Death of a 14-year-old black boy in September 2012, as the result of a fatal stab wound to the heart. Child M was stabbed by another teenager, following an altercation. Child S was found guilty of murder and sentenced to life imprisonment, to serve a minimum of 14-years; the Judge referred to the incident as a "revenge killing". At the time of the incident, Child M had been missing from home for nine weeks; family was not known to children's social care prior to Child M's going missing. Child M attended college a week after he was first reported missing. Police and children's social care were informed and told that Child M did not want to return home as he was scared he would be beaten by his stepfather; neither agency visited the college nor investigated this disclosure and Child M was allowed to leave college without confirmed arrangements for his care. Identifies issues including: difficulties between Child M and mother; and Child M's wishes distracting professionals from considering the risk to Child M as a missing child. Identifies key learning, including: passive response from police and children's social care to a missing 14-year-old child; passive attitude of police to communicating with parents; and insufficient involvement of mother's partner in assessments. Makes various recommendations covering: professional challenge and escalation; communication between schools and colleges and other agencies during school/college holidays; and whether child protection services received by older children are robust and the extent to which gender and ethnicity effect them.
      
 Title:  Overview report in respect of Child M: a 14 year-old teenager. LSCB: Croydon Safeguarding Children Board Author: Ghislaine Miller Date of publication: [2015]  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          Confidential      Croydon Safeguarding Children Board    Serious Case Review under Working Together 2010  Overview Report    In respect of   Child M: a 14 year-old teenager     October 2014      Confidential   2  CONTENTS   Page    EXECUTIVE SUMMARY 3-6   OVERVIEW REPORT    1. Introduction, Terms of Reference and Serious Case Review    process 7-10   3. Family and Professional Context 11-12   4. History of Professional Involvement    12-24 5. Child M’s Journey   25 6. Analysis of Practice 26-33  7. Key Learning Points and Emerging Themes 33-37   8. Conclusions 37-38        9. Overview Report Recommendations 39-40   10. Individual Management Review Recommendations  40-41                                      Confidential   3  EXECUTIVE SUMMARY  1.1         1.2      1.3      1.4     1.5          1.6      1.7 This Serious Case Review (SCR) concerns the tragic death by stabbing of Child M: a 14-year old black teenager from Croydon. He was stabbed whilst travelling on the bus, and was stabbed by another black teenager, following an “altercation”. It is not known what the argument was about, but Child M was found to have a small amount of drugs on his person at the time of the autopsy. It would be speculative to draw any conclusions from this.   CHILD M came from Rwanda to the UK with his mother when he was 14 months old. His mother claimed asylum for herself and her son, and they were later granted indefinite leave to remain and later naturalised as British Citizens. UKBA records confirm that Child M’s father also arrived in the UK that day.  Child M lived for several years with both his parents, but they later separated. At the time of his death, CHILD M was living with his mother, Mrs P, her partner, Mr Q and his stepbrother, Child N.  He still maintained contact with his father, Mr T, who re-married and has a young child from that marriage, Child O.  At the time of his death, Child M had been missing from home for nine weeks, and it is this period that the SCR is focussed on. Prior to being reported missing in the summer of 2012 Child M was not known to Children’s Social Care (CSC).   Child M was known to the Police and had been stopped and searched by them on several occasions during the previous eighteen months, but on each occasion “nothing was found” (quote from Police IMR). During the three year period prior to his death he had been involved in five incidents that the Police attended, where he was part of a group of youths involved in fights with other groups of youths. On one occasion the group assaulted a 14-year old boy. On each occasion no charges were brought and there was no further action by the Police.  Child M was best known outside his family and friends, by staff at the college he attended in another London Borough and was described as “ likeable and very sociable, but on occasions engaged in silly “off task” behaviour. He made friends quickly and was throughout his time at college, a popular pupil”.   Child M left home on a Friday evening in July 2012, following an argument with his mother. This was partly provoked by the fact that she, MRS P, had been to a meeting at the college the evening before (concerning his on-going lateness in getting to college in the mornings) and had locked him out of the house as a punishment. She did not return home until 10pm, which he reported to college staff the next day (Friday) as it had made him Confidential   4  angry and upset. He returned home after college that day, but ran away that evening. This was the last time his family saw him alive.  1.8      1.9         1.10            1.11        1.12    1.13       Once reported missing, the three agencies involved in the case were Education (in the borough where Child M attended college), CSC (Croydon) and the Police. All three agencies have provided Individual Management Reviews (IMRs) that outline their involvement.    A pivotal issue in this SCR is that Child M was seen on one occasion by College staff, a week after he had been reported missing from home. He went into College as it was the last day of term, and was there from 9.30 in the morning until the College closed at 2pm. Although there was telephone communication between these three key agencies, there is a divergence of view in the three IMRS about what happened and what was said that morning. This is analysed in the full report.   Crucially, neither the Police nor CSC sent a member of staff to the college that morning to talk to Child M (he had threatened to run away if they did) and the College (on the advice of the duty social worker in CSC) made a contingency plan that he would go and stay with a relative and CSC would pick up the case from there. In reality no contact had been made with the relative to agree this plan, Child M’s parents were not involved or informed, and at 2pm when the College closed Child M left the premises and was not seen again. PARALLEL PROCEEDINGS Post Mortem and Coroner’s Enquiry: a Home Office Forensic Pathologist carried out a post mortem examination in September 2012. It is of note that during the examination, a small amount drugs was found. The provisional finding about the cause of death was a fatal stab wound to the heart. The inquest was opened later that month, but was adjourned pending the outcome of the criminal proceedings.    Criminal Proceedings: Child S was found guilty of murder and has been sentenced to life imprisonment (to serve a minimum of 14 years). The Judge referred to it as a “revenge killing”.  Independent Police Complaints Commission:  This SCR was commissioned in October 2012 and was due to be completed in April 2013. However, the process was put on hold, as Child M’s mother, Mrs P, made an official complaint to the Independent Police Complaints Commission (IPCC) about their response to Child M being missing. The Police Officers involved were interviewed as part of the complaints process but could not be interviewed by the Police IMR author for this SCR until the Confidential   5          1.14       1.15     1.16 complaint had been fully dealt with. The SCR process resumed at the end of May 2014, with a reconvened meeting of the Serious Case Review Panel (SCRP). The outcome of the complaints investigation is described more in paragraph 1.19 of the Overview Report CONCLUSION It is not known where Child M lived whilst he was missing from home, but there were several sightings of him, and on each of these occasions, he reportedly looked clean and well cared for. The terms of reference state that he was involved in drug related gang activity and was ”harboured” by a gang. No evidence has been provided during the SCR to support this view.   The members of the SCRP and the Overview Author are of the view that   there has been no evidence to suggest that Child M’s death might have been predicted or prevented.   Although Child M was missing from home at the time of his death, there is no evidence to suggest that his death was related to the fact that he was missing from home.     RECOMMENDATIONS 1.17         1.18           Missing Children There is evidence that, despite protocols already being in place, that what is absent, is a real understanding of what can trigger a young person running away and how agencies can respond proactively, including keeping the family informed.  The recent APPG1 report from the Joint Inquiry into children who go missing and the recent Ofsted report2 on Missing Children could be used to enhance learning and improve multi-agency practice in this area.  Recommendation 1 It is recommended that Croydon LSCB monitor compliance with the recently implemented Missing from Home, Care and Education Procedure (January 2014) to ensure a more robust response from all agencies when children go missing and that the LSCB ensure information is gathered regularly about children in Croydon who are at risk of going missing, and aim to reduce those numbers (Outcome: Children who go missing regularly are addressed as a higher priority by all agencies, reducing the number and frequency of such episodes).                                                     1 Report from the Joint Enquiry Into Children Who Go Missing from Care: APPG for Runaway and Missing Children and Adults and the APPG for looked after Children and Care Leavers. June 2012 2 Missing Children, Ofsted, February 2013. Reference no: 120364 Confidential   6  1.19     1.20       1.21      1.22 Professional Challenge and the Use of Escalation There is evidence of poor inter-agency communication and information sharing. It is important that agencies understand and use existing escalation procedures in order to resolve matters effectively.  Recommendation 2 Agencies are to re-assure the LSCB that the current multi agency escalation procedures are understood and used appropriately. (Outcome: staff feel more confident that they are able to raise concerns about the actions of other agencies or staff in their own agencies in order to resolve matters of divergence effectively).  Including Male Partners in Assessments There is evidence of a lack of professional curiosity about the role of Mr Q in this “re-constituted” family and the quality of the relationship between him and Chid M. He was not included in the Initial Assessment and should have been.  Recommendation 3 The LSCB QA and Performance Sub-Committee to ensure agencies understand the importance of including male partners in assessments. (Outcome: to ensure that all those involved in the “parenting” of children or who are part of a family network, are included in assessments)   1.23 Communication Between schools/colleges and other agencies during school/college holidays. This SCR has identified the need to ensure follow through of any safeguarding concern or missing child concern that occurs just before holiday periods. There should be someone with responsibility for making sure that referrals and concerns generated by colleges have been received and acted upon.    1.24 Recommendation 4 The LSCB to be notified and assured by schools and Colleges that there are appropriate arrangements in place to ensure that all have a single point of contact (SPOC) during school holiday periods that is shared with a senior manager in Police, CSC and Health. Conversely, that these other agencies have a SPOC whose details are shared with schools/colleges.  1.25         1.26 Older children who go missing from home  This case has highlighted an underlying assumption by professionals that a seemingly competent and confident 14 year old can look after themself during a 6 week holiday period. This begs the question of how we view the risks of gang and drug involvement and knife crime involving predominantly to young black males in areas of London.  Recommendation 5 The LSCB to commission a review of whether services received by older children who go missing are sufficiently robust and to what extent gender and ethnicity plays a part.  Confidential   7   OVERVIEW REPORT  SECTION 1: INTRODUCTION  1.1  Croydon LSCB commissioned this Serious Case Review (SCR) following the death of Child M in September 2012, aged 14 years and 7 months. On the previous evening he had been travelling on a bus in Lewisham with friends, when there was an “altercation” with another young person, Child R, then aged 15 years and 4 months. Child R’s friends, who were also on the bus, telephoned his older brother, Child S, who was travelling on the bus immediately behind. It is understood Child S got off the bus he was travelling on, and jumped onto the bus the other young people were on. He was witnessed running upstairs on the bus, stabbing Child M in the chest, and then running downstairs, leaving the bus and running away. Child M ran downstairs after him, but collapsed on the bus, at the exit.    1.2  Professionals from the Fire Service were first on the scene, and attempted CPR, gave oxygen and electric shock. The Helicopter Emergency Service (HEMS) were called at 9.42pm and arrived 21 minutes later to find Child M in cardiac arrest. An emergency thoracotomy was performed at the site of the stabbing and he was transferred by helicopter to Kings College Hospital, arriving there at 10.56pm. He was transferred to the Cardiac Theatre, but died in theatre at 3.23am the following morning. Both parents were at the hospital at the time of his death.    1.3  Child M had been reported to the Police as a missing person by his mother, Mrs P, on Saturday 14 July 2012, so at the time of his death he had been missing for 9 weeks. The Missing Person Report was closed by the Police on 20 July 2012, when Child M attended college, and was deemed by the Police to be in a Place of Safety. Later that day, the duty social worker, advised Mrs P to telephone the Police to report that Child M was still missing. Mrs P did not make this telephone call until the evening of 6 August. A second Missing Person report (MISPER) and a MERLIN were completed by the Police on this day (6th August 2014).  1.4  There had been no previous involvement with Children’s Social Care (CSC), but as a result of Child M being missing, the CSC Business Support Officer, was contacted on 20 July 2012, by both an officer from the Police Missing Persons Unit and a member of staff from the College where Child M was a student. The latter resulted in a referral to CSC and the case becoming open to CSC, although Child M was not seen at any point because he was missing.  1.5  The last professionals to see Child M, apart from those involved on the day of his death, were the staff at the College, as he attended on 20 July 2012, which was the last day of term.  Confidential   8  Serious Case Review Process 1.6  The case was referred to the Croydon Standing Serious Case Review Panel (SCRP) and was considered at the meeting on 28 September 2012. It was decided that the criteria for conducting a Serious Case Review (SCR) were met, in accordance with paragraph 8.12 of Working Together 2010 and that a recommendation should be made to the LSCB Chair that a SCR be conducted. The LSCB Chair endorsed the recommendation of the SCRP on the same day, 28 September 2012 and the Department for Education was also notified the same day. Terms of Reference 1.7  Terms of reference for the review were initially drawn up by the Standing SCRP and were agreed at the first SCRP for this particular case on 17 October 2012. The terms of reference were amended following the second SCRP meeting on 17 December 2012. These amendments involved corrections to some family background details.     1.8  The terms of reference are those outlined in Working Together 2010, with two additional specific questions to be addressed, namely:  Child M was a young person who was believed to be gang involved and who was missing for a significant time. Did local agencies respond appropriately to the risks to which he was subject?  Child M was a black boy who was involved in gangs and very vulnerable. Was there evidence to suggest that his ethnicity and gender affected the quality of services that he was offered?   (Author’s Note: Terms of reference should raise issues to be considered and explored during the SCR process. These two issues as they are written in the terms of reference, suggest that they are based on facts about Child M’s involvement in gangs. However, it is the view of the Overview Author and the SCRP is that they are unfounded. In hindsight these two points could have been more carefully worded at the start of the SCR process)  1.9 The agreed timescale for the review was 1 July 2012 up to and including the death of Child M on 16 September 2012.    1.10 Ghislaine Miller, Independent Consultant and Director of Ghislaine Miller Consultancy Ltd. was commissioned as Overview Author and attended all SCRP meetings with a remit to question, understand and challenge.  1.11      The Overview Author has an MA in Social Work and an Advanced Award in Social Work. She has significant experience in the work of Local Safeguarding Children Boards and Serious Case Reviews and is an accredited Overview Author, accredited in October 2010 by the Tavistock Consultancy, London Safeguarding Children Board and Department for Education. The author is also a trained Lead Reviewer, trainer and mentor Confidential   9      1.12      for the Social Care Institute for Excellence (SCIE) Learning Together model of systems based case reviews. The author is independent, with no prior knowledge of or involvement in this case.  Laura Eades, Independent Consultant and Director of Eadeskersewell Strategic Ltd, was appointed as Independent Chair of the SCRP. Panel Membership 1.13 Laura Eades, Independent Chair Representative: Croydon Borough Police Service Manager, ICD, Croydon CSC Designated Nurse, Child Protection Team Manager, Croydon Youth Offending Team  Secondary Consultant, College Improvement Service, Croydon LSCB Education representative from the borough in which Child M attended College CSCB Business Manager  CSCB Administrator  1.14 IMR reports were commissioned from the following organisations:  Children’s Social Care, Croydon  Education and Colleges, Croydon  College which Child M attended in another borough   Croydon Health Services (A&E, college nursing, health visiting and community and acute services)  NHS Croydon (GP)  Kings College Hospital (letter)  London Ambulance Service (LAS) (letter)  United Kingdom Border Agency (UKBA) (letter)  Fire Service (letter)  Children’s Social Care, Lewisham   1.15 The SCRP met on 6 occasions from 17 October 2012 onwards. The original agreed submission date was 30 April 2013.  However, a decision was made to put the process on hold in March 2013, as Child M’s mother, Mrs P, had made a complaint to the Independent Police Complaints Commission (IPCC), This meant that the officers who needed to be interviewed for the Police could not be seen until after the IPCC had dealt with the case.  The SCR process was resumed in May 2014.     1.16       There has been an emphasis on learning lessons from this Serious Case Review, as well as quality assurance. This has been built into the process through:  IMR authors presenting their reports to members of the SCRP on 17 December 2012. This enabled panel members to ask questions regarding omissions, discrepancies in information and provided an opportunity for emerging issues to be discussed.  This discussion Confidential   10         provided an early opportunity to identify lessons for learning that could be used to improve practice, with an emphasis on early implementation of that learning.    The IMR reports have been quality assured by the SCRP. Further work (for example clarification, further exploration of particular issues, ensuring that the recommendations flowed from the analysis and were SMART) was requested by the SCRP on some reports. This additional work was completed within the requested deadlines. Parallel Processes 1.17     1.18       1.19     1.20          1.21     Criminal Proceedings: The criminal proceedings in relation to Child S have been concluded. He was found guilty of murder and sentenced to life in prison (minimum of 14 years). The judge described it as a “revenge killing”.  Post Mortem and Coroner’s Enquiry: a Home Office Forensic Pathologist carried out a post mortem examination of Child M in September 2012. A small amount drugs was found during this examination.  The provisional finding about the cause of death was a fatal stab wound to the heart. The inquest was opened on 25 September 2012, but was adjourned pending the outcome of the criminal proceedings.    Independent Police Complaints Commission The IPCC process commenced on 9 October 2012 and the Investigating Officers report was completed on 18 September 2013. Mrs P lodged an appeal that same day. The report in relation to the appeal was signed off on 24 February 2014.  The complaints made by Mrs P were:  A Police Officer had been rude to her (upheld)  Failure by the Missing Person Unit to keep the family updated on progress (upheld)  Not enough enquiries were made with the college to obtain addresses for friends (upheld)  A photograph of Child M, provided by the family to the Police was not passed on to the Missing Person Unit as promised (upheld)  Involving the Family An appointment was made for the Overview Author and Independent Chair to visit Mrs P, but she was not at home. She had previously been written to twice but did not respond. The LSCB Business Manager and Overview Author visited Child M’s father, Mr T, at home in January 2013. A follow up visit was made in February 2013. Attempts have been made to contact both parents and the family relative on completion of this report, to discuss the outcome and findings of the SCR. However, to date, it has not been possible to contact them at the addresses or on the telephone numbers previously given.   11   SECTION 2: FAMILY AND PROFESSIONAL CONTEXT                           2.1      2.2      2.3         Family Context  Family Composition Name                                  Age at the time of             Ethnicity                                             Child M’s death  Living at Mrs P’s Home Mrs P (Child M’s Mother)              39                              Black/African                                                                                          (Rwandan) Mr Q (Mrs P’s partner)                   n/k                             White British   Child M                                         14                               Black/African                                                                                          (Rwandan)      Child N (half-sibling)                      5                                Black/African                                                                                          (Rwandan/Polish  Living at Mr T’s Home Mr T (Child M’s Father)                 53                               Black/African Mr T’s wife                                     n/k                              Black/African Child O (Mr and Mrs T’s child)       4                                Black/African       Child M and his mother, Mrs P came to the UK from Rwanda in April 1999. Child M would have been 14 months old at this time, and his mother 24 years of age. She claimed asylum for them both. They were granted Indefinite Leave to Remain in April 2004. Child M was naturalised as a British Citizen in September 2005.  Mrs P has told professionals that she was not having a relationship with Child M’s father when she became pregnant, and that he came to the UK some time after her. Clarification was sought from the UKBA on the detail of Mr T’s arrival in the UK and they have confirmed that he arrived in the UK on the same day as Mrs P and Child M.  When Child M was due to start secondary college in September 2009 Child M’s parents had separated but had discussions about Child M’s education. They agreed that he would attend the College local to where his father lived as this would provide continuity as he had attended primary school in that area. They agreed that Child M would live with his father on College days during term time, and Mr T described how he would take Child M back home to his mother’s on Fridays.     12 2.4       2.5     2.6      2.7         2.8        2.9 Mr T could not remember when this arrangement ended, but College records indicate that on 17 March 2011 he went to the College in response to a letter about Child M’s punctuality and confirmed that Child M was now living with his mother on a full time basis. When asked what triggered Child M’s move back to his mother’s Mr T said that is “what she wanted” and shrugged his shoulders.  In 2007 Mr T’s wife had arrived in the UK from Uganda, along with his now 23-year old son from a previous relationship. In March 2008, his wife gave birth to Child O. Child M lived with his father, two half siblings and stepmother on college days between September 2009 and 2011.   In August 2007, Mrs P gave birth to Child N, who is of dual heritage and is Child M’s half sibling. (The SCRP later made a referral to Children’s Social Care because of concerns about Child N. An Initial Assessment was carried out and “identified some areas of potential safeguarding concerns” (CSC IMR report) for Child M and Child N.  The Police were involved in 2 domestic abuse incidents in July and August 2007, when Mrs P alleged that Mr Q had assaulted her. The Police took no action but gave advice to both parties. The Police considered that the first alleged incident was a “malicious” report on the part of Mrs P. There is also evidence that Mrs P was living in a refuge between June 2003 and August 2004, and the Police were involved in 2 incidents where she alleged assault and racial abuse by 2 other residents who were of Kosovan nationality. No further action was taken.   Mr Q has no previous convictions. There is evidence that he has suffered from depression in the past. Mr T has no previous convictions. Mrs P has one conviction for assault in relation to an incident in September 2011, where she allegedly tried to stab a male neighbour. She refused to accept a caution and was found guilty of Common Assault at South London Magistrates Court in February 2012. She was given a conditional discharge. CSC would have been sent a MERLIN in relation to this incident.  Mr T told the Overview author that he got on well with Mrs P and with Mr Q, saying of him, “I completely applaud him and admire him”.   Professional Context  2.10 Children’s Services: An Ofsted inspection of safeguarding and looked after children services took place in May 2012. The overall outcome was adequate but there were some areas for improvement, including arrangements in the Intake Team, supervision and management oversight.  2.11      Police: Child M’s mother, Mrs P, made a formal complaint to the IPCC in relation to the two Missing Person reports. The impact of this has been that the Police IMR is based on written records and no interviews could take place with the Police Officers involved in this case until the complaint process was completed hence the delay in completion of the SCR.   13    SECTION 3: THE HISTORY OF PROFESSIONAL INVOLVEMENT (1 July to 16 September 2012)   3.1        3.2              3.3            3.4 The Education IMR outlined that Child M “was an able pupil who was not achieving his full potential though he had an improved behaviour record. The significant issue continued to be his lateness”. Child M’s mother was invited to the college on Thursday 12 July 2012 to discuss this with the Head of Year. Mrs P and Mr Q attended the meeting. The Head of Year described Child M as “generally polite, co-operative and honest: an intelligent student who had the potential to do well in his studies”.    Mrs P expressed her concern about where Child M went to after College every day, not returning home until late. She told the Head of Year that when Child M refused to get up for College in the mornings she “bit’ him. The Head of Year was not sure whether Mrs P said that she ‘bit” Child M or “beat” him. There is no evidence that she sought to clarify this with Mrs P at the time, and the IMR author reported that in interview the Head of Year said she “was concerned about the nature of the comments made but was unable to follow this up fully with Child M”. (Author’s Note: it would have been good practice to have probed further about what Mrs P was saying in order to assess if there were any child protection issues that needed following up. Mr Q could have been asked by the HOY to clarify what it was that Mrs P was saying, but there is no reference in the College IMR to his part in the discussions).   The following day at College, Friday 13 July 2012, Child M was reported (by the HoY in interview) to be “very unhappy”. He told her his mother was “very unfair on him”. For example, she had told him to be home by 6.30pm the previous evening, but his mother was at the meeting at the College she did not arrive home until 10pm, and as he had no keys to the house (Mrs P had taken them from him as a punishment) he had to wait in the garden. Child M told the HoY that this happened often and that was the reason why he did not go home on time. He described that he and his mother would have arguments about this, but that she did not physically chastise him.  At the end of the day the Head of Year e-mailed the Child Protection Designated Teacher (CPDT) to raise her concerns about Child M.    On the evening of Friday 13th July 2012 Child M ran away from home where he lived with his mother, Mrs P (then aged 37), and his half sibling Child N (then aged almost 5). Mrs P told various professionals that her partner, Mr Q, did not live with her (and he does have a different address in another part of London according to Police records), but the impression is that he did spend quite a bit of time in the household, and was referred to by various people as Child M’s step-father.    3.5  Child M’s birth father, Mr T, who lives in another part of London, told the Overview Author that on the evening of Friday 13th July 2012, at about 9.30pm, Child M’s ‘step-dad” Mr Q, had telephoned him, to say that Child M   14 was being “unruly”, and could he go to the house and either pick Child M up and take him back to his house, or help “try and resolve whatever there was (going on) between the two of the them” (Mr Q and Child M). Mr T said he got on well with Mr Q, and felt he was asking for his help to sort Child M out, and he knew how difficult Child M could be as a typical teenager. Mr T told the Overview Author that he was in another part of London at the time he took this call and told Mr Q that he would get there as soon as he could.         3.6 Mr T said that by the time he arrived at the house “Child M had bolted”. Mr Q had locked the front door to prevent Child M running away, but Child N said that he escaped out of a ground floor window overlooking the garden.       3.7 Mr T said he waited at the house for a while, and tried calling Child M on his mobile telephone, but the phone was closed. He said Child M had never run away from home before, so they were not sure what to do. Mr T suggested that they waited until the morning before they telephoned the Police, in case Child M returned of his own accord later that night.  3.8       3.9        3.10       3.11         3.12 The following morning. 14 July 2012 Mr T, Mrs P and Mr Q started calling the telephone numbers of any friends of Child M, to see if anyone knew where he was. Mr T and Mr Q also went looking for Child M in the Charlton, Woolwich areas of London. Whilst out looking, they met up with a relative of the family, who knew Child M well. This relative helped them look for Child M that day.  Mrs P contacted the Police at 1.45pm that afternoon, 14 July 2012, to report Child M missing. The Police MERLIN record states that Child M had last been seen at 9 am that morning (this is at odds with what Mr T has reported). The MISPER also stated that Mrs P had said Child M and Mr Q had had an argument the night before. She said Child M’s behaviour had changed over the previous few months, but even so, he had never gone missing before.  The initial risk assessment made by the Police at this point was that Child M was a ‘medium” risk in view of his age. (Medium Risk is defined as “the risk posed is likely to place the subject in danger or they are a threat to themselves or others”.) This MERLIN Missing Person Report (MMPR) was reviewed by the Croydon Police Public Protection desk and forwarded to Children’s Social Care (CSC) on Sunday 15 July 2012.  On Monday 16 July 2012, Mrs P, Mr T and the relative all went together to College. Mr T said they went there to see if Child M had gone into College that day and also with the intention of asking staff at the College to speak to Child M’s friends and see if anyone’s knew where he might be. When they arrived there they discovered that Child M was not in College.  The Education IMR states that they were at the College all morning. It is recorded that that Mrs P reported that she had “disciplined” Child M the previous evening after she had returned from the meeting at the college.   Whilst at the College Mr T said they spoke to one of Child M’s friends who   15      3.13               3.14              3.15   3.16           3.17  said they had seen him on the night of Friday 13th July when Child M had gone to his house to pick up a games console. Another pupil said he had seen Child M “in passing” in the Eltham area of London on the morning of Sunday 15th July.     Before the parents had gone to the College that morning their relative had been able to access Child M’s Facebook account and saw that someone called Friend 3 had sent Child M a message on Saturday 14 July, to which Child M had replied. When they went to the college on Monday 16 July, the parents discovered that Friend 3 was a girl in the year above Child M. The Education IMR reported “it emerged through talking to Child M’s friends that he had gone to a friend’s house at midnight on Friday 13 July, and that he had been seen by another friend in Middle Park on Sunday 15 July”.  Friend 3 was spoken to and she confirmed that she was in contact with Child M on Facebook, and was sending him “messages of concern”. She thought he was staying with male friend in Charlton. He was not student at College and she did not know his name. The Education IMR states that they passed this information to the Schools Liaison Police Officer, but the police have no record of this.  According to Mr T, after they left the College that day, they went to Woolwich Police station. The relative had said that although Child M had already been reported missing to Eltham Police, they knew that Child M used to “hang out” in Woolwich, so thought it would be a good idea to go to the Police Station there. Mrs P had a photograph of Child M with her. The Police Officer they saw at the station said, in response to seeing the photograph, that Child M looked familiar and that he thought he recognised him and had seen him previously in Woolwich (not from being in trouble, but from “hanging out’ there). The Woolwich Police Officer telephoned a Police Officer at Croydon Police Station, and they confirmed that a Missing Persons report had been made previously. They tried to give the Woolwich Police Officer the photograph of Child M, but he would not take it and said they needed to take it to the Croydon Police Station.           Mr T said he went back to Croydon Police Station on Wednesday 18 July 2012 to take the photo. There is no record of this in the Police chronology.  Mr T said that he also went back to the College on Thursday 19th July 2012, as Child M had posted some messages on Facebook (that their relative was able to access) to say that he was going into College that day. However, when Child M’s father spoke to one of the staff at college that morning they said that Child M was not in college and in fact all the class were out on a college trip. (Author’s Note: This is reported in the Education IMR. That evening Child M again posted a message on Facebook to say that he was staying at a friend’s house and had already arrived there. This was so that he could go into college from there the following day, Friday 20 July, which was the last day of college term).   According to the Police chronology, also on 19 July 2012, a Police Officer contacted Mr Q. It is not clear if this was via a telephone call or face to   16      3.18            3.19         3.20        3.21                face. Mr Q said he believed Child M was in the Charlton area. In the Police chronology it is quoted as, “he has no concerns. His mother also sent a message on Facebook saying they were both sorry, he should come home as they will not put him into care”.  On Friday 20 July 2012, Child M did go into college.  The Education IMR reported that he was “well presented, clean and tidy and there were no external indicators to suggest any concern about his physical welfare… he was sharp and articulate and he was asked to remain in the office, which he did for the duration of the day”. The atmosphere in college was described as relaxed and cheerful as the college was due to close at 2pm. Child M went to his tutor room during the course of the day to share the doughnuts brought in for the group by his form tutor”. (Author’s note: an over optimistic statement about Child M. By this time he had been missing from home for a week. There should have been a risk assessment at this point)  The Head of Year contacted the Child Protection Designated Teacher (CPDT) and it was agreed that the Police and CSC would be contacted. She told Child M that she needed to contact CSC and the Police and he was “very agitated” about this and “made it very clear to all the professionals involved (by this time the HoY was joined by the CPDT who had been “off-site for a large part of the day”, and the Deputy CPDT) that he would not go home and that if CSC or the Police were contacted he would “run”.   The Deputy Head of Year telephoned the Police and spoke to the Police Constable from the Sexual Exploitation and Missing Person Unit (SEMPO). It is not clear when the SEMPO took over the investigation. It is not recorded what time this telephone call was made. The Deputy Head of Year said that  Child M had “turned up” at College that morning and “he appeared agitated, but confirmed he was safe and well”. He told her that he had spent the previous night with Friend 3.   The Police IMR records that the Deputy Head of Year told the Police Officer that “Child M was frightened of going home and physical abuse was mentioned”. There is no further detail of this information on the Police report. The Education IMR gives a different account of this situation and states “Child M was agitated about the decision (to contact the Police). His main concern was that he would be sent to Africa and he made no reference to being worried that he might be at risk if he returned home”. (Author’s Note: the Police report in their IMR that the College mentioned Child M’s fear of going home and “physical abuse was mentioned”. Sadly, it does not go into further detail. The Education IMR author states that Child M made no mention of being afraid of going home and the fear of being physically abused. This is a clear divergence of view. The nub of the matter is that if Child M did express concern to the HOY about being afraid of going home, this should have formed the basis of considering a child protection referral to CSC. There is no record that the College shared the comments Mrs P had made about biting/beating Child M. This could also   17      3.22             3.23                      3.24          have been included in the referral to CSC, as it is another incident of concern that needed assessing. When Child M spoke to the HOY on 13 July, he said that his mother shouted a lot, but that she had never chastised him physically).   The Police PC advised the Deputy Head of Year to make a referral to Croydon CSC. It is reported in the Education IMR that the Police Officer said that, as Child M had been found safe and well that there was no longer a role for the Police. It was at this point that the Police closed the MERLIN. (Author’s Note: it would have been expected practice for the Police to attend the College to see Child M and conduct an interview with Child M before closing the Missing Persons Report. This view is upheld by the IPCC on 2 grounds a) Their Standard Operating procedures are clear that there must be a de-brief with a missing person who has been found before the case is closed and b) given the comments, albeit vague, about possible physical abuse, a Police officer should have gone out to the college to speak to Child M about this.  The College did challenge the Police, which is good practice, but the Police were clear they would not go out to the college. (Author’s Note: Given the comments the Police said the Head of Year made about Child M being afraid of going home, it would have been good practice for the Police and CSC to have a Strategy Discussion at this point to jointly agree a plan. Some members of the SCRP and the Overview Author are of the view that this was an urgent situation that needed a quick response, with either the Police, a social worker, or both, going to see Child M at the College, given that he had been missing from home for a week. Although he was deemed “safe” at College, it was the last day of term and the College was due to close for the summer in a few hours. However, the Police are clear that with 15 children going missing every day in the Croydon area, they would not have had the resources to go out to the College. They were particularly under resourced at this time, because the Olympics were taking place and several Police Officers had been taken off normal duties. The duty social worker (social worker 3) also made it clear that she was not in a position to go out to the College (which was outside the Croydon area). The impact of these decisions by the Police and CSC was that responsibility was handed the back to the College to make a plan, and this put them in a very difficult position, with the added pressure of them closing in a few hours and Child M threatening to run away.)   The Police advised the College to contact Child M’s parents to let them know he was safe and well, but because Child M was “adamant” that he “wanted nothing to do with his parents, and was threatening to leave” the College did not contact them.  (Author’s Note: While listening to the voice of the child is important, there is evidence that that Child M and his views were driving events at College on the morning of 20 July. This seems to have distracted professionals at the College from considering whether, as a 14-year-old child missing from home, he was likely to be vulnerable and at risk).    18 3.25        3.26                      3.27               3.28     The Police PC then telephoned CSC and spoke to the Business Support Officer to alert her to the fact that someone from the College would be telephoning to make a referral about Child M. It is not clear whether or not the Police Officer told the Business Support Officer that Child M by this time been reported missing for a week, and that he had turned up at College where he had made an allegation of possible abuse. At this point the Police closed the Merlin Missing Person Report.   The SENCO at College (who was also the Deputy Designated Child Protection Teacher) then telephoned CSC and was put through to the duty social worker, SW3. He explained to her that Child M had been reported missing since 14 July 2012, and that Child M, had arrived at College that day, 20 July 2012, and “said that he had been staying with various friends”. The CSC IMR reports that social worker 3 recorded that the SENCO said Child M had disclosed that there had been arguments at home and that he did not wish to return, “as he was afraid that he would be beaten by his stepfather, Mr Q”. The SENCO was also reported by the duty social worker (social worker 3) to have said that there had been no previous concerns about Child M at college, he “had presented as well cared for and clean”. The SENCO gave contact details for Child M’s father, Mr T. The duty social worker asked the SENCO to find out further information from Child M about when he was last hit and where, and where he was currently staying (Author’s Note: it was the role of the social worker to go out to the College and ask these questions as part of her assessment of the situation) .The social worker also advised him to let Mrs P know that Child M was at College. (Author’s Note: This is the second instance where the College view diverges from that of another agency: on this occasion it is CSC. The Education IMR author states that Child M did not mention being afraid of returning home because of possible physical abuse by Mr Q)   The Education IMR recorded that the SENCO ( who was also the Deputy CPDT) “sought advice” from CSC and “it was agreed that the College would try to work with Child M in order to find alternative safe accommodation for that night. They identified, in discussion with Child M, a relative who had been to the College on 16 July as a possible alternative carer. Child M thought this relative might be able to mediate between him and his mother. Child M said he didn’t know the relative’s address but gave College staff the telephone number. They tried to keep Child M with them whilst they telephoned the relative. (Author’s Note: there is no record that the relative was contacted and spoken to, and agreed to the plan of having Child M to stay.) A member of staff offered to take Child M to his relative’s house, but he refused and threatened to run away. The Deputy Head of Year told Child M that he appeared to be “blackmailing” the staff and he agreed.   Child M “did eventually compromise and agreed in principle to being dropped off near to the relative’s house. CSC was contacted for “advice and “their view was that, given the circumstances, that the best course of action would be to let Child M go on the understanding that he would make his own way to his relative’s house. Child M left the College at 2pm when   19   3.29    3.30         3.31          3.32        3.33           3.34      all the other pupils left for the summer break.   The Education IMR report said that Mrs P telephoned the College later that day and was told that Child M had agreed to make his way to the relative’s and “she appeared to be happy with the plan”.   Shortly after this (and probably in response to the telephone call she had received from the SENCO) Mrs P telephoned the duty social worker. She explained that Child M’s behaviour had deteriorated of late since he began to “associate with the wrong peer group”. She said her boyfriend Mr Q, did not live with them, and said that he and Child M had a good relationship, and that Mr Q never hit Child M. The duty social worker (social worker 3) advised Mrs P to contact the Police and report Child M as still being missing.  The duty social worker (social worker 3) then tried to telephone the College, but there was no response. The CSC IMR recorded that, “this was the last day of term and there was no further contact between CSC and the college until early September 2012. No written referral appears to have been made by the College to CSC”.  (Author’s Note: it is striking that communication with the College came to an abrupt halt on that afternoon on the last day of college. It is surprising that there was no point of contact for professionals from other agencies until the new term started. There was no contingency plan in place by the College for following up on Child M).             During the meeting with the Overview Author, Mr T described how he had tried to call Child M’s mobile that day (20th July), but it was still closed. He telephoned the College after 9am and asked the person who answered whether Child M had turned up at college that day. He was told that “no, Child M has not come into college” and “the person who is dealing with it is not in”. He was asked to call back later. It has not been possible to establish whom he spoke to that day.  He telephoned again 30 minutes later (he said that Child M’s mother was not able to call, as she was taking an exam that day). The person who answered the telephone told him that “the case was no longer with them” and that if he wanted any more information he should contact the Police Missing Person Unit, and he was given the telephone number. He said that he immediately telephoned Police PC, as he thought perhaps Child M had been found and was dead. He was told that the case was “no longer with them” and that he should contact CSC. He was given the general CSC telephone number, but not the name of who to ask for. He said he telephoned the number but it “rang and rang and then the line went dead”.  Mr T described that he felt the professionals involved were treating Child M as a “commodity”. He got the impression that “Child M was somewhere, but they didn’t know where he was”. He said that he “just wanted to be re-assured that Child M was alive and well…the anxiety you are going through is not measured in days, hours, minutes, but in seconds….”      20 3.35 Mr T said that Mrs P then telephoned him, to ask what was happening and he updated her. She said that, as she was in Croydon, she would go to the CSC offices. CSC records state that she telephoned the duty social worker but did not go into the office.  3.36 Mr T said that someone from the college telephoned him at 3pm and told him “We have had Child M with us here. He says he doesn’t want to go to his Mum’s, and he doesn’t want to go to yours. He says he wants to go to a relative’s house”.  The person said they had “let Child M go”. Mr T told the Overview Author that he felt as though he was “being treated with suspicion” and wondered if there was an “arrangement” with the relative. He tried to telephone the relative but their telephone was closed as they were at work.    3.37 On 6 August 2012 Mrs P telephoned the Police at 10.26pm to say that her son was still missing. She was informed that the MISPER had been closed on 20 July when Child M went into college. A new MERLIN and MISPER were completed.    3.38         3.39     3.40    3.41        3.42     On 7 August 2012 the Police contacted Team Leader 1 at CSC to ascertain the outcome of the their involvement with Child M on 20 July 2012. Team Leader 1 stated “there had been no formal allegation made by Child M. CSC had contacted his mother who said there was no abuse at home and that Mr Q does not reside with her. Child M has no allocated social worker”’. SW1 telephoned the police later that day to say she was the allocated social worker for the case.  The Police spoke to Mrs P that same day, and she said that she had gone to college to pick Child M up but was told he had left at 1.30pm and was staying with the relative. The Police also checked local hospitals that day and the following day, but there was no trace of Child M.  A CSC diary note by Team Leader 1 on 7 August 2012 recorded a decision to undertake an Initial Assessment, as a result of the contact from the Police and the SENCO.  On 10 August 2012 a social worker from CSC contacted the Police to share information they (CSC) had been given through an anonymous telephone call. The caller said Child M had run away because he was late for College and his mother had threatened to put him into care. Child M knew the caller’s son and told him (the son) he was living in a “crack den’ in Lewisham.  On 10 August 2012 a social worker from CSC commenced the Initial Assessment by visiting Mrs P at home. Child N was at home and was also seen. Later that evening Mrs P went to Greenwich Police Station to say that her son was still missing. She was told that the matter was still under investigation and someone would contact her on Monday. (Author’s Note:   21   3.43         3.44     3.45         3.46        3.47     3.48     3.49       the Initial Assessment was opened on Child M only.)  On 13 August Mr Q contacted the Police and gave them the address of the relative, where it was thought Child M might be staying. (Author’s Note:  the Police did not follow this up). On the same day, 13 August, the social worker had supervision with her team leader: it was stated that Child M had gone missing following a row with his mother during which she had threatened to send him back to Rwanda, to stay with his maternal grandmother. It was agreed that a Strategy Meeting would be convened.   On 15 August 2012 the social worker, SW1, telephoned Mrs P. Mrs P told her that Mr T had telephoned her to say that Child M had been spotted in Woolwich a few days previously. Mrs P had passed this information on to the Police, but there had been no response from them.  Later that afternoon, Mr T went to the social work office and spoke to the social worker, SW1. He said that Child M had been spotted in Greenwich on a couple of occasions, and that he also had evidence through Facebook entries that Child M had stayed with Friend 3 (a female friend from college) on 19 July 2012, the night before he went into College and was last seen. Mr T told the social worker that Mrs P had been making allegations about him; saying he had kidnapped Child M, but he was trying to stay calm, and he wanted to tell the social worker his side of the story.  On 16 August Mrs P contacted the Police, to say that she thought Child M had run away because she had threatened to send him back to Rwanda because his behaviour was getting worse. She also told the police “she believes that he may have gotten involved with gangs and that they are using him to sell drugs, due to age, in the Woolwich area.” (Author’s Note: this was not followed up by the Police).  On 20 August 2012 the relative contacted the Police to say they had last heard from Child M about three weeks before when he had asked if he could stay. They told the Police they would try and contact him again on Facebook.  On 20 August CSC completed the Initial Assessment and a Core Assessment was triggered. That afternoon Police PC contacted the social worker to say that she could not make the Strategy Meeting planned for that afternoon, but “could make Friday.”  On 22 August, the mother of a friend of Child M telephoned the Police to say that she thought Child M was being used by a local gang to sell crack cocaine for them. The Police recorded that “Greenwich officer will familiarise herself with report and explore how they can pro-actively patrol the area to find Child M”.    22 3.50        3.51         3.52          3.53           3.54       3.55      On Friday 24 August 2012 a Strategy Meeting took place and was  attended by Police PC. This was nearly 6 weeks after Child M had been reported missing and 9 days after the Police had opened a new MISPER and the social worker had agreed with her team leader that a Strategy Meeting was necessary. (Author’s Note: It is concerning that there was such a delay in convening a Strategy Meeting. This suggests that there was little sense of urgency.)  It was noted (in the Police chronology) that the outcome of the Strategy Meeting was that “once found Child M would be assessed by CSC and placed in s20 accommodation if necessary; that CSC will try and get more information from his family and will try and contact Child M on Facebook; the Police would continue their enquiries and would contact the College for details of Child M’ friends; and that the Police would circulate Child M’s image and a briefing note to Lewisham and Gangs Unit.”  On 28 August a CSC manager’s decision note was recorded “Child M still missing. Core Assessment to be completed although he has not been seen. Case can then be put forward for C&A team. Copy of the assessment to be sent to the family.” (Author’s Note: What was the purpose of undertaking a Core Assessment? It suggests that matters were being procedurally driven, and that the options available were to close the case or proceed to a Core Assessment. This would then allow the case to be transferred from the duty team, to a long- term team, and this is what subsequently happened. These were system driven decisions.)  On 30 August 2012 the relative spoke to the Police and said they had been in touch with Child M on 28 August and he said that he did not want to return home as “Mum and dad stress him out”. The Police informed the social worker of this conversation, and also advised the relative to contact Child M and tell him that if he would go to their house then a social worker would go there and assess him and that if he did not want to return home, then that would be discussed with him. The main concern was that he returned safe and well. The relative did try to say this to Child M during a telephone conversation, but he said the credit on his phone had run out and he was cut off.  On 31 August a Missing from Home Strategy Meeting was held, attended by Police PC, Team Leader 3 and SW1. The case was referred to the “Missing Panel” on 3 September 2012. This Missing from Home Strategy Meeting took place 18 days after he was reported missing for the second time.  On 4 September 2012 a social worker did a Child in Need visit to the family home and spoke alone to Child N. She then spoke to Mrs P who gave her family background information, but also said that she felt “Mr T and his partner were trying to get Child M back into their care to try and get status in the UK”.   23 3.56             3.57         3.58     3.59       3.60         3.61    3.62   On 5 September 2012 a Missing Person Panel was held. It was agreed that the case would be transferred to one of the longer-term teams in CSC, and that checks would be done with Greenwich CSC where the family previously lived. The social worker had completed a detailed report and later recorded in her diary notes ”It is hoped Child M will re-surface once College re-opens”. (Author’s Note: This meeting should have been held sooner. There is an assumption running through that case that Child M will turn up when he is ready, and this is reinforced by the social worker’s comment. From what people knew of Child M from second hand information was that he appeared to be very much in control. However, this seems to have masked the need to consider his vulnerability and conduct a risk assessment).  On the same day, 5 September 2012, the Head of Safeguarding in CSC sent a memo to the Director-Social Care and Family Support and the Executive Director, Children, Families and Learning, informing them that Child M was missing and that the Panel had agreed the following action: that publicity will be pursued; that friends from College would be contacted, the Police would access his Facebook account; Police to liaise with other local forces; and case to return to Panel in October.  The following day, the case was transferred to Pembroke Team in CSC and the allocated social worker became SW2. A manager’s note on the electronic system that day stated that the social worker was to complete a Core Assessment.  On 6 September 2012, Mrs P telephoned the SW1, to say that Child M’s  Friend 3 had told her that Child M might go into college on Monday 10 September.  Mrs P wanted to let CSC know that they could “act this time due to the confusion last time” (i.e. no-one going to the college when Child M had been there on 20 July 2012). Mrs P was given the details of the new social worker.   On 7 September 2012 the Police contacted the College. The Deputy Head spoke to Friend 3, who confirmed that she had spoken to Child M “most days during the summer break”. The Police then spoke to SW1 to update her on this. A message was later left for the Police, stating that the new social worker was SW2. The Police then left her a message  “stressing that Child M could possibly be in college on 10 September 2012 and that this was an opportunity regarding his welfare and placement”.    On 10 September 2012. The social worker, SW2, contacted the College but Child M had not turned up. Mrs P telephoned social worker 2 that afternoon and was told the Child M had not gone into college.   On 12 September 2012 the Police were contacted by a missing person charity that said they would do poster and web-based appeals.    24 3.63     3.64    3.65                 3.66      3.67   On 13 September the relative contacted the Police to say that Child M had been in contact on Facebook, and said he would go round to their house that day. Social worker 2 was updated on this by the Police and said she would liaise with her team leader about what action was to be taken.   The relative had also contacted the Missing Person Unit to provide them with this information, and they then contacted social worker 2 and repeated what the Police had already said.   Social worker 2 then telephoned the relative herself at 1.50pm. The relative said they did not know what time Child M was going to visit.  He was waiting for a lift from a friend. Social worker 2 asked the relative to tell Child M that CSC was worried about him. The relative said this was not possible as they were the only person who had managed to keep Child M’s confidence. The relative was happy for Child M to come and stay with them. They said  “Mrs P is in denial as to the real reason as to why Child M had run away. She was protecting her partner instead of Child M”.  (Author’s Note: this relative was involved in helping the parents look for Child M from the outset, passed on information to the College, Police and CSC, but was not interviewed by any of the agencies and was not asked to contribute to the Core Assessment. This is concerning. A clear statement is made that suggests that Child M was at risk from Mr Q, but this was not followed up. Mr Q was not interviewed by social worker 1 as part of the Initial or Core Assessment and this is concerning.)  On 14 September 2012 social worker 2  and her team leader discussed the matter of Child M possibly staying with the relative. It was agreed they would do a joint visit to discuss this with Mrs P and then with Mr T the following week and that they would also have a professionals meeting that week (beginning 17 September 2012).  On the evening of 15 September 2012 Child M was stabbed on the bus. He died in hospital the early hours of the morning on 16 September 2012.        4.1        SECTION 4: Child M’s journey - what was daily life like for him? How did professionals perceive him and engage with him?  The only information we have about Child M has come from his parents and those professionals from the College who knew him. What comes across about him from the conversation between Mrs P and the College at the parent’s evening on 13 July 2012 is that they saw two different sides of behaviour. The College saw a young person who was “likeable and very sociable, but on occasions engaged in silly “off task” behaviour. He made friends quickly and was throughout his time at the college a popular pupil.” The only problem the College was concerned about was his lateness: a   25        4.2       4.3             4.4        4.5               problem that had been going on for some time. “Child M was often off task. not fulfilling his potential: he had been placed on report, and failed it. However, Child M was not identified as a pupil with significant difficulties and did not require any specific pastoral support”. The Deputy Head of Year described him as a “generally polite, co-operative, and honest and intelligent student who had the potential to do well”.  There is evidence, from when the Deputy Head of Year who met Mrs P and Mr Q on the evening on 13 July 2012, what the former observed and noted was that Mrs P had a very negative view of her son; that his behaviour had deteriorated, he would not get out of bed in the morning and that he did not come straight home from College at night and would not tell her where he had been.  There is evidence from what Child M told the Deputy Head of Year the next day at College, that Child M was insightful about his relationship with his mother. He said they argued a lot, “which meant that she shouted and he listened’”. There is also evidence that he had a good relationship with his birth father Mr T, but less evidence about his relationship with his mother’s partner, Mr Q. There is some evidence that he was embarrassed or ashamed that his mother’s partner was White British and that he was being teased about this at College. There is also some implied evidence that he did not get on well with Mr Q and was afraid of him (the relative implied that Mrs P was “covering up” for Mr Q, see paragraph 3.65). Nothing is known about Child M’s relationship with Child N or Child O, despite Initial Assessments being carried out by social worker 1.   From the two meetings the Overview Author had with Mr T, he was obviously very proud of his son and thought him as a typical teenager, who sometimes fell out with the family. In this case, the family he lived with was his mother, Mrs P, half-brother and Mr Q, who we still know nothing about. Perhaps Mr T was able to have a good relationship with his son, because he was not part of the immediate family/household, and he showed a degree of objectivity about the situation?  In putting together the pieces of information that we do have, an impression emerges of a 14 year-old (who was tall and looked older than his age) who was getting increasingly “worldly wise” and “streetwise”, who wanted to impress his friends and was getting fed up with the pressure of the arguments at home. He was clearly able to make and maintain friendships and viewed his friendships and College positively. It seems clear that an argument did take place after Mrs P and Mr Q returned home from College after 10.00 pm on 12 July 2012, and although the full details are not known, it included threats by Mrs P of sending Child M back to Rwanda or having him taken into care. Child M was also frustrated and angry with his mother because he had been locked out of the house all evening and had to wait in the garden until she came home (she had taken away his house keys as a punishment). Whatever happened was enough to trigger Child M to jump out of the window and run away the following evening.     What does not appear to have been taken into account is the level of   26 4.6        4.7                       5.1                  5.2 violence in the family: there had been two reported incidents of domestic violence between Mrs P and Mr Q; Mrs P had previously been found guilty of Common Assault (trying to stab a neighbour following a dispute); and Child M had been questioned by the police on several occasions  (he was part of a group who on one occasion assaulted a 14 year-old. No charges were brought).   Another matter that does not seem to have been considered is the quality of the attachments Child M had with the different members of the family He came to the UK with his mother and spent many years living with her. He also spent time living with his father. It is significant that in 2007 his stepmother gave birth to Child O and his mother gave birth to Child N. At this time his mother, Mrs P, was also in a relationship with Mr Q and there is evidence that domestic violence was a feature of this relationship. It may be that Child M felt displaced from both households with these changing dynamics. There is also evidence that he was not comfortable living in a dual heritage household and that he was being teased at College about this (Mr Q is White British, and Child N is of dual heritage).  SECTION 5: ANALYSIS OF PRACTICE  This section identifies some Key Practice Episodes and analyses the quality of professional practice.  KEY PRACTICE EPISODE 1: Mrs P and Mr Q attended College on 12 July 2012, Child M attends College on 13th and is Reported Missing from Home on 14 July 2012  Mrs P and Mr Q had attended the parents evening at the college on 12 July 2012 and Mrs P was negative in her attitude towards Child M. She said that would get angry with him when he would not get up in the mornings and would ‘bite” or “beat” him. These comments should have been explored further and consideration given to making a referral to CSC. It is interesting to note that Mr Q was with Mrs P at the meeting, but is not referred to at all when these discussions were taking place. He could have been helpful in clarifying what it was that Mrs P was saying, but there is no suggestion that this was considered, or what part he played in the discussions, if any. He appears to be invisible: it is almost as if he was not there. The focus is solely on Mrs P. It would be interesting to know why this was so: was it because he was not Child M’s father and did not have Parental Responsibility, or was it that the Mrs P dominated the conversation? We have not been able to answer the why question, as the member of staff from the College is currently unavailable. However, this incident does raise the question of how well equipped and confident professionals are to communicate with parents under such difficult circumstances.   On 14 July 2012, Mrs P reported Child M as missing, to the Police. She told the Police Officer that Child M had left home after an argument with Mr   27           5.3                  5.4         Q. A Police MERLIN Missing Person Report (MMPR) was completed and Child M deemed to be of medium risk.  This was not properly reviewed during the 9 weeks he was missing. There is a view (IPCC appeal report) that if further information had been taken into consideration he would have been deemed high risk (the allegation recorded by the Police of the possibility of physical abuse by Mr Q and the suggestion, made through an anonymous telephone call to CSC that Child M was “living in a crack den” and was being used to traffic drugs)   A recent change to Police policy deemed all young people under 18 to be at medium risk. The MMPR was reviewed by the Croydon Public Protection Desk (CPPD) on 15 July 2012 and then forwarded by e-mail to CSC. It was discovered on 16 July 2012 that Child M’s name had been misspelt on the records so as the IMR highlighted “It is unclear in the early contacts with the family if the personal details recorded, including the family name, were checked. Based on the (mis) spelling of his last name, research carried out internally and externally showed Child M was not known to the Police. Consequently, early opportunities to access information about Child M and his associates retained on Police systems were therefore missed and potential lines of enquiry not identified” The Police have recognised this error and made an appropriate IMR recommendation in relation to this. KEY PRACTICE EPISODE 2: Child M went to college on 20 July 2012.  In appraising the practice of professionals involved on this day (the College, the Police and CSC) it is the Overview Author’s view that it fell below the standard that would have been expected as laid down in the inter-agency procedures.   The communication trail between those involved was quite complex, but the net result was that Child M, who had been missing for a week by this time, was in College all day. Both the Police and CSC were made aware of this, but neither went to the college to investigate his alleged disclosure to a member of staff that he had run away because of arguments at home and “did not want to return as he was afraid that he would be beaten by his step-father”. It is the Overview Author’s view that one or both agencies should have attended to undertake a single/joint section 47 enquiry based on Child M’s disclosure to the DHOY, and this should have been  agreed between them beforehand via a telephone Strategy Discussion. The Education IMR states that Child M did not made such a disclosure; but both CSC and the Police IMRs record that this was the information that was given to them by the College.  Even without the disclosure by Child M, the Police should have gone to the College to speak to Child M, as a missing child who had been found, before closing the case. This view is upheld by the IPCC.  The professionals at the College (the CPDT, the Head) appear to   28 have been confused about their safeguarding responsibilities, in not notifying CSC straightaway that Child M was in College, and it seems they were somewhat misguided in their response to the situation.   Although they did listen to what Child M had to say and did engage with him, they did not recognise that he was a child possibly at risk of significant harm and act accordingly by considering notifying CSC and the parents straightaway that he was in College, in compliance with Working Together 2010 and the inter-agency child protection procedures.   It is of concern that Child M was allowed to leave the College that day without being interviewed by the Police or a social worker. There is evidence of an over-reliance by staff at the college who were involved with him on the last day of term, on what Child M said, taking it at face value, rather than recognising his vulnerability and the underlying risks. They should have carried out a risk assessment and the matter should have been escalated at this point by involving the Head of the College and contacting a senior manager in CSC and the Police.  There is also evidence that both the Police and CSC were clear they did not intend to go to the college to interview Child M and this left professionals at the College in a very difficult position.  CSC was notified about Child M being missing by the Police on 20 July 2012 (and they had been sent the MMPR by the Police on 15 July 2012). They attempted to telephone the College on the afternoon of July 20th, but there was no response. No consideration had been given to going to the College with the Police in the morning, or asking the Police to go, as Child M had been missing for a week.     On 20 July the Police closed the missing person MERLIN as, in their view, Child M was no longer missing, as he was at College: a place of safety. In the view of the Overview Author, this was an error of judgement, possibly influenced by the fact that it was the last day of term and they were due to close in a few hours. It is the Overview Author’s view that a Police Officer should have gone to the College to undertake a section 47 enquiry either as a single agency, or with a social worker. As it was there was an over-reliance on the view of the professionals at the College, who appear to have had an over optimistic view of Child M, and they believed that when he left College that day he would go to the relative’s house, but he did not. It is the Overview Author’s view that the Police Missing Person Report was closed prematurely.     The decision by CSC not to send a social worker to the College may have been influenced by the fact that Child M was at College in another borough, some considerable distance from Croydon. One option would have been to contact CSC in this borough and ask them to send a duty worker to the College.  The Police’s decision not to go to the College was probably influenced by the fact that it is normal practice not to go out on such visits. 15 children go missing every day in Croydon and the Police   29                                                  3 Inspection of safeguarding and looked after children services, London Borough of Croydon, May 2012, published 28 June 2012. 4 Inspection of safeguarding and looked after children services, London Borough of Croydon, May 2012, published 28 June 2012, paragraph 17. have stated that they do not have the capacity to follow up matters in this way. This is a significant issue, as the IPCC report is clear that a Police Officer should have gone to College that day and returned Child M to his parents care.      5.5                 5.6            5.7       5.8 KEY PRACTICE EPISODE 3: CSC Allocated a Social Worker to complete an Initial Assessment  A social worker was not allocated this case to undertake an initial assessment until 7 August 2012; 2 weeks after the referral came in from the Police and the College. This is practice that falls below the standard required. The CSC IMR author identified ”From reviewing the case records and from a discussion with the social worker it appears that the case remained unallocated for 2 weeks as information received on the duty desk was not entered appropriately onto the system…This was not work-flowed (i.e. did not follow the normal process for progressing cases). I only noticed this when I was reviewing new contact”.   The fact that the case was allocated on 7 August 2012 was only because it was triggered by 2 additional contacts by the Police that day: firstly, a MERLIN report was received that stated that Mrs P was unhappy that the Police had closed the case on 20 July 2012 on the basis of Child M going into College that day, and secondly, a Police Officer had telephoned CSC to ask if the case had been allocated, and said that Mrs P was filing a compliant against the Police as “nothing had been done regarding her missing child”.  The CSC IMR author has attributed this problem to “human error”, “possibly due to the lack of familiarity of uploading information onto Croydon ICS system, on the part of a locum social worker receiving the initial referral”. A CSC IMR recommendation has been made in relation to this (see section 9). However, this is an issue that has been raised in another SCR in Croydon, (Child X) when in July 2011 there was said to be a problem with the Intake Service with a “a backlog of contacts and referrals, with 200 or more that had not been looked at”. The team leader at that time stated, “the system was not robust and the management oversight was poor due to the number of processes a contact went through before it came to the attention of the duty manager.”   This is also an issue that was highlighted during the Ofsted Inspection of Safeguarding and Looked After Children Services3 which although it rated overall effectiveness of the safeguarding services as adequate did note “there is more progress to be made, for example with the quality of assessments and the management of contacts and referrals to the service”. 4 The CSC IMR author for the Child X SCR has recently stated “However,   30                                                  5 Understanding serious case reviews and their Impact: a biennial analysis of serious case reviews, 2005-2007, Marion Brandon et al, 2009.               5.9             5.10             5.11       there has now been a significant change in how contacts and referrals are dealt with in the Intake Service which is ensuring that there are timely and appropriate responses. One of the most significant changes is a Screening Team Leader overseeing all contacts and ensuring cases are dealt with promptly and commensurate to the seriousness of the situation. The service is now in the process of implementing a Multi-Agency safeguarding Hub (MASH) in line with other London Boroughs”. (CSC IMR author, Child X SCR, March 2013). Key Practice Episode 4: Social Worker Visit to the Family on 10 August 2012 and Completion of an Initial Assessment.  The social worker 1 made a visit to Mrs P on 10 August 2012 during which she spoke to Child N alone. According to the CSC IMR author no child protection concerns were raised and Mrs P “came across as a concerned and caring mother”. She did tell the social worker that Child M “had struggled with Mr Q’s ethnicity (White British) and was being teased at college, with his friends saying that he ‘would become English” and “joking that he will be staying in on a Sunday to eat a roast dinner”.  She thought that Child M running away was prompted by an argument they had had the evening before (he ran away), when she was angry with him always being late home from College and was worried about his deteriorating behaviour which she attributed to him being involved with a boy’s gang in Woolwich, and was afraid he was involved in carrying and selling drugs.  The Initial Assessment (opened in Child M’s name, not Child N) was completed and signed off within the expected timescale of 10 working days. However, in appraising practice, it was, in the Overview Author’s view, a major omission that Mr Q was not seen and interviewed as part of the assessment, or during any subsequent visits, given the allegations Child M is said (by the Police and CSC) to have made to college staff about Mr Q hitting him and that Child M was afraid of him. The lack of inclusion of men who are involved in the parenting of children in assessments has been highlighted in previous SCRs: “ A number of issues emerged including the dearth of information about men in most serious case reviews. Failure to take fathers and other men connected to the families into account in assessments”.5  The Police had records of 2 domestic abuse incidents between Mrs P and Mr Q, but it is not known if CSC became aware of this when they made routine enquiries as part of the Initial Assessment (the MERLINS should have been uploaded on to ICS).       31       5.12         5.13        5.14                 5.15          Key Practice Episode 5: The Strategy Meeting on 24 August 2012 and Missing from Home Strategy Meeting on 31 August 2012.  On Friday 24 August 2012 a Strategy Meeting took place and was attended by Police PC. It was noted (in the Police chronology) that “once found Child M would be assessed by CSC and placed in s20 accommodation if necessary; that CSC will try and get more information from his family and will try and contact Child M on Facebook; the Police would continue their enquiries and would contact the College for details of Child M’ friends; and that the Police would circulate Child M’s image and a briefing note to Lewisham and Gangs Unit.”   The meeting had originally been arranged for 21 August 2012 but was re-arranged because of the unavailability of Police PC, the Police Officer from the Sexual Exploitation and Missing Person Unit. The only agencies who were represented at the meeting were CSC and the Police. There was no one from education there as it was still the College holidays. There is no CSC entry on the integrated chronology about the meeting or any minutes of the meeting available. This falls short of expected practice.  There was at this time a comprehensive Croydon procedure entitled “Safeguarding Children Missing from Care & Home” endorsed by the LSCB in August 2011, which states that a Strategy Meeting should be convened within 7 days of the young person going missing and that “where a child/young person is missing for more than 7 days the child/young person’s social worker, in consultation with the CQASS and the Service Manager for the Operational team, should arrange a further Strategy Meeting. (Author’s Note: This procedure has now been superceded by the Children Missing from Home, Care and Education Procedure, January 2014. Under this a Strategy Meeting would need to be convened within 5 working days of the child going missing). The meeting should include all the key people, including foster carer/residential staff/parents, Police, Council’s press office, legal services etc. to decide whether any other action should be taken.  Consideration should also be given to invite a representative from the National Missing Person’s Helpline (see contact details in Section 8.1).    The Operational Manager in the Children’s Quality Assurance & Safeguarding Service (CQASS) should chair the meeting.  The purpose of this meeting is to ensure that all appropriate action is being taken to locate the child and to consider what further action needs to be taken. The Service Manager and Head of Service must be updated weekly by the Operational Manager on all missing children and informed of progress against the action plan.  The Head of Service must update the Directors of Social Work and Youth Inclusion on a weekly basis. If the child/young person is still missing after 7 days, two weekly (or, as required) meetings   32                                                  6  “Safeguarding Children Missing from Care & Home”, Croydon LSCB, August 2011     5.16              5.17            5.18             5.19     should be held. The Social Care Service Manager, following every meeting must provide a written briefing for Director: Development and Care who will brief the Executive Director. The Executive Director will brief the Lead Member for Children and Young People”6.  In appraising practice, the procedure that was in place at the time Child M was missing was not complied with, as the Strategy Meeting was not held within 7 days of the young person being reported missing. Child M had been reported missing on 14 July 2012, and the first Strategy Meeting took place just under 6 weeks later, on 24 August 2012. It is not clear who chaired the meeting and whether or not there are minutes of the meeting. The actions of the meeting recorded in paragraph 5.1.13 above have been taken from the Police chronology. There was a Missing Person Strategy meeting held on 31 August 2012. Key Practice Episode 6: Missing Person Panel 5 September 2012  The case was discussed at the Missing Person Panel on 5 September 2012 and this did comply with procedures.  However, the minutes of the meeting record Child M as being missing since 7 August 2012 and this is incorrect as he had been missing since 13 July 2012 and reported missing to the Police on 14 July 2012. Following this meeting, the Divisional Director and the Executive Director were notified in writing by the Head of Children’s Quality Assurance and Safeguarding Service, and the mistaken date was rectified in this memo, which stated that Child M had been missing for 7 weeks and “ was considered to be at risk of being exploited and becoming involved in criminal activity, as Police intelligence suggested that he was involved with the Woolwich Boys Gang”.  Actions from the meeting included the case being transferred to a longer- term team, and a Core Assessment being completed. It is the Overview Author’s view that this approach was reactive and process driven. It is baffling that the Police were not challenged by the College and CSC about the complacent approach being taken to trying to find Child M. There seems to have been an assumption by all that he would be alright and would “turn up” when he wanted to”. Key Practice Episode 7: Police and CSC contact with the relative  On 30 August 2012 the relative spoke to the Police and said that they had been in touch with Child M on 28 August who said that he did not want to return home as “Mum and dad stress him out”. The Police informed the social worker of this conversation, and also advised the relative to contact   33                                                  7 Missing Children, Ofsted, February 2013. Reference no: 120364     5.20                  6.1                 6.2        6.3 Child M and tell him that if he would go to the relative’s house then a social worker would go there and assess him and that if he did not want to return home, then that would be discussed with him. The main concern was that he returned safe and well.   The relative did try to say this to Child M during a telephone conversation, but he said the credit on Child M’s phone had run out and he was cut off. There was good liaison between CSC, the Police and the relative at this point. However, something more proactive could have been done: the relative could have been used to find Child M and been part of the multi-agency team trying to make sue he was safe and well, and provide him with accommodation. It was a missed opportunity that the relative was not involved in the Initial Assessment or seen by the Police as a key line of enquiry. SECTION 6: KEY LEARNING POINTS AND EMERGING THEMES A Child Missing from Home But a Passive Attitude on the Part of Professionals  There has been a recent thematic inspection by Ofsted on Missing Children,7 based on tracking 105 cases of missing children from a range of local authorities. The issues it addresses include the quality of inter-agency working and communication (most notably Police, CSC and Education), strategic systems in place, and perceptions and attitudes towards children who run away. The report tries to identify the reasons why children run away:  “The complex and often varied reasons identified on a national basis why children go missing were reflected in the nature of the cases seen by inspectors. Children’s histories included inadequate parenting, past or current abuse, bullying and domestic violence. Some children who were looked after had experienced several placement moves. Children who went missing were subjected to considerable associated risk, most often from sexual exploitation, drug and alcohol abuse, and becoming the victim or perpetrator of crime”.      It also identified that:   “Running away or going missing was often symptomatic of wider problems and in turn, was likely to exacerbate and add to those difficulties. “Push” and “Pull” factors were evident: some children sometimes ran to a situation that presented risks to them whilst some ran away from something or someone. Push and Pull factors were often both apparent in cases”.     34                                                  8 Working Together to Safeguard Children, Department for Education, 2010      6.4           6.5     6.6               6.7          6.8  From the evidence we now have about Child M, and with the benefit of hindsight, it is possible to speculate that he was running away from the arguments at home and was worried that his mother’s threats to send him back to Rwanda or have him taken into care might turn into reality. There is also a suggestion that he was afraid of Mr Q and of being beaten by him.   There is also a sense that Child M knew what he was doing and there was an allure to whatever it was that he was running to. During the morning that he spent in College on 20 July 2012 a clear description is portrayed of a young person who knew exactly what he was doing and he was seen as totally in control of that situation and was the one with the power: telling staff that he would run away if the Police or CSC were contacted. The Deputy Head of Year remarked that it was as though he was “blackmailing” them and he agreed.  However, he was still a 14-year-old child who had been reported missing and he was potentially exposing himself to risk and danger.  The Ofsted report refers to the “tenacious partnership working” needed across agencies to safeguard children at risk of going missing. One of the lessons for learning from this case is that, in the Overview Author’s view, there was no evidence of such tenacity.  There is evidence that, for reasons unknown, both the Police and CSC professionals were passive in their responses to a 14 year-old boy missing from home. A picture emerges of the parents frantically looking for Child M in the local area in the days immediately after he ran away, but this response was not matched by a similar response from the Police. There is little evidence of them actively searching for him, and the fact that they had mis-spelt his name on the MERLIN report meant that any opportunity to make connections with any other boys in the neighbourhood, or with local gangs, was lost. There was quite a lot of evidence that he was good friends with Friend 3, and that he had stayed with her on the19 July 2012 and that ”she was in contact with him throughout most of the summer” but there is no evidence that they interviewed her in connection with their enquiries. This was a missed opportunity. If she had been interviewed early on, she could have played a key role in contacting Child M.  The response of both the Police and the social worker when contacted by the college on 20 July 2012 fell below the standard expected by Working Together 20108 and the local Missing Children procedures, which state that the Police should take the lead on missing children enquiries. This was a line of enquiry that should have been pursued rigorously, given that Child M had been missing for a week by this time. The response of the Police to the College is concerning: that as Child M was at College then de facto he was safe and well, and there was no further role for them, so they closed the missing person report.  There is a sense that professionals (the Police and CSC) were complacent   35                                                  9 Report from the Joint Enquiry Into Children Who Go Missing from Care: APPG for Runaway and Missing Children and Adults and the APPG for looked after Children and Care Leavers. June 2012.                 6.9           6.10 about Child M being missing and there is evidence that they assumed he would “turn up” at some point. Although the Police had assessed him as being at medium risk, there is no sense that any of the professionals viewed him as a vulnerable young person, but rather as a streetwise young man who knew exactly what he was doing, that he was probably staying with friends and would contact his family when he was ready to do so. The Ofsted inspection and a recent APPG Enquiry9 both raised concerns about some professionals’ attitudes towards children who go missing and the prevailing culture of (poor) child protection responses to older children. One social worker commented: “some behaviours of an older child are seen by agencies as expressing a choice, but this doesn’t consider the risks that the young person is placing himself /herself in.”  This resonates with professional practice in this case. Inter-Agency Communication and Divergence of Views  The events of 20 July 2012 when Child M went into College on the last day of term portray a pattern of communication between professionals from the Police, College, CSC and the family that was not effective in protecting Child M from the risk of significant harm. He was 14 years old and had been missing from home for a week, and despite the various communications that took place that morning, Child M left College unaccompanied at 2pm that day, and was not seen alive again. In that sense, the practice of all the professionals involved fell short of what would have been expected, and the ineffectiveness of the communication that took place had a negative impact on outcomes for Child M.   There was a lack of curiosity in following up possible lines of enquiry. For example:  the anonymous telephone call (paragraph 3.41) was not responded to  Mr Q telephoned the Police to give them the relative’s telephone number, but the relative was not contacted  Mrs P called the police to say Child M had been spotted in Woolwich (paragraph 3.44), but this was not followed up     6.11      Communication with the Parents  Similarly, there was a passive attitude by the Police in keeping the parents up to date with their missing child enquiries. There is a strong evidence that it was Mrs P and Mr T who were chasing the Police for information and updates, and this view is endorsed in the findings from the Independent Police Complaints Commission report     36 6.12                  6.13 The communication between the College and the parents during this period was limited to the parents going to College on 12 July 2012 and then responding to the parents request to go into college for the day to talk to Child M’s friends, to see if anyone had any information, which was helpful. Their responses to the parent’s telephone calls to the college on 20 July 2012 were less than helpful, in failing to provide them with basic information about Child M’s welfare (see paragraph 3.32). It is of note that all communication came to an abrupt halt when College closed at lunchtime on Friday 20 July 2012, with the exception of a telephone call made by the Police to the College at 3pm, to which there was no response. The parents and the relative were driving the search for Child M and feeding information to the Police, College and CSC, but the energy and drive they invested in this was not matched in the response from the professionals who were passive and complacent and thought Child M would turn up when he was ready. They saw him as a young man who was in control of his life, who was doing what he wanted, and they overlooked the fact that he was only 14, and still a child.  Generally the communication between CSC and the family was of the standard expected once the case had been allocated. After Child M’s death Mrs P telephoned the social worker and thanked her for her support. Professional Challenge  6.14  Professionals at the College were clearly unhappy and dissatisfied with the response they received from the Police and to some extent CSC on 20 July 2012. They did challenge the Police about their decision not to come to the College. It would have been good practice if the matter had been escalated that day by the Head of College to a senior officer in the Police and a senior manager in CSC.     6.15     Involving Male Partners in Assessments It is crucial that male partners who are involved in the dynamics of family functioning are included in assessments. It is concerning that Mr Q was not seen and interviewed by the social workers as part of the different assessments. 6.16      6.17     The Initial Assessment was signed off by a manager when there was no evidence of Mr Q being involved, despite the fact that he was a significant figure within the family dynamics and there was a suggestion that Child M was afraid of him and was being teased by his peers because of his mother’s relationship with a white man.    There is evidence that there was insufficient management oversight in the Intake Team as there was a 2-week delay in processing the referral from the College about Child M being missing. The matter only came to light when the Police made contact to see if the case had been allocated.    37 6.18 The Missing Person procedure states that a Strategy Meeting should be held within 7 days of the child going missing. Child M had been missing nearly 6 weeks when the first Strategy Meeting took place. It is concerning that this was not picked up in supervision.   SECTION 7: CONCLUSIONS       What Might Have Been Done to Ensure Better Outcomes for Child M?  7.1              7.2   If the Police had been more pro-active in following up lines of enquiry they may have been able to gather more information about where Child M was staying during the 9 weeks he was missing and thereby locate him. By all accounts, on the few occasions he was seen, he looked clean and well kept, and there was soft intelligence that he was staying at someone’s house. There was no suggestion that he was “sleeping rough”. Friend 3 said that she had been in touch with him on Facebook “most of the summer”. There is evidence from the Police Independent Police Complaints Commission report that the Police were not proactive in following possible lines of enquiry, such as speaking to Friend 3 or the relative, or trying to trace Child M through the use of his Oyster Card, mobile telephone or Blackberry. Instead, in the view of the IPCC, the Police were reactive; responding to contacts from M’s parents.   Professionals should have responded differently on 20 July 2012 when Child M went into College, and either the Police and/or the social worker should have gone to the College to talk to Child M and conduct a section 47 enquiry if necessary. The IPCC report states that a social worker should have gone out to the College to speak to Child M and should have contacted the Police if Child M did make allegations of abuse, so that they could attend the College as well. The IPCC (appeal) report expresses the view that “the Police should have returned Mrs P’s son to her on that day (20th July) he attended College and this may have altered the outcome”     7.3        Could his Death Have Been Predicted or Prevented?  There is some suggestion that Child M was involved in a local gang and was being used to carry drugs, but no evidence has come to light during this SCR to confirm that. There is no explanation for the “altercation” that took place on the bus on the evening of 15 September 2012 and ended with Child M being murdered. If Child M had been found during the weeks after he ran away from home, it may be that he would have disclosed what he was “up to” and a risk assessment could have been completed. It may be that he was living a high-risk life style, but that remains supposition.   38                                                  10 Brandon. M. et al. New Learning from Serious Case Reviews: a two year report for 2009- 2011, DfE-RR226    7.4       7.5                   8.1         8.2         There is no evidence to suggest that his death might have been predicted or prevented.  There is no evidence to prove that Child M was involved in gang activity. However, there is “soft intelligence” via messages to professionals from his friends that he was involved in some activity selling drugs and this was related to gang activity. The autopsy discovered that Child M was in possession of a small amount of drugs, but it is not possible to know whether this was for his own use or for sale.  There is no evidence to suggest that his ethnicity and gender affected the quality of services that he and his family were offered. The family have a view that their race and his gender did affect the services they received. The social worker told the Overview Author that they compared the response they received when Child M went missing to the response that was given to a very high profile case of a young white girl who went missing in the same area at around the same time. There has been no evidence to support this throughout this SCR. SECTION 8: OVERVIEW REPORT RECOMMENDATIONS:  “SCR recommendations are still very numerous and the endeavour to make them specific, achievable and measurable has resulted in a further proliferation of concrete and procedural tasks to be followed through. Part of the issue may lie with the skills and knowledge of those conducting the reviews but also with the need to distinguish between learning lessons and making recommendations. The best learning from serious case reviews may come from the process of carrying out the review”.10 Missing Children There is evidence that, despite protocols already being in place, that what is absent, is a real understanding of what can trigger a young person running away and how agencies can respond proactively, including keeping the family informed.  The recent APPG report from the Joint Inquiry into children who go missing and the recent Ofsted report on Missing Children could be used to enhance learning and improve multi-agency practice in this area.  Recommendation 1 It is recommended that Croydon LSCB monitor compliance with the recently implemented Missing from Home, Care and Education Procedure (January 2014) to ensure a more robust response from all agencies when children go missing and that the LSCB ensure information is gathered regularly about children in Croydon who are at risk of going missing, and aim to reduce those numbers  (Outcome: Children who go missing regularly are addressed as a higher priority by all agencies, reducing the number and frequency of such   39   8.3     8.4       8.5      8.6       8.7        8.8       8.9       8.10 episodes).   Professional Challenge and the Use of Escalation There is evidence of poor inter-agency communication and information sharing. It is important that agencies understand and use existing escalation procedures in order to resolve matters effectively.  Recommendation 2 Agencies to re-assure the LSCB that the current escalation procedures are understood and used appropriately.  (Outcome: staff feel more confident that they are able to raise concerns about the actions of other agencies or staff in their own agencies in order to resolve matters of divergence effectively).  Including Male Partners in Assessments There is evidence of a lack of professional curiosity about the role of Mr Q in this “re-constituted” family and the quality of the relationship between him and Chid M. He was not included in the Initial Assessment and should have been.  Recommendation 3 The LSCB QA and Performance Sub-Committee to ensure agencies understand the importance of including male partners in assessments. (Outcome: to ensure that all those involved in the “parenting” of children or who are part of a family network, are included in assessments)  Communication Between schools/colleges and other agencies during school/college holidays. This serious case review has identified the need to ensure follow through of any safeguarding concern or missing child concern that occurs just before holiday periods. There should be someone with responsibility for making sure that referrals and concerns generated by colleges have been received and acted upon.   Recommendation 4 The LSCB to be notified and assured by schools and colleges that there are appropriate arrangements in place to ensure that all have a single point of contact during school holiday periods that is shared with a senior manager in Police, CSC and Health. Conversely, these other agencies need to have a SPOC whose details are shared with schools/colleges.  Child protection and older children. This case has highlighted underlying assumption by professionals that a seemingly competent and confident 14 year-old can make their own way over a 6 week holiday period. This begs the question of how we view the risks of gang and drug involvement and knife crime to predominantly young males and sadly to young black males in areas of London.  Recommendation 5 The LSCB to commission a review of whether services received by older   40          9.1     9.2    9.3     9.4        9.5      9.6     9.7    9.8 children who go missing are sufficiently robust and to what extent gender and ethnicity plays a part.   SECTION 9: SINGLE AGENCY (IMR) RECOMMENDATIONS POLICE  It is recommended that the Croydon Senior Leadership Team remind staff of the requirement to enter all details, such as family names, accurately onto MPS computer systems in support of National and MPS Recording Standards.  It is recommended that the Croydon Senior Leadership Team remind staff of the requirement to complete detailed MERLIN/PAC reports at the conclusion of MISPER investigations so that appropriate information is shared with partner agencies.  It is recommended that the Croydon Senior Leadership Team remind staff of the importance of completing and recording detailed research on a missing person prior to carrying out a risk assessment to ensure all available information can be considered for the risk assessment.  It is recommended that the Croydon Senior Leadership Team remind staff investigating and supervising missing person investigations that any information that may impact on the current risk assessment is reviewed and the risk assessment re-assessed. The MERLIN record should reflect any rationale for the decisions made.  CSC Practitioners (including locum social workers) need to be fully aware of the process for appropriately entering data onto IVCS to ensure that cases are not lost and are brought to the immediate attention of the Intake Team Manager. Appropriate ICT training needs to be provided before any practitioner undertakes work on duty. Where there are men involved in families, whether in the role of fathers or partners, due consideration needs to be given to their involvement/participation in any assessment process concerning the protection of children.  The Croydon LSCB to ensure that all agencies adhere to agreed procedures concerning Missing Children and Children Affected by Gang Activity.  Key messages from this review to be incorporated into safeguarding children training.    41      9.9   9.10   NHS CROYDON  To update and brief staff of the wider learning from this Serious Case Review specifically issues relating to missing children and gang activity.  To ensure Independent contractors are aware and follow guidelines and policies when dealing with child missing and safeguarding children affected by gang activity EDUCATION  9.11 The college to ensure that when dealing with young people where there is no indication that they are at risk of significant harm, parents with parental responsibility are appropriately involved in any decision making regarding referrals to social care agencies.   9.12 Ensure that when decisions are made in phone discussions that agencies use e-mail communication to confirm what has been agreed. 