otherwise be overshadowed by parental needs. Other approaches to assess sexual abuse were in use at the time, including the four preconditions to sexual abuse and the sexual behaviours traffic light tool; the latter tool was in use by staff at the children’s school.  Furthermore, learning from serious case reviews from this period, highlighted risks relating to “hidden men” and the importance of hypothesising and professional judgement. Rigorously applying these approaches to sexual abuse may have led to a better focus on the children’s welfare and need for protection from possible sexual abuse.   The dissonance between the children’s  apparent presentation at times, the home environment and family dynamics they were living in, should have raised concerns. Staff should have displayed more professional curiosity and thought ‘what does the child mean to the parent and what does the parent mean to the child?’ This approach challenges the optimistic view that their circumstances had sufficiently improved.  Professionals may also have viewed mother as a “victim” and not a perpetrator of known neglect which led to her needs overshadowing the children’s experiences and feelings.   The children were medically examined in relation to sexual abuse more than two years after  professionals initially discussed the need to undertake sexual abuse medical examinations. There is a difference of opinion within the professional network, as to whether the initial decision that medicals were not in the children’s best interest was (a) due to the allegations being historic and therefore unlikely to produce credible forensic evidence or (b)  whether a decision was made that a medical was not needed. The written records of the meeting are ambiguous therefore the reason cannot be clarified. Professionals later challenged the need for medical examinations on the same basis – but they did eventually take place.  Another possible reason for the medical examinations not taking place at the earliest opportunity was the absence of ongoing multi-agency meetings to specifically co-ordinate and plan responses (including the investigation) to the numerous ongoing disclosures. The children’s individual reviews (as children who were looked after by the local authority), rightly focused on their care needs; however, the same level of multi-agency attention to the                                                            Final version  – September 2020 5  ongoing investigation into disclosures was lacking. It is possible that an earlier examination may have achieved more conclusive results: the delay meant any physical signs may have healed and the experience was likely to have been retraumatising.  The independent reviewer looked at how the children were supported once taken into care.   This was a complex and lengthy investigation, where the children made disclosures over a long period of time once they were removed from the mother’s and partner’s care and felt in a safe environment.  The length of the investigation was due to a number of issues including, protracted disclosures by the children, delays in ability to interview the mother due to health issues, delays in disclosure of material to the criminal investigation and staff resourcing challenges. It was a long timeframe in the children’s lives given their young ages. Overall, it is likely that these delays constrained the professional network’s ability to fully safeguard and plan for the children e.g. limitations to therapeutic work until the conclusion of the criminal proceedings in case the children were required to give evidence, and the need for therapy to adhere to Crown Prosecution Service guidance. Furthermore, the delay is likely to have had a negative psychological effect on the children, some of whom wanted to see their mother during the timeframe. The children were also aware that their mother and  her partner were subjects of protracted criminal law proceedings and this was also known to have impacted adversely on the children’s emotional wellbeing. The analysis noted areas of good practice; for example, the local authority worked with multiple agencies and organisations to provide appropriate co-ordinated therapeutic support by a lead psychotherapist for the children and training support for their carers.   6. Activity undertaken to date  A Child Sexual Assault Referral Centre (CSARC) is operating, providing an enhanced referral pathway, and a multi-agency CSA pathway has been produced. There are regular CSARC open days and the CSARC provides CSA training including the role of a CSA medical examination. There is a video available to explain CSARC health assessments.  Children’s Social Care  has moved to a relationship-based social work model as part of a restructure; this change of practice also addresses some of the learning identified as needed in this SCR. This revised approach has significantly reduced transition points in the system and changes of social workers and managers along with drift and delay. Audits of social work chronologies are now part of the quarterly audit cycle. The NSPCC neglect toolkit is being rolled out across the partnership.                                                            Final version  – September 2020 6  An action plan to address the 8 recommendations produced by the review author and review commissioners is under development.  Further Information about the SCR process can be found at Appendix A  7. Lessons Learned  7.1 In respect of an understanding of the extent to which indicators of child sexual abuse may have been missed prior to the children’s disclosures:  • Information exchanged between professionals must be comprehensive and timely so that all members of the multi-agency network have full knowledge of concerns in order to fully assess the level of risks to children. • Professionals need to recognise the different indicators of possible child sexual abuse so that potential indicators are not misunderstood, dismissed or ignored. • Professionals must equip themselves with up to date knowledge of child sexual abuse, including female perpetrators.   • Professionals need to be aware of the co-occurrence of neglect and other types of significant harm including child sexual abuse.  • Professionals need to use curiosity, hypothesising and a critical analytical mindset throughout the risk assessment process.   • Professionals should consistently use chronologies to understand and assess the emerging pattern of risk over time.  • Risk assessment should be rooted in child development.   7.2 In respect of how well agencies’ concerns were identified, assessed, evaluated and how effective was the response to these:  • Professionals need to ensure that identified concerns lead to effective assessment, clear analysis, evaluation and robust interventions.  • If an agency decides not to implement an important case conference recommendation, the relevant agency professional must notify the case conference chair with reasons.   • Professionals must ensure that the content of written agreements effectively address the needs of children and parental compliance is closely monitored.  • Professionals should produce a multi-agency chronology to inform a co-ordinated child centred response to repeated police call outs.  • Risk assessment and analysis must include the role and presence of new partners.                                                            Final version  – September 2020 7   7.3 In respect of the effectiveness and response of the agencies to the initial referral of child sexual abuse:  • Where there are ongoing allegations and an emerging picture of child sexual abuse, review strategy meetings should be convened at timely intervals to coordinate and plan effective responses.  • Where there is ongoing supervised contact, a review of contact should be held to consider the safety and welfare of children in such circumstances.  • Where child sexual abuse is known to have occurred, multi-agency professionals must work together to ensure that timely, specialist medicals are undertaken to reassure children and to provide a thorough understanding of the child’s medical needs and to support criminal investigations.    7.4 In respect of how the children’s views and feelings were ascertained and responded to:  • Professionals need to apply knowledge and understanding of child development, in order to recognise and be alert to issues of concern.  • Professionals need to ensure that parental issues do not overshadow children’s needs within risk assessments.   7.5 In respect of the extent to which interagency / agency policy and procedures (government guidance at the time) were followed in this case:  • Risk assessments must include critical analytical reflection in order to counterbalance over optimism.  • Where there is a lengthy and concerning chronology of risk and harm to children, consideration should be given at an early stage to the need to issue care proceedings.   • Management oversight must result in timely, effective safeguarding interventions to robustly protect children.  • During departmental restructuring and times of high staff turnover, senior managers should risk assess the impact of this to ensure there are enough practice resources to keep children safe.                                                                Final version  – September 2020 8  8. Recommendations  1. Professionals must be equipped with the knowledge to enable them to identify and respond effectively to children who are or who may be at risk of suffering multiple categories of abuse.   2. Professionals must be equipped with knowledge of child sexual abuse, including female perpetrator behaviours.     3. Professionals working with neglected children must identify and implement timely, effective support and interventions.   4. Professionals working with neglect must be vigilant and open minded to the potential of co-occurring and different types of harm, including sexual abuse.    5. Achieving Best Evidence (ABE) interviews and medicals must be child centred and undertaken in a timely way. ABEs must be carefully planned in order to achieve an evidentially sound interview.  The lead agency should share their findings in a way that is understood by professionals working with the family.  6. When working with neglecting families, professionals must apply knowledge, understanding of child development and remain child-centred in order to identify the holistic needs of children.   7. Effective management oversight and multi-agency oversight must be child focused, analytical and reflective.  The practice of management oversight by the Head of Service and Service Manager must be consistently applied in cases where children are subject to child protection plans in excess of 18 months.  8. Strategy meetings and subsequent review strategy meetings must be convened when appropriate (and include Health/SARC) and at timely, child centred intervals where there are ongoing allegations to specifically co-ordinate and plan responses (including the investigation) and to progress outstanding actions.                                                                       Final version  – September 2020 9  Appendix A Independence   Safron Rose, child protection consultant, is the independent reviewer and lead author. She is a full-time independent child protection consultant and trainer providing a range of safeguarding services to multi-agency managers and practitioners across England and the Channel Islands.   Safron Rose has thirty years’ experience in child protection social work. She has been involved in a number of serious case reviews since 2012 and has held various operational and strategic roles in Children’s Services and is a former Director at the NSPCC.   Methodology  The review used an adapted Significant Incident Learning Process (SILP). The approach explores practitioners’ views of the case at the time the events took place. It analyses significant events and deals not only with what happened but why it happened. Essentially the aim is to promote reflective learning and practice improvements and reduce the notion of blame.   The local authority established a serious case review group, referred to as a panel, to manage the review process. The panel comprised of senior managers of the agencies providing services to children and families across the local authority area and was independently chaired.  The role of the panel was to assist the independent lead reviewer in considering the evidence, considering lessons that could be learned to improve practice and formulating the recommendations of this report. The independent reviewer produced and presented a full report with detailed analysis to the Board to enable their understanding of the review author’s findings and recommendations. This Executive Summary was produced with the Safeguarding Children Board.                                                                 Final version  – September 2020 10  Key issues for the review:   o An understanding of the extent to which indicators of child sexual abuse may have been missed prior to the children’s disclosures,   o How well were agency concerns identified, assessed, evaluated and how effective was the response to these?   o The extent the exchange of information was effective: within the agency and between the agency and other agencies.  o Agency management oversight and supervision of this case.  o The extent to which interagency / agency policy and procedures (government guidance at the time) were followed in this case.   o Any other issues identified as impacting delivery of services at that time that agencies would like to comment on such as volume of work; staff turnover; sickness / leave cover; administrative support; budgetary constraints; access to legal advice, training, etc  o Were there indicators of sexual abuse in relation to any of the children? If so, what was the response to this? What action was taken to address this?  o How were the children’s views and feelings ascertained and responded to?  o Were there any examples of good practice that can be highlighted in this case?  o Any changes to practice recommended or systemic issues identified?  o The effectiveness and timeliness of the response to the initial referrals of concerns of child sexual abuse.  o The timeframe between the allegations being put to the mother and step-father and them being charged. Was this a reasonable timeframe?   o Did the perceived delay (from charge to trial) constrain the professional network’s ability to safeguard and protect the children?                                                                   Final version  – September 2020 11  References (Bibliography)  I. NSPCC Statistics Briefing Child Sexual Abuse 2019 – NSPCC Knowledge and Information Service   II. Exploring the relationship between neglect and adult-perpetrated intra-familial child sexual abuse: Evidence Scope 2 D. Allnock. Edited by Steve Flood and Dez Holmes. Dartington – NSPCC-Research in Practice – Action for Children   III. Finkelhor, D., Ormrod, R.K. and Turner, H.A. (2007) Re-victimization patterns in a national longitudinal sample of children and youth. Child abuse and neglect    IV. Female Sexual Offenders: Theory, Assessment, and Treatment -  An Introduction. Edited by Theresa A. Gannon and Franca Cortini.   V. Toro, Jacqueline (2009) The problem of recognising and treating female sexual offenders. Seen and Heard, Vol.19, Iss.3.  VI. Ford, Hannah (2006) Women who sexually abuse children. Chichester: Wiley NSPCC/Wiley  VII. No one noticed, no one heard: A study of disclosures of childhood abuse. D. Allnock & P. Miller, NSPCC 2013.  VIII. Things children say – Disclosure, allegations and why language matters: Transparency Project.    