Sexual abuse and sexual exploitation of a 12-year-old girl and her 11-year-old sister. Sam, aged 12 years, and Charlie, aged 11 years are of Roma heritage and moved from Slovakia to the UK in 2012. Charlie has significant learning difficulties. In January 2015-July 2016 there were concerns around episodes of missing from home, missing school, risk of sexual abuse and child sexual exploitation (CSE), physical assault and two allegations of rape. In February 2016 both children became subject to child protection under the category of CSE concerns. Sam had also been assaulted by an older male following a refusal to engage in a sexual activity with an adult male. Charlie was the victim of two rape incidents by different perpetrators and both children became subject to police protection orders and interim care orders. Learning includes: the importance of assessment to ensure that the needs of minority ethnic children are considered; there was a delay in moving the initial joint investigations forward which resulted in a delay to direct work; the importance of accurate assessment; and the use of professional interpreters within safeguarding practice. Makes a number of recommendations around management of CSE concerns, assessment and information sharing.
      
    Serious Case Review No:  2018/C7043  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.          SERIOUS CASE REVIEW  Charlie & Sam                        Authors: Jane Carwardine and Melanie Hartley   Page 2 of 57  CONTENTS PAGE.      SECTION CONTENT  PAGE   Content Page 2  Abbreviations 3 1 Executive Summary 4 2 An Introduction to The Review 6 3 Charlie: A Portrait & A Brief Case Synopsis. 11 3.1 A Portrait of Charlie.  11 3.2 Charlie: Brief Case Synopsis.   12 4 Charlie - A Chronological Narrative & Analysis of Specific Events & Themes. 13 4.1 Charlie: A Perspective of Opportunities for Early Help. 13 4.2 Charlie: The Escalation of Concern - A Child in Need. 22 4.3 Management of Risk through Child Protection Planning 28 4.4 Offender Disruption  37 4.5 Charlie: Conclusion. 38 5 Sam:   A Portrait & A Brief Case Synopsis. 40 5.1 A Portrait of Sam.  40 5.2 Sam: Brief Case Synopsis.   41 6 Sam: A Chronological Narrative & Analysis of Specific Events & Themes. 42 6.1 Sam: The Management of Initial Concerns 42 6.2 Sam: The Management of Risk through Child Protection Planning 43 6.3 Sam: A Perspective on Direct Work. 46 6.4  Sam: Further Issues Requiring Consideration. 50 6.5 Sam: The Conclusion. 51 6.6 Addendum to SCR: Conversations with Charlie, Sam and their Mother 53 Appendix 1 Bibliography 57   Page 3 of 57  ABBREVIATIONS.   ABBREVIATION/TERM DESCRIPTION ACE  Adverse Childhood Experiences  CAMHS Children and Adolescent Mental Health Services CRG Critical Review Group CIN Child in Need CRP Case Review Panel CSE Child Sexual Exploitation CSP Community Safeguarding Practitioner  EAL  English as an additional language  FME Forensic Medical Examination MACE Multi-agency Child Exploitation Meeting  MACSE Multi-agency Child Sexual Exploitation Meeting  MARF Multi-agency Referral Form MASH Multi-agency Safeguarding Hub PPO A Police Protection Order  SARS Sexual Abuse and Rape Service SCB Safeguarding Children Board SCR Serious Case Review SENCO Special Educational Needs Coordinator       Page 4 of 57  SECTION 1: EXECUTIVE SUMMARY.  1.   Charlie (aged 11years) and Sam (aged 12 years) were sisters who attended the same secondary school, having lived in the United Kingdom for around 4 years.  The sisters’ heritage was Roma, a deprived minority ethnic community and they lived with their parents. It was known that Charlie had some level of learning difficulties although understanding of the challenges she faced were not fully assessed. Both children made below average progress in their educational attainment. Their parent’s understanding and use of English was extremely limited and during the subsequent court proceedings it was noted their father had significant learning difficulties.   2.   Between January 2015 and July 2016 there were several contacts with the Contact Centre by universal professionals. The concerns related to missing events (home and education), escalating concerns regarding the risks of sexual abuse and child sexual exploitation, physical assault and two allegations of rape. In October 2015, concerns were expressed that Charlie had a “boyfriend” aged almost 18years old. The incident was assessed to meet the threshold for early help, it was not perceived as a high-risk situation. The next month Charlie disclosed she had been sexually assaulted by her “boyfriend” and the case was then assessed to meet the threshold for section 17 intervention. There was a delay in the commencement of the joint investigation. Concerns persisted for the children’s safety and parental capacity to keep them safe.   3.   In February 2016, following a section 47 investigation the children became subject to a child protection plan under the category of sexual harm due to child sexual exploitation concerns. Sam had also been subject to an assault by an older un-related male and suffered bruising to her legs, prior to the plan being put in place. Although at the time she advised the bruising was due to an accident. Sam disclosed she had been physically assaulted following refusal to engage in sexual activity with an adult male. Whilst subject to the plan there was increasing missing events and risk-taking activity indicating the challenges for the parents in keeping the children safe. Charlie was the victim of two rape incidents by differing perpetrators. Following the second rape incident the children became subject to police protection orders and interim care orders.   4. The review process identified several examples of good practice and it was apparent that involved practitioners strived to ensure the needs of the children were met. Learning has been identified in the following areas:   Equality and Diversity: whilst Charlie and Sam were offered additional support services in school, there was no holistic multi-agency assessment undertaken to ensure their needs as minority ethnic children from a highly deprived community was fully assessed and intervention planned. There was subsequent evidence they had experienced trauma in their early years, therefore had experienced adverse childhood experiences (ACEs). Yet there was no assessment of this issue and the negative impacts on their physical, social and emotional development.   Early Intervention: Charlie and Sam were vulnerable due to their young ages, minority ethnic status, the language difficulties faced by their parents and, for Charlie, significant learning difficulties. Multi-agency assessment and early intervention was not adequately considered after their migration to the United Kingdom, despite limitations in developmental progress. The case was de-escalated to early help when Charlie disclosed having an older boyfriend rather than using this as an indicator of the risk of sexual abuse. There was no joint investigation or effective offender disruption activity.   Management of CSE concerns: there have been recent changes to practice in relation to the management of CSE concerns. It is vital that all practitioners are aware of these changes and are confident and competent in responding to CSE concerns.        Page 5 of 57   Delay and Drift: there was a significant delay in progressing the initial joint investigation which resulted in delay in establishing multi-agency planning and delays in commencing direct work with the children and their families. The delay in commencing direct work meant that information obtained could not inform the risk assessment and child protection planning processes in a timely manner.         The Importance of Accurate Assessment: an agreed action within the initial child protection plan was that a parenting capacity assessment should be undertaken. The assessment of parental needs including learning difficulties was considered necessary as part of the assessment of parenting capacity to inform the risk assessment. An inadequate assessment of parenting capacity under the domains of the Framework for the Assessment of Children in Need and their Families was undertaken. The comprehensive assessment was not completed. The limitations in the assessment along with perceived parental compliance resulted in a professional acceptance the parents could protect their children, which proved not to be the case.    The Importance of Challenge: involved practitioners from several agencies raised concerns about the risks to the children and/or parent’s capacity to protect them as the case progressed, some challenges were responded to positively but others weren’t. The case highlights the importance of utilising the formal escalation processes where practitioners have concerns that they can’t resolve.   Use of Professional Interpreters: as both parents understood and spoke very little English, the use of professional interpreters was vital. This case highlighted good practice with one professional interpreter being used frequently to provide consistency. However, occasions were noted of Sam being asked to interpret for her parents. Professional interpreters should always be utilised within safeguarding practice- children for whom there are safeguarding concerns should not undertake this role.   Information Sharing: there was much effective information sharing seen in this case. However, there were instances of agencies becoming aware of new and significant information which could have informed the child protection planning and/or criminal investigation processes which was not shared in a timely manner.  There were multiple practitioners involved at various points and often two or more practitioners from a single agency- it is important that information sharing processes are effective at a single agency level to support robust multi-agency safeguarding practice. Practitioners attending meetings on behalf of their agency should ensure agency information is collated ahead of meetings and that involved colleagues are updated after meetings.          5.   A joint targeted area inspection of the multi-agency response to abuse and neglect was undertaken following which key changes have been made in relation to CSE practice.  6.   The Pathway for Concerns of Child Exploitation has been implemented which ensures that cases identifying CSE concerns are all discussed at the multi-agency daily strategy discussions within the MASH. Where concerns are substantiated, the multi-agency CSE Assessment tool is completed to determine the level of risk and actions are agreed. Such cases are now also all discussed and regularly reviewed within the MACE meetings.   7.   Actions are agreed at the MACE about direct work with young people- these interventions are provided by the NSPCC Protect and Respect service for low and medium risk cases and by the Children’s Services Protect Team for high risk cases.                                             Page 6 of 57  SECTION 2: AN INTRODUCTION TO THE REVIEW.  2.1 THE SERIOUS CASE REVIEW METHODOLOGY.  8. Copyright. This serious case review (hereafter known as SCR) has been jointly authored and produced by Jane Carwardine and Melanie Hartley, independent reviewers. Its content has been quality assured by the Safeguarding Children Board’s Case Review Panel (hereafter known as the CRP) and the Safeguarding Children Board (hereafter known as the SCB). It is owned by and copyright remains with the SCB. Permission should be gained prior to sharing the content of this review either in paper form or electronically with any organisation or individual.  9. Anonymity. The review has been written in a way to protect the identity of Charlie and Sam, the family and practitioners. The emerging themes, key lines of enquiry and significant events will be discussed in a style which minimises the risk that either child or family’s identity will be unintentionally revealed. Multi-agency employees will be described in respect to their job role to protect their anonymity. This approach is taken to encourage open and honest reflection of safeguarding practice.   10. Thanks. The independent reviewers would like to thank practitioners, managers, multi-agency organisations and independent providers who openly and honestly reflected on and shared their experiences whilst working on the case. Their contributions were extremely advantageous, enabling enhanced learning and the identification of good practice. The motivation and passion of front-line practitioners, to make a difference to the life of Charlie and Sam was evident throughout the process.  11. The Decision. The case was notified to the Case Review Group (hereafter known as the CRG) and discussed in October 2016. In November 2015, Charlie (aged 11 years) disclosed she had been sexually assaulted and her case was assessed to meet the threshold for section 17 intervention. Concerns persisted for her safety and in February 2016, following a section 47 investigation, she became subject to a child protection plan under the category of sexual harm due to child sexual exploitation concerns. Whilst subject to the plan she was the victim of two more sexual assaults by different perpetrators. Her older sister, Sam (aged 12 years) was similarly made subject to a Child Protection Plan. She had been subjected to an assault by an older un-related male and suffered bruising to her legs, prior to the plan being put in place. Sam disclosed much later that she had been physically assaulted following refusal to engage in sexual activity with an adult male. The CRG agreed Working Together 2015 SCR criteria had been met1. Both children had been abused or neglected, both had suffered serious harm and there was cause for concern as to the way in which the Local Authority, board partners or other relevant persons had worked together to safeguard the children. The CRG reviewed additional information from partner agencies to inform the development of the SCR research question and terms of reference. A case review panel was convened to work with the Independent Reviewers to support the completion of the review. The decision was made that Charlie and Sam’s cases would form separate review within one overarching review.   12. The Case Review Team.                                                            1 HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of Children. Crown Copyright. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of s. This includes the requirement for s to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an ’s function in relation to serious case reviews.   Page 7 of 57   SCB Business Manager, Administration Support, Training Coordinator, Education officer.  Police: Detective Chief Inspector.  Children’s Services: Service Manager Quality Assurance and Safeguarding.  The Local Authority Contact Centre: Service Manager.  CCG: Designated nurse, Safeguarding Children.  Education: High School, Head Teacher.  CCG: Named General practitioner.  NSPCC  13. The Serious Case Review. A hybrid methodology was used combining several theoretical models and techniques.2 3 4 These methodologies are regularly used to undertake safeguarding reviews within Children’s Services. The format ensures key events, lines of enquiry and themes relating to safeguarding practice are critically analysed, with practitioner and service user involvement. This approach provides a greater understanding of Charlie and Sam’s experience. A combined inter-agency chronology was developed and further information was sought as gaps in data appeared. A timeline of significant events was developed in preparation for the practitioner event. Single agencies produced learning summaries including analysis of specific incidents and themes. All agencies/services were requested to share information relating to single agency incident reviews undertaken in respect to the case. The NSPCC provided their agency internal management review.  14. Participation.  The case review panel considered the participation of the children and their family in the process. At the time of the review’s completion their participation had not been secured. This will be an ongoing consideration. There are plans to share the review when professionals involved in supporting the children and their family assess it to be the most opportune time.   15. The multi-agency services accessed by Charlie, Sam and their family were provided by agencies working within the children’s responsible Local Authority area. There has been no involvement of cross-boundary services or Local Authorities. Multi-agency organisations and practitioner participation was encouraged to enrich the information within the chronology. An initial introductory practitioner event was followed by a half-day practitioner event. These events were well attended and positive feedback received. The practitioner event improved understanding of significant events, key lines of enquiry and emerging themes at the time of the events. Additional verbal and email conversations were convened when necessary. The content of the review has been shared with practitioners.  16. Practitioners from the following agencies participated in the process;   Children’s Social Care: Safeguarding, Looked After Children and Family Support Teams  The Local Authority Contact Centre  Secondary Education  Primary Education  Police  General practitioner Services   Community Nursing Services (school nursing)  Sexual Assault Referral Centre                                                            2 Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. 3 SCIE Learning Together to Safeguard Children: a systems model for serious case reviews. 4  HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of children. Crown Copyright.   Page 8 of 57   NSPCC   17. Research Question and Terms of Reference. The following research question was established:   “Is the SCB assured that multi-agency arrangements are timely and appropriate in recognising and responding to the protection of vulnerable children known to be at risk of CSE, especially where parenting capacity is limited and where the understanding of risk (including that of the children) is unclear?  The following terms of reference were agreed.”  The review will seek to consider; 1 Quality and timeliness of the assessment of risk, in relation to risk of CSE, particularly when the parents’ capacity to understand risk is limited by learning difficulties or language barriers. 2 The quality and sufficiency of the Child Protection Plan arrangements in protecting the children from further harm. 3 Did multi-agency planning account for increasing concerns raised by partner agencies.  4 Quality of information sharing at a time of escalating concern. 5 Changes to CSE processes sufficiently address matters highlighted within the JTAI as illustrated in this case.   18. Definitions of CSE. At the time, this case was in practice the definition of CSE nationally was:  “Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. CSE can occur through the use of technology without the child’s immediate recognition; for example, being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability.” 5  19. In February 2017 during the review process the definition was amended following a national consultation process;   “Child sexual exploitation is a form of child sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology.” 6                                                             5  Safeguarding Children and Young People from Sexual Exploitation: Supplementary Guidance to Working Together to Safeguard Children (DCSF, 2009). 6 DfE (2017) Child Sexual Exploitation. Definition and a Guide for practitioners, Local Leaders and Decision Makers Working to Protect Children from Child Sexual Exploitation. Crown Copyright 2017.   Page 9 of 57  The CSE systems and processes may need to be reviewed to consider the implications of new national definition.   20. Considerations of Parallel Investigations, Offender Profile, Charges and Convictions. There have been no parallel investigations, other than criminal investigations disclosed to the review. Several arrests have been levied against alleged offenders in respect of offences against Charlie and Sam. There have been significant challenges in respect to the identification of offenders due to language barriers, the number of aliases used and the vulnerability of the victims. At the time of the completion of this review there had been no charges or successful prosecution against the alleged offenders for the assaults against Charlie and Sam. Offender disruption activity is discussed later in this review.  21. Equality and Diversity Considerations. The review highlights several issues related to diversity and equality which are referenced within the content of the review. The use of the term “Child” throughout the review is used intentionally to make the reader consider that child abuse and neglect including CSE can impact on all children irrespective of gender, race, culture, disability and/or sexual orientation. The impact on the child is devastating and can be catastrophic in the longer term unless adjustments are made in the provision of services.  22. The child’s behaviours are frequently both reflective of how they adapt to their situation and are a defence mechanism to enable them to cope. Too often the child’s behaviour becomes the focus of blame rather than the management of the abuse they have had to or continue to endure. Unfortunately, these children are often perceived in society as the most troublesome children, sometimes resulting in criminalisation which impacts negatively on their future life chances for good health, education, socialisation and employment. They are the most troubled children in society, who need not only our empathy but long term, consistent, specialist support to recover and lead a fulfilled life. Their childhood journey through to adulthood will be more difficult than their counterparts yet frequently they do this alone without a consistent or supportive parental figure.   23. This case identifies that Charlie and Sam had protected characteristic under the equality and disability legislation due to Charlie’s learning disability and being children from a migrant family. Charlie was developmentally immature although it was not clear the basis of her developmental delay. Whilst adjustments were in place to support her learning and communication, there was no evidence of an early cognitive assessment to enable greater understanding of the extent of her disability. A cognitive assessment would have been beneficial to understand her level of functioning. In January 2016, a referral for a cognitive assessment was made to CAMHS by a consultant paediatrician however the assessment was not provided. It has been highlighted this provision possibly exists within a few multi-agency services but in practice would be difficult to access.   Learning Point: It is important that children have the opportunity for a cognitive assessment to enable greater understanding of the extent of their developmental delay i.e. is the delay specific to learning or more global in respect of cognition? This should be a multi-agency provision and is critical to the assessment of risk and vulnerability when working with children.    24. Charlie, Sam and their family originated from the Roma community in Slovakia. The Roma form the second largest minority group in Slovakia and its population is 253,943 (equating to 4.8% of the total population). Roma political and cultural activists estimate that the number of Roma in Slovakia is even higher, more likely between 350,000 and 400,000.  The Roma population is known to suffer from higher rates of poverty, unemployment, illiteracy, crime, disease and live in very poor rural and urban conditions in their homeland. They often live outside of a village/town in camps of settlements with only   Page 10 of 57  a few dirty houses without facilities, in cellars, or in cardboard or wooden shacks. There is a strong history of persecution and discrimination against the Roma community, with negative impact on their human and civil rights.   This has created some tensions for the Roma community resulting in a reluctance to disclose their cultural background, challenges and issues with professionals who may be perceived to be in positions of power, due to a fear of persecution.  25.  Current national data is highlighting that Roma children are three times more likely to be taken into care than any other child and there has been a significant rise in children becoming subject to foster care. The challenge for professionals is to remain child centred whilst also developing positive, trusting communications with families who may have had significant experience of institutional prejudice. Professionals involved with the Roma community need to have cultural awareness and competence of the issues faced when working with these families. This issue will be discussed within the content of the report.  26. The Independent Safeguarding Reviewers. Jane Carwardine has worked as an independent safeguarding consultant since April 2015 and has completed several case reviews. She holds an MA in Child Care Law and Practice (Keele) and a BA Honours in Health Studies (Bolton).  Her professional background is in nursing (nurse, health visitor and midwife). Jane has undertaken a range of strategic, provider and commissioning management roles. She has 15 years dedicated safeguarding experience in a variety of leadership roles including; senior and line management functions, named nurse role, designated nurse for safeguarding (including adults and children) and head of safeguarding. Examples of safeguarding activity includes; supporting the completion of serious case reviews, leading on multi-agency safeguarding learning and development, assuring the quality effectiveness of safeguarding activity, complex case management, the development of multi-agency teams, developing supervision systems, development and leadership of safeguarding advisory teams, membership on safeguarding boards and providing advice to a range of strategic boards. Jane has been directly involved in the completion of more than twenty serious case and multi-agency learning reviews. She has worked intensively to improve the quality effectiveness of the case review process and has recently represented the Royal College of Nursing on the Royal College of Paediatrics and Child Health Child Protection Committee. She has not been employed by any organisation aligned to this review.  27. Melanie Hartley has recently retired from the NHS after 41 years of service, to undertake the role of independent safeguarding reviewer. She holds an MA in Child Welfare and Protection (Huddersfield) and firmly believes that effective multi-agency working is vital if vulnerable children are to be adequately safeguarded. The case review process is a key component in this work. It ensures that multi-agency lessons are learnt and that actions are implemented leading to improvements in multi-agency safeguarding practice. Melanie’s professional background is also in nursing (nurse, health visitor), including 20 years’ frontline experience as a health visitor, working with complex and vulnerable families and 10 years’ specialist safeguarding experience (named nurse safeguarding children, designated nurse for safeguarding children/children looked after and the head of safeguarding). These roles required the development of expert skills and knowledge in all areas of multi-agency operational and strategic safeguarding work. Melanie has been involved in the production and quality assurance process for numerous single and multi-agency case reviews. She has significant experience of leading and chairing a Safeguarding Board’s case review panel which enhanced her experience in case review methodologies and practitioner involvement. This is her second review as an Independent Reviewer. In preparation, Melanie has undertaken relevant training and fully participated in and shadowed a serious case review process undertaken by another Independent Safeguarding Reviewer. She has not been employed by any organisation aligned to this review.     Page 11 of 57  SECTION 3: CHARLIE: A PORTRAIT & A BRIEF CASE SYNOPSIS.  3.1 A PORTRAIT OF CHARLIE.   28. Charlie was born in Slovakia and her cultural heritage was Roma. She lived in her country of origin until her migration to the United Kingdom, when she was 8 years of age. She later described her experience of living in the camps in her homeland “as horrible things happened there”. Charlie had lived in the United Kingdom for around 4 years, with her parents and sister (Sam) prior to the escalation of concerns. She was the youngest child in a sibling group containing four children. Her adult brother and adult sister shared the same mother and lived locally. The family had a large extended local family network. Professionals advised her parents had only limited education, resulting in limitations in their literacy skills. Her father was thought to be more limited in his understanding. Language difficulties were a significant issue, with an interpreter being required to support communication. The older adult sister was reported to have a good understanding of English and supported her mother and step-father in respect of this issue.  29. Practitioners described Charlie as a slim girl, of small stature although looked more mature than her years. She appeared well looked after with brown eyes and shiny hair. She was always well “turned out” and well groomed. She could appear older than her peer group. Professionals said she used much more make-up, wore more jewellery and liked to dress more provocatively than her peers. Initially she presented as quiet and timid but given time became very smiley with good social skills and a lovely “giggly” sense of humour. She was noted to be very caring and eager to please others. Charlie appeared to have a close relationship with her mother and sisters. She was reluctant to talk to professionals about her family and cultural background but also tended to be more “open” than her sister.  30. Charlie attended the same Primary Education school for 3 years. She had significant learning needs and had additional support in the classroom. Her language development was of concern as despite additional support her comprehension and spoken English remained limited. The school advised she had made some but limited progress whilst attending school. On entry to Secondary Education she was only functioning educationally at around the age of 5 years. During practitioner conversations, it was identified she spoke Roma fluently and communicated with her mother in a dialect that only her and her mother spoke. Sam and her father were unable to understand this dialect. Some professionals advised that Charlie could communicate and would say if she didn’t understand. There were times if she didn’t want to answer a question she would not respond. Professionals thought Charlie could be selective in her understanding of English, however it was also advised her language and comprehension in her first language was immature.  31. In the last year of Primary Education, she went missing from education and it was reported she had an older boyfriend who attended the local Secondary School. There were no other additional concerns highlighted in respect of behavioral or health challenges. On entry to school, she presented as disruptive in class and was frequently put in isolation. Exclusion periods due to behavioral challenges were also evidenced. There were concerns about truanting. Charlie was referred to the educational psychologist for a holistic assessment of her needs, as the first step to an assessment of her educational needs in the first term of Secondary Education.   32. Charlie has reportedly settled well in foster care, has supervised contact with her mother and is reported to be generally happy and settling within the new school environment. The contact arrangements are enabling Charlie to maintain her links with her family and cultural heritage. It has been noted that since being placed in foster care her presentation has become more in keeping with that of her peers and that her group of friends has become more diverse.                 Page 12 of 57   3.2 CHARLIE: BRIEF CASE SYNOPSIS.    33. In an 18-month period, between January 2015 and July 2016, a number of contacts/referrals were made to the Contact Centre and Children’s Social Care due safeguarding concerns for Charlie’s safety and wellbeing. The contacts provided an escalating picture of her vulnerability. Professionals were increasingly concerned due to her perceived vulnerability in respect of child sexual exploitation. Several referrals were made to the child sexual exploitation team. Despite significant multi-agency activity, the risks for Charlie continued to escalate. She became the victim of one alleged sexual assault and two alleged rapes. The rape offences were whilst she was subject to a protection plan (under the category of sexual harm due to the identified risk of child sexual exploitation).   34. In January 2015, an initial contact was made with the Contact Centre by the police. Charlie had been recovered, following a missing from education event reported by the Primary School. The event was logged for information and closed. It was highlighted at the time, she had an older boyfriend and she may have recently been involved in a violent incident that involved the use of knives.   35. In October 2015, a second contact was made with the Contact Centre by Secondary Education, as Charlie was thought to have a much older adult “boyfriend”. The school knew her “boyfriend’s” identity and age. Education was advised to work with Charlie’s parents to ensure they understood the risks and could keep her safe. The case was closed and was not escalated to the Children’s Social Care Safeguarding Team.   36. In November 2015, a third and fourth contact was made with the Contact Centre by Secondary Education and the school nurse. Charlie disclosed she had been inappropriately touched by her “boyfriend”, who was an adult male, after she had been given a “drink to make her sleep”. The case was escalated to the Safeguarding Team within Children’s Social Care. Following a significant delay the incident became subject to a criminal investigation and Charlie undertook to a forensic medical examination. The case was assessed to meet the threshold of section 17 intervention. There was additional information during this intervention period that a male thought to be Charlie’s “boyfriend” had stopped her getting on the school bus and had pulled her hair.  37. In February 2016, professional concerns for Charlie’s safety escalated. Her parent’s capacity to keep her safe was of significant concern. Child Protection proceedings were instigated. Charlie became subject to a child protection plan. Due to parental lack of insight or ability to adhere to safety measures, Charlie was placed in the care of her adult sister. Following a period of assessment there was positive social work feedback in respect of parenting capacity and Charlie was returned to her parents’ care, with a contract of expectation in place. On return to her parents’ home safety plans were put in place and Charlie was to be either transported or accompanied by an adult on her journey to and from school. In May 2016, on the first occasion she walked home without supervision, Charlie alleged she was raped, in a local park, by a young male who also attended her school. She underwent a second forensic medical examination and this incident remains subject to investigation.   38. In June 2016, Charlie was found in a park approximately two miles from her home address in the early hours of the morning. She appeared confused but had not been reported missing. The key social worker did not receive information regarding this event, until a few weeks later. Her parents were immediately advised of the plans to seek legal advice and agreed to supervise the children inside and outside of the family home. However, in July 2016, she left the family home early one evening through an open bedroom window. She met up with a group of males and a female in a local park, was taken to a local house, where she alleged she was raped. A criminal investigation was commenced, Charlie was then subject to a third forensic examination which revealed medical evidence to support the allegation. She was placed into foster care and her case became subject to care proceedings.   Page 13 of 57   SECTION 4: CHARLIE - A CHRONOLOGICAL NARRATIVE & ANALYSIS OF SPECIFC EVENTS & THEMES.  39. This section will describe and analyse specific events and emerging themes from practice identified during the timeline of the review, linking the discussion to the research question and terms of reference. Learning points, good practice and recommendations will be identified throughout the text. Each section will contain a conclusion. The focus for information gathering was the period between, September 2014 and November 2016. Historical information prior to September 2014 will be referred to when relevant to the safeguarding issues under discussion. The timeline for the review was extended from original 12-month timeline to capture absences from school as identified by the police.   4.1 CHARLIE: A PERSPECTIVE OF OPPORTUNITIES FOR EARLY HELP.  40. This section will analyse the opportunities that multi-agency professionals had to assess and provide early help services and will hypothesise the impact these opportunities may have had to improve the outcomes for Charlie. There was 1 historical issue and 3 events identified for further analysis.   Event /Issue Links to terms of reference  Charlie: Entry to Education as a Child from a Migrant Family. 1, 3, 5 Charlie: Missing from Primary Education. 1, 5 Transition from Primary to Secondary Education.  4 Disclosure by male school pupils that Charlie had older boyfriend. 1,3   41. Charlie: Entry to Education as a Child from a Migrant Family.  In October 2012, Charlie was around 8 years old when she commenced Primary Education, following her migration to the United Kingdom. Her heritage as a Roma child, meant she belonged to one of the United Kingdom’s most disadvantaged minority ethnic groups, who in their homeland were also subject to extremes of disadvantage, violence and deprivation. A group also known to be at disproportionately at risk of exploitation and intimidation.7 8 It was not until commencing Secondary Education that Charlie described her experience growing up in a “gypsy camp” and described it as “a horrible place as there was lots of screaming and horrible things happening”. Children who experience early trauma are at increased risk of developmental delay, with post-traumatic stress disorder being a contributory factor.9 10                                                              7 EHRC (2016) Research England’s most disadvantaged groups: Gypsies, Travellers and Roma – an is England Fairer? Review spotlight report. Equality and Human Rights Commission. 8 Hurley B., Baptiste M-J., Pande S (2015) Free to Move, Invisible to Care, Coordination and Accountability towards Romanian Unaccompanied Minors’ Safety. NSPCC, ICARUS, European Union. 9  NHS Choices (2015) Post –traumatic stress disorder(PTSD). RCPSYCH (2015) Traumatic stress in children: information for parents, carers and anyone who works with young people. Perry B D. (2007) Stress, Trauma and Post-Traumatic Stress Disorders in Children - an introduction, The Child Trauma Academy. 10 Post-Traumatic Stress Disorder (PTSD) can affect children as well as adults. Children can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares. Children may also lose interest in activities they used to enjoy and may have physical symptoms such as headaches and stomach aches. However, there are some specific symptoms for children with PTSD, such as: bedwetting, being unusually anxious about being separated from a parent or another adult, re-enacting the traumatic event(s) through their play    Page 14 of 57  42. A probable hypothesis could be that Charlie had already experienced significant early adverse childhood experiences11(ACE) which may have impacted negatively on her ability to learn and make developmental progress in Primary Education. There is no evidence the impact of early trauma was a consideration within the assessment or whilst planning intervention for Charlie. Practitioners were not clear how such interventions would be accessed. Specialist trauma services should always be available for children, to prevent the psychological aftermath of child abuse impacting on areas of a child’s development. This should be available within the CAMHS service specification but could also be provided by other specialist services.  Learning Point: A holistic multi-agency assessment of the child, which includes greater understanding of early adverse childhood experiences would enhance the assessment, contribute to improved planning and intervention and enable the provision of specialist trauma support for children.   43. Whilst Charlie attended Primary Education, an Ofsted inspection report (2014) identified the school was; good and experienced in working with children whose first language was not English (68%) and positive in how the school supported and tracked these children.  It was known at the time that Charlie had additional educational and language needs and received support in the classroom. The review has not received any information in respect of significant behavioural challenges other than low attendance for which improvement plans were monitored by an educational welfare officer. On entry to Secondary Education, behavioural and learning difficulties were almost immediately apparent to educational professionals.  44. Primary Education advised at the time of Charlie’s attendance the number of Roma pupils were thought to be increasing but the actual numbers were hard to identify as the school reported “Roma families regularly preferred to identify themselves just as Czech, Slovak or Romanian”, which is a known feature for this minority group.   45. It is positive that Primary Education establishment had a good spread of resources, staff were trained to teach EAL12  pupils (but not Roma children specifically) and the school also employed designated EAL staff. There was a high proportion of EAL pupils in the school, who were supported (along with the migrant children) in a variety of ways. This included;  Initially employing and training staff to work with EAL pupils in timetabled small groups to develop their language knowledge and skills.    Payment for translators to liaise with parents.  The assessment of all new EAL pupils and include them in a 10-week induction programme.  All assessed pupils were taught using the NASSEA steps.13  During 2015 - 2016 there was an after-school club specifically for Roma pupils, organized by a Roma representative of the Citizen's Advice Bureau and parents.  That since 2015 the school had appointed additional EAL designated staff.  Additional resources for children when English is an additional language.  Development of an Inclusion Team   The school was awarded the Antony Walker Foundations Schools Equality Charter Bronze Award14                                                            11 Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and wellbeing. These experiences range from physical, emotional, or sexual abuse to parental divorce or the incarceration of a parent or guardian. Downloaded 19.4.17 https://childtrends.org  12 Definition of EAL: “English as an additional language” and refers to learners whose first language is not English. The learner may be fluent in several other languages or dialects.  13 NASSEA: The Northern Association of Support Services for Equality and Achievement: the association aims to make sure EAL, Black and minority ethnic pupils have access to quality Education   14 The Antony Walker Foundation is a registered charity established after his racially motivated murder in 2005.   Page 15 of 57   46. Primary Education advised Charlie entered school with no spoken English and was well below expectations in all areas when she left, but had made progress, especially with her spoken English. There was no data available to provide greater understanding to the review of her academic progress and whether at the time this was in line with or below expectations. Primary Education focused their intervention on English, basic skills and life skills. Her attainment scores were below average for her chronological age on entry to Secondary Education. She was functioning at a pre-school level, which is evidence of a significant development delay. There is no evidence there was consideration of commencing an education, health and care needs assessment15 to support the understanding of her special educational learning needs, until she entered Secondary Education. In November 2015, the educational psychologist report documented Charlie had a very poor understanding of “social interpretation and no effective vocabulary”. The assessment remains outstanding.  47. At the time, there was an expectation that children with perceived additional needs could be offered a holistic assessment under the framework of early help intervention.16 The area had clear guidance in place for multi-agency partners to work within these thresholds. This would have enabled an accurate assessment of her health, social and educational needs including what was known about her family or other networks, the environmental factors she experienced in daily life and her parental capacity to safeguard and protect her. The practitioner conversations highlighted at the time this type of assessment would not have been undertaken unless the child presented with issues that may trigger such an assessment. Primary Education did not observe factors in Charlie’s behaviour that would have triggered the early intervention process. However, at that time Ofsted also identified the use of early intervention processes across multi-agency partnerships needed to be strengthened and this work is ongoing.  48. There are significant challenges for multi-agency services establishing, assessing and investigating a child’s situation who has moved across borders and then enters education. It cannot be a single agency (education) responsibility and requires the combined skill expertise of all multi-agency partners and support organisations.17 It is crucial multi-agency professionals working with these children are more inquisitive to develop knowledge and understanding of the complexities a child may have experienced. This will facilitate a more accurate assessment of a child’s holistic needs and enable individual planning based on the child’s experience, including consideration of adverse childhood experiences. There was no evidence of effective communication with Charlie at the time to support further understanding of her experience.   49. There are assessment tools,18 aligned to the framework for assessment 19 20 to support the early assessment of migrant children. There is no evidence that Charlie was assessed with her previous experience taken into consideration. The challenge is whether professionals have the capacity and skills to undertake this type of assessment. During conversations, it was identified that practitioners                                                            15 A statutory assessment is an investigation made by the local authority into what the special Educational needs of a child are and what provisions are needed to meet those needs. This is the first step  16 The Early Help Framework In the Local Authority was designed to support children when there are concerns about progress/ needs are unclear and/ or the support of more than one agency is needed. It was last reviewed in July 2014.  17 An example of a support organisation is the Roma Support Group which provides professionals and organisations with practical information on how to improve engagement, holistic assessment and recommendations for future work within the communities which can be found at romasupportgroup.org.uk  18 See the IAMAF (international multi-agency assessment framework described in: Hurley B., Baptiste M-J., Pande S (2015) Free to Move, Invisible to Care, Coordination and Accountability towards Romanian Unaccompanied Minors’ Safety. NSPCC, ICARUS, European Union. 19 DH () Framework for the Assessment of Children in Need and their families, London The Stationary Office.  20 A framework for Assessing Children in Need that provides a systemic way of analysing, understanding, and recording what is happening to children and young people within their families and the wider context of the community in which they live.   Page 16 of 57  sometimes felt out of their depth when working with this group of migrant children and their families. It is crucial that multi-agency safeguarding practice finds solutions to the complex challenges faced by migrant children21 and the development of professional cultural competence of all minority groups is key component to prevent the development of professional misconceptions and biases.22 Early assessment and interventions should be developed to respond to the child’s experience. The intervention should build the child’s resilience and reduce the risk of further adverse childhood experiences. It is positive that services have developed for this minority group both in school and the community, including a dedicated development worker to bridge the gap between communities.23   Learning Point: Charlie should have been identified as a child with additional needs due to her minority ethnicity status, language and significant developmental needs. Early intervention assessment and planning with other multi-agency partners (school nurse, developmental paediatrician) may have improved the outcome for her. Migrant children from disadvantaged minority ethnic groups should be holistically assessed at an early opportunity to ensure that multi-agency early intervention planning is based on an accurate assessment of their experience, adverse childhood experiences, wishes and feelings. The assessment should not be solely educationally based and the multi-agency workforce should have sufficient cultural competence to undertake this work.   50. Charlie: Missing from Primary Education. Charlie was 10 years 7 months when she went missing from Primary Education. There had been no previous incidents of concern. Charlie failed to arrive at school one morning, despite being seen approaching by a teaching assistant. It is positive she was reported missing to the police, who subsequently recovered the child near her adult sister’s home. It is also positive Charlie was spoken to by the attending police officer, however her version of the events differed from the schools. She repeatedly told the police officer she had attended school that day but was thrown out of school by a teacher. This was because she and her friend had opened a fire door and set off an alarm.   51. At the time, male pupils reported Charlie had been involved in a fight with a group of boys a few days previously and a boy had been stabbed. It was reported Charlie’s mother had given her a knife which she waved around and stabbed the boy, who was thought at the time to be Charlie’s boyfriend.  This boy attended a local Secondary Education school.The incident was said to be linked to the boy biting her sister’s ear in an earlier incident. Charlie and her mother denied this and said there had been an incident the previous week outside her home when a few boys had assaulted Charlie and pulled her hair. The exact timing of the events was unclear and the police could not confirm which version was accurate. It was also acknowledged that Charlie had “special needs” and was a “low level learner” with “poor language skills” (when considering she had been in Primary Education 3 years at that point).   52. The incident was notified by the police and logged with the Contact Centre24 for information only. No further action was taken. The Contact Centre have reviewed the decision taken at the time. Within their learning summary it was documented “given the information available this was the correct decision. Missing episodes are a possible indicator of CSE, but on its own and without a pattern, this would not be a signifier to explore further”. During the practitioner event, it was reaffirmed that this would be in line                                                            21 Janta B., Harte E (2016) Education of migrant children Education policy responses for the inclusion of migrant children in Europe. RAND Europe, downloaded 18.4.17  22 Kirkman E, K Melrose K (2014) Clinical Judgement and Decision-Making in Children’s Social Work: An Analysis of the ‘Front Door’ System, Research Report, April 2014, The Behavioural Insights Team, DFE. 23 See cho 15.11.15  24 The Local Authority Contact Centre is a 24x7 Contact Centre for all social care enquiries and referrals from both the public and professionals. The service can help with all issues relating to children, adults, homeless and those at risk of homelessness. The service can signpost the caller to the most relevant department and close contacts down when indicated.    Page 17 of 57  with current practice. This event was perceived as an isolated incident and Primary Education indicated this was an initial event, having previously had no problems with Charlie. There is no multi-agency evidence to suggest any further risk assessment or interventions were considered at the time, in line with either safeguarding or missing children guidance. Whilst Charlie was seen by the police officer there is no evidence she received a formal safe and well check on recovery. Current guidance is not clear whether this would be offered when children go missing from education, as happens when they go missing from home or care, which could be an inconsistency in practice.  Learning Point: In practice when a child goes missing from education there are instances when a safe and well check is indicated in line with those carried out when children are missing from care or home. The missing from education policies and procedures do not currently provide guidance on this issue.   53. This was an early indicator that Charlie was a child in need of support. She was a very young child, from a migrant heritage, known to be at greater risk of exploitation and intimidation, with significant learning and communication difficulties, functioning at a pre-school level and went missing from Primary Education. In practice, it is unusual for children of this age to go missing and given the additional factors, the disclosures she had a boyfriend, her developmental immaturity, her communication challenges and the disclosures of violence it could have been a missed opportunity for a more inquisitive multi-agency response and the building of an ongoing holistic assessment through early intervention frameworks. The guidance at the time discussed frequent and repeated missing episodes as indicators for support. However, each case should be considered individually with careful consideration of all the presenting risk factors including the age and vulnerability factors of the child.  Learning Point:  Policies and procedure provide indicators in relation to the circumstances and processes that should be followed when a child goes missing from home/care/education. The risk to a child should be accurately assessed on an individual basis. There is no evidence that a formal safe and well check was undertaken and guidance does not provide clarity whether these checks are undertaken when children go missing from education.   54. Charlie: Transition from Primary to Secondary Education. In September 2015, Charlie commenced Secondary Education. Secondary Education did not receive an effective handover of information. The only information received was a “Key stage 2-3 Transition Document: SEN and Vulnerable Pupils Common Transfer”. This document was completed by a special educational need co-ordinator (SENCO) and had the potential to be an effective tool for the transfer of information. Its format could have provided a holistic approach to the gathering of specific information and provided a trigger for further multi-agency information sharing. However, it contained very limited information and advised that Secondary Education did not need to make contact for additional information, therefore there was no additional verbal handover. There is no evidence school nursing were aware of Charlie’s difficulties and did not have contact in that period.  55. Primary Education reported when Charlie transitioned to Secondary Education her common transfer file would have been sent via the management information system. Secondary Education did not receive this information. There was no safeguarding file transferred. The missing event during Primary Education was not shared. The limitations in information sharing created a significant challenge for Secondary Education who felt they quickly picked up the challenges shortly after she commenced school. They ensured Charlie was assessed by an educational psychologist, following which the school applied for additional funding. The school secured teaching assistant support which was in place by May 2016. The school was undergoing a transfer to a different trust which impacted negatively on information sharing. The school was not certain how the transition was managed during 2015 within the previous structure. The transfer system between Primary and Secondary Education has since been   Page 18 of 57  strengthened. The Secondary Education establishment now has a dedicated member of staff responsible for primary liaison to ensure all the necessary information is received.  56. It is positive the Secondary School recognised the needs of Roma children and have enhanced their services in recognition of the adjustments this minority group of children require. In September 2015, the following adjustments were in place;   An EAL department where students could receive intervention/support.  An employed community worker (2 mornings per week) supporting students in the classroom and communication through interpreting. This worker developed close links to the community, proving vital links to the school due to knowledge of the families and improved insight into the needs of the community.  Work with a local community centre, as many Roma students attended the centre in the evenings/weekends.   Additional support for any child with a low reading age with access to multi-sensory teaching for 1 hour a week.  Other types of support including EAL withdrawal/intervention support on a 1:1 basis, literacy support, mentoring from pastoral year team, counselling psychologist and outdoor weekly intervention to build self-esteem/resilience/team work etc.  Good Practice: Primary and Secondary Education have developed systems to support EAL children which also supports children from minority ethnic groups who requiring adjustments under equality and diversity legislation. This service has been enabled to evolve since Charlie’s attendance within Education.   57. In September 2015, the transfer of information could have been more effective. Seemingly Primary Education did not have concerns for Charlie other than her attainment and language, despite the evidence of her functioning at the developmental age of a pre-school child. Primary Education advised Charlie had made progress in relation to her language development. There are significant risks if information does not follow the child’s journey through education resulting in the possibility of the assessment of a child needing to be started again. The transition of information between Primary and Secondary Education is crucial for all children but especially so for children who have complex needs relating to educational, developmental, social and behavioural needs.  These children should be allocated a key worker and the information should be shared both verbally and in writing. Multi-agency involvement including the school nurse and community resources is essential. Whilst the schools have worked to resolve the issue the should be assured that the system for sharing information in respect of children with additional needs, who are transitioning between Primary and Secondary Education is effective.    Learning Point: The transition of information between Primary and Secondary Education is crucial for all children but especially so for children who have additional needs relating to ethnicity, educational, developmental, social and behavioural issues.  These children should be allocated a key worker and the information should be shared both verbally and in writing. Multi-agency involvement including the school nurse and community services should be highlighted as a crucial component.    58. Disclosure by Male School Pupils Charlie had an Older Boyfriend. In October Secondary Education became aware through disclosures by other pupils that Charlie may have a much older boyfriend. She had only been in the school a few weeks at this point. The education practitioner was managing a significant incident. Charlie and a peer had set off a school fire alarm   Page 19 of 57  earlier that day. It is positive practice the practitioner had a private conversation with Charlie who confirmed she had a 15-year-old “boyfriend”. The education practitioner knew the identity of the “boyfriend” and understood him to be 17 years 8 months of age. He had previously attended the school. Education was concerned about the age difference and made a contact with the Contact Centre to highlight the concerns for Charlie’s safety.  59. This information raised the “alarm bells” for education practitioners that Charlie at the age of 11 years, was possibly at risk of sexual abuse, through a relationship with a much older male. It is positive that a contact/referral was made with the Contact Centre. At that time, education explained safeguarding practice was to make a contact with the Contact Centre. There was no expectation to complete a written referral. The system has now been strengthened and education clearly understand the recent expectation would be to complete a written multi-agency referral form after a verbal contact/referral.  Good Practice: Secondary Education recognised the early indicators that Charlie was at risk of sexual abuse by an older male and acted to seek further expert advice.   60. The advice offered by the un-named social worker in the Contact Centre was that education should speak to Charlie’s parents and discuss their concerns. The Contact Centre was at that time switching to a new system, which is understood to be a factor explaining the loss of information, regarding the identification of the social worker. The Contact Centre advised if her parents responded appropriately education should continue to monitor the situation and make sure her parents managed the concerns appropriately. Education agreed to undertake a home visit, the next day, to share the issue with Charlie’s parents. The Contact Centre advised they asked for feedback however this was not understood to be an action by the school, unless there were further concerns. At that time, the Contact Centre social worker did not assess Charlie to be at risk of sexual abuse or child sexual exploitation, even when considering her age, learning disabilities and the “older boyfriend” scenario. The case was not escalated into the Local Authority Safeguarding Team or the Multi-Agency Safeguarding Hub, nor is there evidence that Education challenged the decision made by the Contact Centre.   61. The meeting held the following day in the home of Charlie’s parents was supported by an interpreter. The practitioner event highlighted her parents agreed to stop her seeing the “boyfriend”. Her mother later told the Consultant Community Paediatrician during the first forensic examination, she had previously chased Charlie’s “boyfriend” away with a “brush,” which would have coincided with the school’s request. Charlie was at that point excluded from school because of the fire alarm incident. Whilst it is understandable education must manage such incidents, it is of concern that such a vulnerable young person was excluded from school at a time when there was escalating risk in her life, an escalation of challenging behaviours combined with her having a significant learning disability.   62. This focus on her behaviour could have detracted professionals from the risks she faced in respect of child sexual abuse. There are challenges for education effectively managing challenging behaviours which lead to exclusion, when the home circumstances are not fully understood and the risk to the child is not accurately assessed. A troubled child may also be perceived as a troublesome child. The emerging professional’s belief system may be that the child’s behaviour is the focus of the problem rather than the situation the child is living with. There was no evidence education put in place an early help plan with other multi-agency partners to support Charlie at that time. At that time, the Local Authority had in place a handbook25 for all its schools to support the strategy for early help, whilst promoting inclusion which would have supported the intervention.                                                             25 Integrated Early Help Strategy: handbook for all Schools in the LA, April 2014   Page 20 of 57  Learning Point: Research provides significant evidence the most vulnerable children are often the most marginalised children in school exclusion systems.26 The exclusion of vulnerable children from education at a point in time when there are professional concerns for their safety due to the potential of inappropriate relationships with older adult males is of concern. The exclusion of children from education should only be considered following a robust early help assessment of their circumstances including the identification of significant risk factors. Alternatives to school exclusion should always be an option for children at risk of sexual abuse and or child sexual exploitation.   63. The Contact Centre response was explored in practitioner conversations. Contact Centre practitioners advised that the same response would still occur for cases with similar features. The Contact Centre learning summary advised;  “The decision to log for information pending school obtaining further information was correct, as the integrity of the information shared was unclear. It is the responsibility of the referring agency to give accurate information to abide by any actions agreed, however, on reflection, the decision for the school to get back to Contact Centre if there were any concerns, could have been firmer with feedback being given in a defined timescale. No assessment of risk could be given in the absence of any feedback.”  64. It is not clear what additional information was required or why the integrity of the initial information was not sufficient. The verbal information provided by education to the Contact Centre should have heightened concern regarding the risk indicators i.e. this was an 11-year-old girl was in a relationship with a 17-year old male. The identity of the male was known, as was the identity of the child and her family. The Contact Centre had previous information regarding a missing from education event and Charlie’s learning difficulties. This information alone should have triggered a multi-agency investigation into the incident and planned disruption activities in respect of the adult male. A multi-agency strategy discussion would have enable improved assessment and planning to create a safety plan for Charlie.   Learning Point: The information within this contact should have been sufficient to trigger an early CSE response to the concerns highlighted, a strategy meeting to assess the level of risk and consider potential offender disruption activities should have been considered at the time. The process has recently been strengthened and now providing this case was escalated by the Contact Centre for discussion at the daily multi-agency strategy discussions, the case would be assessed within 24 hours of the notification.   65. The investigation of concerns regarding potential sexual abuse is normally led by the Police Force and supported by multi-agency partners. It is not expected practice for universal services to lead this process. Their role is to gather information, share with the lead agency and participate in the planning/intervention when requested to do so. A hypothesis should have been considered; “What is a 17-year-old male’s intention when forming a relationship with a young female under the age of 13, with a developmental age of 5 years”. There was a significant imbalance of power in the relationship, yet it seemed this was perceived simplistically as a “boyfriend and girlfriend” relationship. This was a missed opportunity to instigate an early multi-agency investigation either under the guidance “Working with Sexually Active Young People Under the Age of 18 Years”27  or through the work of the multi-agency child sexual exploitation meetings (hereafter known as MACSE) which was operational at the time. It has been identified these processes are more likely to respond if sexual assault/activity had been disclosed rather than providing a preventative response. The MACSE operating framework has since                                                            26 Evans J (2010) Not Present and Not Correct: Understanding and Preventing School Exclusions. Barnardo’s 27 Safeguarding Guidance: Policy 5.23 Working with sexually active young people under the age of 18 years   Page 21 of 57  been reviewed and now responds more effectively to these types of cases. The guidance should be strengthened to include the preventative response.   Learning Point: Key guidance and systems appear to be more responsive when a disclosure of sexual activity/abuse is made. When working with young people practitioners should always consider the advantages of hypothesis, especially in cases when a child under the age of 13 years may be at risk of involvement in sexual activity with an older adult. The focus of intervention should be to prevent the activity through effective multi-agency safety planning. The Working with Sexually Active Young People Under the Age Of 18 Years Policy should be amended to strengthen the preventative response.   66. In conclusion, the opportunity for early help, multi-agency assessment, planning and intervention was not maximised through multi-agency partnership working. There were sufficient indicators of risk to raise concerns. Charlie was in a relationship with an older adult male therefore at risk of exploitation and child sexual abuse. It is positive this issue was raised by education with the Contact Centre but of concern that it was not deemed to require further multi-agency strategy discussion or planning. It is also of concern that there is a strong belief the response would be the same today. However, further discussion within the case review team has identified that the whole system has developed and now a case with these features would be signposted to the multi-agency safeguarding hub for further assessment. A random multi-agency case audit around the front door activity in the Contact Centre will provide  with assurance the system works proactively to prevent child sexual abuse rather than waiting for an incident of sexual abuse to occur.  Learning Point: This case demonstrates that the preventative approach to child sexual abuse should be strengthened in frontline practice and the system has focussed more on intervention following an assault rather than preventing the assault in the first incidence.    4.2 CHARLIE: THE ESCALATION OF CONCERN - A CHILD IN NEED.  67. This section of the review will discuss the multi-agency arrangements to assess the risk, ensure robust planning and provide intervention to support Charlie as a Child in Need between November 2015 and February 2016.   Event /Issue Links to terms of reference  Charlie: Multi-agency Contacts/Referrals and CSE  1,3,5 The Thresholds of Concern 3, 4,  Charlie: The police Investigation and the 1st Forensic Medical Examination. 1, 4, Charlie: The Referral to CAMHS for a Cognitive Assessment. 4, 3, Charlie: Inappropriate Videos Found on Mobile Phone. 1,5  Charlie: 2nd Missing from Education event January 2016 4, 3,   68. Charlie: Multi-agency Contacts/Referrals and CSE intervention. On the 16th November 2015, Charlie disclosed to a secondary education practitioner she had gone to a house with her “boyfriend”. Charlie reported “she had fallen asleep and when she woke up her boyfriend was kissing her boobs, bum and belly. She asked him to stop and he didn’t”.  It was later understood Charlie had been given alcohol and her “boyfriend” only stopped when six young girls came into the room. Her sister was present and later provided evidence to the police investigation. The “boyfriend” had a different name than the “boyfriend” described previously although it was later   Page 22 of 57  confirmed this was the same “boyfriend”. A child protection referral was made by secondary education the same day to the Contact Centre and the referral was allocated to Children’s Social Care Referral Team.   69. In November 2015, secondary education had additional concerns as Charlie exhibited sexualised behaviour in class involving three boys. A contact was made with the Contact Centre who passed the information to the key social worker. There is no evidence the case was allocated at this point, as the first recordings by the key social worker was not until the December 2015. However, the practitioner conversations highlighted this information would have been available for the social worker to access on allocation.   70. In November 2015, it is positive that the school nurse was asked by the education safeguarding lead to see Charlie at the school nurse Drop in Clinic. The school nurse was made aware of previous concerns and provided Charlie with support and the opportunity to talk about her life. Charlie thought her school was “OK” and she was aware that “she gets into trouble which makes her sad”. She disclosed that “some girls had been fighting with her”. She said she had some friends and “her sister Sam would help her too”. She described her family unit and provided clarity her father didn’t live with them.  Charlie said that “she was worried about her boyfriend as he had told her he was 15 years old but he was 18” and stated that the boyfriend had ‘…tried to touch her, she didn’t like it…told him to stop but he didn’t” Charlie said she had met the “boyfriend” in the park, had now ended the relationship but was still worried about it. The school nurse informed Charlie she would be in school the following week if she wanted to attend the drop-in clinic to talk some more. The school nurse liaised with education, advising about the conversation, made a Section 47 child protection referral to the Contact Centre and completed a CSE form which was forwarded to the MACSE team for further investigation. The CSE form was discussed in a pre-meeting in November 2015, which screened referrals, with a plan to discuss further in a MACSE full meeting planned for December 2015.  71. This episode of care demonstrates excellent multi-agency communication and information sharing and universal professionals confidently followed the expected safeguarding practice. The school nurse’s practice was child centred and included being open and honest, putting boundaries in place and ensuring that Charlie understood these messages. This piece of work shows clearly the positive intervention when school nurses effectively engage with children. It may have been more effective if ongoing intervention with the child could have been planned on an ongoing basis, rather than leave the child to access this service.   Learning Point:  The school nursing service was effective in early communications with Charlie. These communications were child centred and provided the basis for early help intervention. Further intervention did not occur as the system encouraged children to drop-in. A more structured approach may have enabled a programme of early help to support Charlie in managing the risks she faced.  72. In November 2015, it is thought the social worker undertook an initial visit to the family. The information does not provide clarity as to when the case was allocated to the social worker and the electronic recordings within Children’s Social Care do not provide comprehensive detail of the visit. Children Social Care was at that time transferring to a new electronic case management system which may have been a contributory factor in the loss of information. However, this is not a certainty. The only recording of this visit is when the Secondary School documented the social worker provided an update November 2015. The social worker had visited the family and had “no immediate safeguarding concerns -parents had been made aware of keeping both Charlie and Sam safe”.   Learning Point: There was no recording of the initial home visit by the social worker on Children’s Social Care electronic recording system. A contributory factor was thought to be the information may have been lost in the transition to a new system however this is not a certainty therefore. The   Page 23 of 57  importance of contemporaneous record keeping should be re-enforced in front-line practice and remain a focus of ongoing audit.   73. The single assessment provided limited detail 28 and the agency learning summary advised “the initial allegation was serious and significant harm…. but particularly so given the children’s ages and their learning needs…. allegations of this type would be exceptional at this age. Despite this there was no assessment of the children’s needs taking into account their capacity and learning needs.” In addition, there was no recorded comprehensive assessment of parenting capacity. Practitioners advised the children’s father had very limited understanding although this was not formally assessed until the court proceedings in the summer of 2016. At this point the extent of their father’s learning difficulties was fully understood and detailed to be significant in respect of learning difficulties.   Learning Point: The initial allegation was serious and met the threshold for significant harm especially given the children’s ages and their learning needs. Despite this there was no assessment of the children’s needs which considered their capacity and learning needs nor was there an effective parental capacity assessment therefore the risk was ineffectively managed. The system however has been reviewed and this would now be co-ordinated through the multi-agency child exploitation team.  74. Education documented that a Section 47 child protection investigation was to be initiated and there was consideration of convening a strategy discussion. During the practitioner event the social worker advised this case did not present high-level concerns in comparison with the other cases being managed at the time. It was the view this case presented with low level risk indicators and the parents were assessed to have capacity to keep Charlie and her sister safe at that time.   75. In December 2015, an education practitioner observed a male waiting for Charlie outside school and stopped her getting on the school bus and smacked her on the back of the head as they walked away. This information was shared with the Contact Centre who advised the case would probably not go into child protection proceedings but would be managed under MACSE processes. Secondary Education remained vigilant and responsive to the risks of CSE and were proactive in raising their concerns.  Good Practice: Secondary Education consistently made contact and referred their concerns in a timely manner to the Local Authority regarding Charlie’s safety and wellbeing, clearly identifying the risks of CSE  76. The single assessment identifies the case was discussed in a MACSE meeting December however there is no information in respect of the emerging plan to support Charlie. At this point in time CSE focussed preventative work was not an intervention provided for young people considered at low risk of child sexual exploitation. This was a lost opportunity undertake direct work with Charlie. There have been significant improvements in the CSE pathway which was revised with effect December 2016. Children at low-medium risk of CSE are now signposted to the NSPCC or another relevant service for CSE focussed preventative work.  Learning Point: Charlie made a clear disclosure which should have prompted focussed preventative work as a priority to reduce the risk of further incidents. At the time CSE focussed preventative work was not a provision for children assessed at low risk of CSE. The CSE pathway was amended in                                                            28 Framework for the Assessment of Children in Need and their Families (DH 2000) is statutory guidance to be used in the assessment of all children in need including those in need of protection. It considers the child’s development needs in the context of family and environmental factors and the parenting capacity to respond appropriately.   Page 24 of 57  December 2016 and CSE focussed preventative work, provided by the NSPCC and schools is now a provision for children assessed at low risk of CSE.   77. Charlie: The Thresholds of Concern. Social Work records do not determine whether this case was being worked under Section 17, Child in Need or under Section 47 Child Protection arrangements. It was confirmed at the practitioner event Charlie was deemed to be a child in need of support rather than a child in need of protection, therefore the case was managed under a lower level of concern. Under child in need arrangements there would still be an expectation for the key worker to facilitate multi-agency communication however there is limited evidence of robust and regular communications between the key agencies in the early stages of the investigation. There was evidence of communication by the social worker with education and the police. However, there was a significant delay in allocation of the case by the police to a senior investigating officer which delayed the onset of the joint investigation into child sexual abuse/CSE.   78. There was no evidence of a child in need meeting to coordinate the multi-agency response, as would be the expectation in practice. However, the case was known to the MACSE process so there was also an expectation the response to the child would be managed through that system. The process followed was difficult to untangle. Therefore, the case was left “floundering” in the system following no clear pathway It is positive the process for intervention has been amended and now provides more clarity. Practitioner conversations highlighted practice had changed significantly and cases would no longer be left “floundering” in the system. The cases are reviewed at daily meetings now.  79. In conclusion, Secondary Education effectively assessed and highlighted several incidents that should have raised significant concerns about the risks of CSE.  These were re-enforced by the school nurse. The early joint response to Charlie’s disclosure of a sexual assault should have been more effective. The initial assessment did not appear to be comprehensive or robust enough to identify significant factors that may have impacted negatively on the parental capacity to protect Charlie. The joint investigation was significantly delayed and neither the CSE nor Child in Need pathway sufficiently interfaced to ensure robust planning to adequately manage the risk for Charlie. It is of concern that early preventative work with Charlie was not a provision at that time although the provision is now available in front line practice. The incident should have been assessed as a child in need of protection. It was managed at too low a threshold which meant the focus of concern was lost. Children’s Social Care have systems in place and managers are expected to provide adequate supervision. The oversight of cases that border child protection concerns but are worked under Section 17 Child in Need arrangements could benefit from independent scrutiny i.e. via an independent reviewing officer.  Learning Point: The case was managed at a low level of concern without sufficient management oversight. The  should be assured that there is independent scrutiny of cases that are managed under Section 17 Child in Need arrangements to ensure these cases are subject to good quality assessment, planning and intervention.  Recommendation: Children’s Social Care should provide the with assurance that the cases managed under Section 17 Child in Need arrangements are robustly and independently supervised.   80. Charlie: The Police Investigation Leading to the 1st Forensic Medical Examination. There is no evidence of early multi-agency strategy discussions, inclusive of education as an agency in daily contact with Charlie. The investigating officer was not allocated the case until the 6th January 2016, when arrangements were made with the key social worker to undertake a joint visit. This delay in allocation was due to the case being held in the multi-agency safeguarding hub (MASH) for one month before it was allocated to an investigating officer. The investigating officer had an excessive workload at that time. There was a significant backlog of cases awaiting processing and during practitioner   Page 25 of 57  conversations it was highlighted three separate police teams managed the investigations emerging from the MASH. This resulted in confusion in respect of the co-ordination of investigations. The police learning summary highlights significant concerns regarding delays in allocating an investigator, arranging the forensic medical examination, co-ordinating strategy meetings and sharing information with key professionals.  The process has now been streamlined to reduce the risk of delays in allocation by the police.  81. In January 2016, 6 weeks after Charlie’s disclosure, the police commenced the investigation and met with Charlie. Plans were made a forensic child sexual abuse examination at the local Sexual Assault Referral Centre (SARC). It is positive that the SARC centre has a 24-hour consultant paediatrician on call service to undertake child protection medical examinations and offer the child support. The forensic child sexual abuse examination currently is undertaken by a qualified consultant paediatrician and a forensic medical examiner. The timeframe for the appointment was slightly longer than would be the normal expectation due in part to the availability of the forensic medical examiner. The forensic medical examiner service is provided by a different health provider and conversations highlighted there can be delays in allocation. However, as the case wasn’t acute the timing was advised to be less important in relation to forensics etc.  Good Practice: The SARC is a bespoke facility within the tertiary centre. There is an on call 24hr consultant led service to undertake child protection medical assessments to minimise the risk of delay in the investigation and intervention for the child.  82. The conversations with the SARC centre identified it would be beneficial for the centre to be involved in the initial multi-agency strategy discussion when the initial referral of sexual abuse is made to enable more effective planning and timely intervention for the child. Currently the data identifies that whilst there are increasing referrals for child sexual abuse the referrals to the SARC centre are not increasing. The SARC centre offers a range of services to support a child in these circumstances and their involvement in the initial stages of the investigation would be beneficial for the child.  Learning Point: The initial strategy discussion following a sexual abuse referral should include consultation with the SARC centre to contribute to effective holistic planning and intervention for the child.   83. In January 2016, 8 weeks after her initial disclosure, Charlie attended for the examination at the SARC centre. The examination was undertaken by a consultant developmental paediatrician and a forensic medical examiner. The context of the examination was due to the disclosure of historical abuse. The primary event was advised at the time to have taken place in end of August or September 2015 and disclosed in November 2015. It was documented there had been a 6-month history of concerns relating to Charlie’s sexualised language and dress. There was a lack of clarity about the incident date due to Charlie’s recall. A ‘missing’ episode around August/September 2015 was thought to be the key event. However, there is no documentation regarding this missing event. There was discrepant information as during conversations, education advised it was their belief it had occurred just prior to the disclosure in November 2015.  84. She was accompanied by her mother, a police officer and a social worker. Her key social worker was unable to attend. Her mother did not present as either understanding or speaking English very well and provided a very limited history. An interpreter was present and was described as a significant asset to the process. The practitioner conversations highlighted the advantages of using this interpreter, commending her professionalism and dedication to the role. The interpreter worked with Charlie at her school, so could offer additional information in respect of her circumstances and developmental needs. Charlie’s vulnerability was identified during the examination by the medical examiner who suggested   Page 26 of 57  that both an Intermediary29 and an interpreter would always be required in future contacts with Charlie. The medical examination was inconclusive.  Good Practice: The school interpreter was commended by several professionals and her support and intervention significantly enhanced communications and information sharing at critical times in the process.    85. Charlie: The Referral to CAMHS for a Cognitive Assessment. At the time of the forensic medical examination Charlie was described as a quiet child, who struggled to understand, was passive and didn’t question. It was recognised that English was her 2nd language and this may have been the rationale for her presentation. However, the interpreter advised this was how she presented in her own language. The consultant paediatrician recognised that Charlie had significant learning difficulties and wrote a letter to the SENCO for further assessment also querying whether she had been assessed by an educational psychologist. Normally the consultant paediatrician would have referred Charlie to the local sexual abuse centre but decided due to her complex presentation would refer her to the in- house CAMHS for a cognitive assessment. A cognitive assessment would have been beneficial to understand her level of functioning.  86. The response to the CAMHS referral was not robust. As the referrer, the consultant paediatrician would have expected to receive feedback from CAMHS but received no further response. The referral was signposted to an asylum seeker support service. This was not an appropriate response and had the consultant been aware would have challenged the decision and/or referred Charlie to another service. It was noted in the CAMHS information system that the general practitioner was included in the response however General Practice records did not contain a response to the referral either. The review has not been able to gain further insight into why CAMHS made the decision to signpost the case to another service who could not provide the service requested by the Consultant i.e. a cognitive assessment. It was highlighted the provision of cognitive assessments for children was thought to be service provided by CAMHS but in practice this provision was not consistently available. A recommendation has been previously made in this review in respect of this provision.   Learning Point: It was not appropriate for CAMHS to signpost the consultant paediatrician’s referral to an asylum-seeking support service without consultation with the referrer. The system should always provide direct feedback to the referrer to enable appropriate and timely planning for the child.   Good Practice: The consultant paediatrician and medical examiner at the SARC centre were child centred. They quickly assessed Charlie to have significant developmental concerns and acted to support Charlie by advising the police to appoint an intermediary and referred Charlie for a specialist cognitive assessment to CAMHS and the SENCO.  87. Charlie: Inappropriate Videos Found on Mobile Phone. Towards the end of January 2016, the school’s safeguarding lead contacted the key social worker advising of inappropriate videos on Sam’s mobile phone. The safeguarding lead was advised to bring the phone to the planned Child in Need Meeting and to hand it to the police. It was thought Sam had taken inappropriate pictures of Charlie on her mobile phone in the family home. After the phone had been seized the images were viewed by the police.                                                             29 An Intermediary works within the justice system to enable vulnerable victims, witnesses, suspects and defendants to give complete, coherent and accurate evidence to police and to courts. Downloaded intermediaries-for-justice.org    Page 27 of 57   88. The risk assessment at the time advised it was an isolated incident which did not warrant further action. It was understood that Sam had been coerced into taking the pictures by a third person on the phone and the incident was not perceived to pose an ongoing risk.  89. In conclusion, this was a significant incident when considering the emerging picture that these children were at risk of exploitation and sexual abuse. It is of concern that there may have been another person involved coercing Sam to take the pictures of Charlie.  The issue is complex however, this type of evidence should not be considered as just normal activity between two children. It is not clear whether there was a comprehensive investigation into this issue, including a robust analysis of the images, a comprehensive assessment of the circumstances and further investigations into the third person. This issue should form part of any disruption activity and is discussed later in this review.  90. Charlie: 2nd Missing from Education Event Jan 2016 At the end of January 2016, Charlie and a friend absconded over the school fence following concerns about inappropriate and sexualised behaviours in school. The missing from education incident was reported to the police. A CSE form was completed by the attending officers who highlighted concerns about the risks Charlie faced in respect of abuse by a known adult male whom she referred to as her “boyfriend”. The police made significant attempts to find Charlie including visiting her parents and the child who absconded with her. Her mother felt confident Charlie would return home by her curfew time at 20 00hrs and contacted the police to say she had returned. The police undertook a safe and well check at 20.20hrs and Charlie was thought to be well and made no complaints. Charlie said she had been with the friend she had absconded with, however this friend said she had not seen Charlie since the end of the school day.  There is no evidence that the police understood where her “boyfriend” lived or attempted to recover her from her boyfriend’s address. The delay in the police investigation process may have contributed to the limitations in intelligence for the attending police officers in respect to the identity of the “boyfriend”.  91. The issues relating to events when children are missing from education have been previously discussed and the same pattern followed here in that there was no formal safe a well check which may have provided the opportunity for more understanding of the missing episode.   4.3 THE MANAGEMENT OF RISK THROUGH CHILD PROTECTION PLANNING.  92. This section will focus on the child protection work undertaken with Charlie and Sam as the child protection planning related to both children.  Event /Issue Links to terms of reference  The Section 47 Investigation and Initial Case Conference. 1, 2, ,5 Initial Core Group Meetings and Child Protection Planning. 1,2,5 Charlie: Child Protection Planning in Response to First Allegation of Rape. 1,2,3,4 Charlie: Child Protection Planning Following MFH Incident. 1,2,3,4 The Escalation of Risk and The Initiation of Care Proceedings. 1,2,3,4,5  93. The Section 47 Investigation and Initial Case Conference.  At the end of January 2016, a decision was made to commence a Section 47 investigation. This decision was made at an emergency strategy meeting involving the police and Children’s Services one week after the first forensic medical examination of Charlie. The outcome of the Section 47 investigation was to arrange an initial case conference for the middle of February 2017.    Page 28 of 57   Learning Point: The initial CSE concerns for Charlie were raised in the middle of November 2015. The first multi-agency meeting was the initial case conference in the middle of February 2016 therefore resulting in a delay in establishing multi-agency plans and interventions. The importance of multi-agency involvement in strategy discussions and meetings was highlighted in the JTAI inspection. The JTAI action plan includes actions to ensure that multi-agency strategy discussion and meeting processes are robust.      94. One action from the strategy meeting was that a written agreement was to be put in place between Children’s Services and the children’s parents. This agreement was felt necessary due to education reporting Sam and Charlie had continued to arrive late in school and leave school alone. This was despite advice by the key social worker at the initial home visit at the end of November 2015 for parents to take the children to and from school. The first written agreement was signed by their mother. It stated she understood the concerns and would take them to and collect them from school each day. She also agreed to supervise Charlie and Sam in the evenings and at weekends. The agreement stated that Children’s Services may seek legal advice if the written agreement was not adhered to. The police officers were very proactive in contacting Children’s Services to escalate their concerns, in respect of the need to convene an initial child protection conference and the efficacy of the first written agreement, including a query whether it had been translated into the family’s own language.   95. Nationally, findings from serious case reviews have highlighted the importance of translating information into a family’s birth language to improve safeguarding practice.30  Children’s Services responded positively to the concerns raised by requesting further detail around how the concerns could be met and agreed it would be updated. Two written agreements were reviewed. They were written in English with a professional interpreter used to ensure mother understood their content prior to signing them. However, their mother would not have had ongoing access to the document to reflect on as she could not read English.   Good Practice: There was effective challenge by the police and a positive response by Children’s Services.     Learning Point: Charlie’s parents were not provided with written information in their 1st language to reinforce their understanding of the contracts made with Children’s Social Care to keep their children safe. This is an adjustment required under Equality legislation.     96. Twelve days after the first written agreement Sam and Charlie were placed in the care of their adult half-sister who was heavily pregnant. Formal arrangements were agreed for Sam and Charlie to be escorted to and from school. This placement resulted because their mother had left the country to attend a family funeral and left the children in the care of their father, thereby it was considered she was failing to adhere to the written agreement. Another written agreement was discussed and signed by the half-sister who was fluent in English. This written agreement was more detailed and included that Sam and Charlie; were to be supervised always when not at school, the police should be notified immediately of any missing incidents, any mobile phones found in the possession of either Charlie or Sam should be confiscated and the police and Children’s Services to be notified immediately.                                                                30 NSPCC People whose first language is not English: learning from case reviews Summary of risk factors and learning for improved practice around people whose first language is not English- accessed 01.05.17 nspcc.org.uk   Page 29 of 57  97. In Mid February 2017, the initial case conference was held 10 days after Sam and Charlie had been placed with their half-sister. There was a clear understanding at the conference the children would remain in the care of their half-sister, until risk assessments had been completed. It was noted there had been an occasion when Sam and Charlie had asked the taxi driver to take them to their own home instead of to their half-sister’s home. The outcome of the conference was a unanimous decision for Sam and Charlie to be made subject to child protection plans under the category of sexual harm due to the identified risk of CSE.   98. Both parents, their adult half-sister and the professional interpreter were present at the conference. There were no concerns noted around the day to day care provided to the children or about parental willingness to protect them. There were concerns about parental capacity and concerns about parental learning needs, particularly in respect of father. One outcome from the conference was for the core group to determine which agency was best placed to assess their parent’s additional needs, to enhance the risk assessment. Actions were agreed for a family support worker to undertake direct work with parents and for the NSPCC to undertake direct work with Sam and Charlie. At the practitioner event, the parenting capacity assessment was discussed. It was reported this piece was work was undertaken however the review has not received any documentation in respect of its findings nor could the learning summary author find a capacity assessment.  99. Initial Core Group Meetings and Child Protection Planning.  Following the initial case conference, core group meetings were held regularly in accordance with safeguarding procedures. The children’s services summary notes from these meetings do not reference which multi-agency practitioners were in attendance.   Learning Point: Minutes and records relating to core group meetings should include the name and agency of practitioners in attendance and the child protection plan actions each practitioner is responsible for. This facilitates effective multi-agency safeguarding practice and enables future audit of multi-agency working in cases involving children subject to child protection plans.    This currently forms the basis of core group practice therefore no recommendation is made.        100. Information reviewed in respect of these meetings identified the focus of discussion was on the needs of the children and the actions being taken to reduce the risk of CSE. The assessment of parental needs was discussed at the first core group meeting. There was no action agreed to progress this assessment and therefore none of the agencies took responsibility for addressing this aspect of the child protection plan.  The Children’s Services learning summary noted a single assessment of the family had been undertaken, however there was limited evidence of assessment of the parents or children within the overarching single assessment. A risk assessment had not been undertaken and there was limited assessment of parenting capacity. The learning summary noted that procedures are in place for these assessments to be undertaken where children are subject to child protection plans. However, the feedback from the practitioner event was that detailed capacity assessments including parental needs would normally only be undertaken if directed within public law outline proceedings.    Learning Point: Whilst the assessment of parenting capacity was considered at the 1st core group meeting there was insufficient understanding gained until the Public Law Outline proceedings were instigated. It is uncertain in practice how a cognitive assessment of an adult would be accessed to support greater understanding of parenting capacity when a case has not met the threshold for PLO proceedings.     Page 30 of 57  101. Further feedback provided at the practitioner event was Sam and Charlie’s parents presented as very willing to work with agencies to protect their children and agreed to comply with agreed actions. They were perceived as easy to work with and made practitioners feel confident in them. Practitioners highlighted that on reflection their mother may have agreed to carry out all these actions due to fear of the children being removed from her care.  However, was not then able to comply for several reasons including her own physical ill-health needs. This issue was not fully understood until after the children had become subject to care proceedings.    102. The first core group meeting was held 8 days after the initial case conference. At that time both children were being taken to and from school. Sam was walking to and from school with a family support worker and Charlie was being transported by taxi, provided by the school. Their parents did not attend this meeting and the key social worker visited the home four days later to inform them of the agreed actions. At the beginning of March 2016, a second visit was undertaken to complete an assessment. In mid-March 2016, the key social worker then undertook a third visit, the day prior to the second core group meeting. The mother signed a second written agreement, which included the need for Sam and Charlie to be supervised always, any mobile phones to be confiscated and the police and Children’s Services to be notified immediately should either Charlie or Sam go missing.    103. A duty social worker attended the second core group meeting as the key social worker was not available. The duty social worker advised the key social worker had undertaken a parental risk assessment which was positive. The parents were reported to understand the CSE concerns and assessed to be able to protect their children. Their adult half-sister was due to give birth and would not be able to provide the same level of support. Both parents and the interpreter were present at the meeting. The outcome of the assessment was that the children should return to the care of their parents, with a new written agreement. It was noted that police investigations were ongoing and Sam and Charlie had undertaken achieving best evidence interviews. It was also noted the transport arrangements would continue until the Easter holidays, after which Sam would commence walking to and from school alone. A family support worker had been allocated to undertake work with both parents and direct work with the children would be undertaken by the NSPCC. The decision to return the children home at this point was not challenged by core group attendees. A hypothesis could be that challenge would have proved too difficult given that both parents were present, the key social worker was not in attendance and therefore attendees were not able to request any clarification on the parental assessment undertaken.   Learning Point: Whilst Children’s Services are the lead agency responsible for progressing the child protection plan, the central decision to allow the children to return to their parent’s care should have been agreed by the core group rather than the decision being presented as information only. This is the expectation of practice guidance. Agencies should use the escalation policy when they disagree with a decision.    104. Towards the end of April 2016, during the third core group meeting it was noted that Sam had seen the alleged perpetrator whilst on a bus with her mother and aunt. This had unsettled her and it was agreed her parents would collect her from school each day. Charlie continued to be taken to and back from school by taxi, until her re-integration into mainstream school. The children had met their key NSPCC workers and the family support worker had commenced work with the parents. Their mother was reported to show an insight and understanding. Whilst the meeting notes evidenced the child protection plan was progressing, the initial delay in the allocation of the case by the police following the referral made in November 2015 contributed to a significant delay in direct work with the children and their parents. This work did not commence until five months after the referral had been made. The police learning summary noted this delay in allocation and confirmed that practice has been strengthened. All cases are allocated on the same day as notified.    Page 31 of 57   105. Charlie: Child Protection Planning in Response to the First Allegation of Rape.  At the beginning of May 2016, Charlie alleged she had been raped after school when walking home through the park by a boy who attended the same school. This incident occurred on the first day she had been allowed to make her own way home from school. Sam had been walking home with Charlie and had tried unsuccessfully attempted to intervene when the boy had grabbed Charlie and pulled her away. Sam subsequently disclosed further information about the incident at a session with the NSPCC community safeguarding practitioner (hereafter referred to as NSPCC CSP). The first review case conference was the next multi-agency meeting, held six days after Charlie’s rape disclosure. This meeting was well attended and was inclusive of both parents and an interpreter. The police sent apologies for this meeting and did not provide an update or report.   Learning Point: Safeguarding procedures provide guidance that when agencies are unable to attend a child protection case, either an initial or a review case conference, a written report must be provided. This case identifies the guidance was not always adhered to. Information from all participating agencies is necessary to ensure robust risk assessment and decision making within the case conference                106. The outcome of the conference was their parents had done everything that had been asked of them. The child protection plans were effective but would remain in place due to the recent allegation of rape which was in the community. Sam had initially stated that she wasn’t aware that her sister had made the rape allegation but later disclosed being too frightened to report it. Sam disclosed she was fearful of the alleged perpetrators of the abuse. She wanted to walk to and from school on her own and felt she was not at risk when alone.   107. The practitioner conversations highlighted the NSPCC CSP challenged the decision as to why the transport arrangements to and from school had been changed, without the agreement of the core group. The key social worker advised this had been an independent social work decision, with a view to progressing the child protection plan. There was no agency challenge. Practitioners become attached to their judgements and can employ strategies to ensure that challenge is not recognised or explored. The dominant view of the key professionals can result in an outlying view being ignored or not heard, as was a possible hypothesis in this case. This is known as a confirmation bias31 when practitioners tend to maintain their intuitive beliefs even when considering evidence that challenges them. In addition, most professionals did not provide challenge preferring to leave key decision making and accountability to the lead agency rather that active involvement, also known as the bystander effect.   Learning Point: It is positive that the CSP provided challenge in respect of the changes to the safety plan which enabled the children to walk home without supervision. However, this challenge was left “unheard”.    108. The assessment of parental needs within the child protection plan was discussed during the review conference. It was noted their parents could understand the concerns and were able to act to prevent the future risk of CSE.  An action was agreed to obtain an update from the police and it was noted two different officers were investigating the incidents. This issue was raised at the practitioner event when it was identified three police teams were involved. Practitioners felt that this caused challenges in information sharing and the teams were not aware of the progress of investigations being managed in the different teams.                                                            31  Kirkman E, K Melrose K (2014) Clinical Judgement and Decision-Making in Children’s Social Work: An Analysis of the ‘Front Door’ System, Research Report, April 2014, The Behavioural Insights Team, DFE.    Page 32 of 57   109. Multiple practitioners were involved, at different points in the case, in addition to the three police teams who were coordinating the criminal investigations. Other workers included the NSPCC workers allocated to each child, alternative social workers when the key social worker was unavailable, two school nurses and police patrol officers who responded to incidents. The number of practitioners involved made it difficult for the key social worker to ensure all practitioners were aware of new information in a timely manner.  The more practitioners involved, the more challenging multi-agency information sharing becomes and the key social worker should be supported in ensuring that information is shared effectively. Practitioners should provide support by ensuring information is shared effectively within their own agency.   Learning Point: It is good safeguarding practice that practitioners attending safeguarding meetings on behalf of their agency ensure they obtain updates from colleagues to inform the safeguarding arrangements and provide feedback after meetings. Where multiple practitioners from one agency are involved, discussions and agreement should be reached as to how information will be collated and shared at meetings.     110. At this point, parents were viewed as able to protect the children and the original child protection plan was continued despite the significant incident. The fourth core group meeting was held at the end of May 2016. Documentation of this meeting was inconsistent with Children’s Services information, noting the child protection plans were progressing well yet NSPCC information noted challenges were raised about the risks to the children. The NSPCC CSP questioned why had Sam had been able to see an alleged perpetrator given the safety plan and raised the fact the work that had been undertaken with Sam would not yet have had a positive impact. It was this practitioner’s opinion that Sam was being allowed excessive independence. The key social worker agreed to advise mother to increase her supervision of Sam until the NSPCC CSP had undertaken further work with her.    111. Charlie: Child Protection Planning Following MFH Incident.  In mid-June 2016 at (2.40am) Charlie was found alone in a park. The fifth core group meeting was held two days later but not attended by parents. The key social worker had not been made aware of the missing incident, therefore it was not discussed and did not influence the child protection planning process. This issue was raised within the practitioner event where it was identified this significant new information increased the level of risk for Charlie who had not been reported as missing in accordance with the written agreement. Knowledge of this information could have resulted in the key social worker seeking legal advice much sooner.    112. The police learning summary confirms this information was not shared with the key social worker for a further 17 days, despite the two investigations already underway. A police protection order (PPO) should have been considered at the time of the incident. The learning summary also makes a recommendation for facilitation of the police MASH to review referrals and if the child is already part of an investigation then the referral should be forwarded as a priority to the Contact Centre.   Learning Point: There was a significant delay in processing the case through the MASH due to a backlog of cases within the system.   113. A key discussion at this fifth core group meeting was the family were about to be evicted and how the family could be supported. Whilst the parents had paid the required rent to a relative living in the house prior to their residence, it had not been forwarded to the landlord. Two days after this meeting, the police were called to the home. It was reported that two males had been outside and were kicking and banging on the door. Charlie said that they both had knives and shouted through her window in broken   Page 33 of 57  English. Charlie disclosed that they had said they would “fire the house”. Charlie disclosed the name of one of the men. It was later discovered he was the alleged perpetrator in an investigation relating to her allegations. The police officers were proactive in contacting Contact Centre who offered the family bed and breakfast accommodation. When the officers returned, the family declined to accept this offer. The police completed a threat assessment32 and put in place several measures to protect the family, until it was confirmed in July they had moved to a new house. These measures included treating all calls as urgent, placing a marker on the address, requesting a police reassurance visit, patrols to pay passing attention to the home, referral to the Fire and Rescue Service and inform the CSE team.  Good Practice: There was a very robust response by the police to this incident including both single-agency actions and referrals to multi-agency partners for further support including the contact centre. This service offered bed and breakfast accommodation and undertook a home visit 2 days later.            114. Escalation of Risk and The Initiation of Care Proceedings. At the beginning of July 2016, the rape and sexual abuse practitioner working with Charlie notified the key social worker that she had disclosed being out with Sam on the previous Saturday night and that Sam had been drinking vodka. Sam had become very intoxicated and both girls had walked home in the dark. Charlie also disclosed this information at school on the same day and the safeguarding lead updated the key social worker. In addition to this new information, the key social worker had also recently received the police referral, for the missing incident in June 2016. The key social worker visited the family in their new home on this date and discussed the recent concerns. Parents stated at the visit that they hadn’t reported Charlie missing in June due to having no phone and mother said that she had not been aware of the girls being out the previous Saturday night as she was asleep in bed.  The key social worker advised parents that legal advice was to be sought due to the concerns about their lack of supervision of the children. The following day, the NSPCC CSP for Sam sent a detailed email to the key social worker raising concerns about both children and requesting that these be raised at the forthcoming core group meeting. The key social worker subsequently contacted the NSPCC CSP to provide an update.       Good Practice: The NSPCC CSP was proactive in collating the ongoing concerns about the risks to the children and ensured that these were shared with the key social worker ahead of a planned core group meeting in order that they could be shared and inform the child protection planning.             115. Two days after this home visit, Charlie escaped from the family home through a bedroom window and was reported missing by Sam who advised that she had reported Charlie missing because their parents didn’t speak English. The incident was afforded high priority due to the known risk of CSE. Charlie returned home at 11pm and wouldn’t discuss where she had been with the police officers in attendance. A referral was made to the police MASH which was documented to be received two days later. This referral was not forwarded from the police MASH to Contact Centre for a further 18 days. The police learning summary notes this is a practice issue of concern given the risks already understood as previously highlighted.     116. The day after this MFH incident, Charlie disclosed in school that she had been raped the previous night. This incident was responded to promptly and actions undertaken included a strategy discussion and an FME examination.  It was agreed at the discussion that Sam and Charlie would, with the consent of their mother, reside with their adult half-sister. A written agreement was put in place.                                                                   32 A Threat Assessment is a violence prevention act that involves identifying the threats to commit violent act, determining the seriousness of threat, developing intervention, plans that protect potential victims and address underlying problems that stimulated the threatening behaviour. Downloaded Wikipedia.    Page 34 of 57  117. The planned sixth core group meeting that had been planned for 4 days after Charlie’s disclosure became    an emergency CSE strategy meeting. This meeting was well attended with all relevant multi-agency partners in attendance. The findings from the medical examination undertaken the day after Charlie’s disclosure were shared at this meeting. Charlie had sustained internal injuries consistent with having been raped. Information was shared at this meeting that their adult half-sister had left Sam and Charlie in the care of their mother and had therefore breached the written agreement. Following parental refusal to give consent for Sam and Charlie to be accommodated under section 20 of the 1989 Children Act, the police secured police protection orders and the children were placed in foster care.   118. There was feedback at the practitioner event about joint training being provided to police and Children’s Services about applications for emergency and police protection orders with emergency orders being the preferred process. The police secured police protection orders in this instance due to urgent need to safeguard the children after normal working hours. Interim Care Orders were granted at a court hearing one week after Charlie’s disclosure. Five days later, a conference (child protection and looked after child) was held. It was noted the child protection plan had not progressed and that concerns had escalated. The outcome of this conference was for the child protection plan to cease given Sam and Charlie were now subject to interim care orders. In the middle of August 2016, during the care proceedings, the directed psychology assessment report in respect of the father of Sam and Charlie was made available. This report stated that he was learning disabled, lacked capacity for the care proceedings and that a specialist parenting assessment was required. A subsequent care management order stipulated that a PAMS33 assessment of parents was required.   119. At the end of August 2016, a Local Authority Solicitor wrote to the Slovakian Embassy asking whether there had been any previous child protection concerns, Children’s Services involvement or court proceedings.   120. The incidents disclosed by Charlie throughout the investigations were also subject to discussions within the MACSE process in place at that time. The alleged rape in May 2016 was discussed. The outcome decision was the incident was not CSE but rape/violent sexual assault. Safeguarding measures were in place through the child protection plan and the case was closed. There were then further discussions at MACSE meetings following the rape in July up to October 2016, at which point the case was closed as Charlie had become a looked after child. Information did not identify that MACSE discussions influenced the child protection planning in this case. The JTAI Inspection identified that the multiplicity of meetings in place for the management of CSE cases had resulted in duplication and delays in progressing required work. Changes to practice have already been implemented in accordance with the JTAI action plan. The previous monthly MACSE meetings have now been replaced by daily multi-agency meetings at which all cases involving child exploitation are discussed and actions agreed through a strategy discussion and monthly multi-agency child exploitation meetings (hereafter known as MACE). Additionally, the pathway for concerns of child exploitation was launched towards the end of 2016, to provide clarity on the referral and management of such across for all agencies.     121. At the beginning of October 2016, a visit was undertaken by the key social worker from the Care Planning and Court Team. Sam and Charlie were spoken to alone. Charlie alleged she had been hit by a member of the extended family who was currently being assessed as a potential carer. Charlie stated that she did not want to live with this family member and did not wish to press charges. This disclosure was explored further and Sam denied that it had happened. At the end of October 2016, at a strategy discussion between the police and a Children’s Services Team Leader it was agreed that the matter                                                            33 Parenting Assessment Manual (PAM’s) was designed originally to assess parents who had a learning difficulty and has evolved into an assessment to assess the parents’ capacity to parent.  The PAM’s assessment is recognised in a court of law.  practitioners must be trained and accredited to undertake a PAMs assessment.     Page 35 of 57  could not be progressed further. Towards the end of the timeline reviewed there are reports of challenges for both girls within school in relation to name calling, sexual comments mainly for Charlie, and harassment. This was responded to positively with effective information sharing and an action agreed to arrange a risk management plan.    122. In conclusion, the multi-agency child protection work in this case was very challenging given the language issues, the lack of understanding of cultural norms and learning difficulties which should have been clear for Charlie and her father. There was consistency in the practitioners involved within the core group meetings once the direct work commenced.  Whilst information was sought about any previous concerns during the court proceedings, in general practitioners were required to rely on the information gained since the family arrived in the United Kingdom. Prior to the initial concerns being raised about Charlie, the family had been known only to universal services and the information known was very limited. The practitioner event highlighted that practitioners were very concerned about the children and strived to meet their needs and keep them safe.   123. However, there were several key issues which impacted negatively on the multi-agency work undertaken. Firstly, the assessment of parent’s capacity to safeguard their children as agreed at the initial case conference was not undertaken and the parent’s stated willingness to comply with stipulated requirements was accepted as compliance despite there being evidence of non-compliance including instances of breaching the written agreements. Research findings indicate that there can be an over-reliance on parental compliance with written agreements to keep children safe rather than sound safeguarding practice34. Secondly, there were two instances of significant changes being made to the child protection plan by children’s services outside of the core group meetings. Whilst there were attempts made to challenge Children’s Services at various points by the police, school and the NSPCC, no agency used the formal escalation process when their challenge was not effective. Thirdly, key information required to inform risk assessment and child protection planning processes was not consistently shared in a timely manner. This was particularly the case for information obtained by the police as incidents occurred. Further, the initial delay in the instigation of multi-agency support to the family including direct work resulted in the belated identification and sharing of information relevant to the risk assessment process.       Learning Point: Multi-agency child protection work is inherently complex and it is understood that Children’s Services is the lead agency. Partner agencies will at times have a greater understanding of key issues including risk factors particularly when undertaking direct work with families. They require both an understanding of how and the confidence to escalate any concerns about the progress of a case at any point from making a referral onwards.                124. Offender Disruption Activity. The evidence highlighted several young people may have been in the same environment when the first incident against Charlie occurred. Her sister Sam was present. The police information highlights “Charlie asked the male to stop as she didn’t like it but he carried on and then some of the girls came in the room and he stopped.” In November 2015, education were informed by the social worker that Charlie had “named 6 other young girls who had been taken to the property by the male.” Therefore, group based CSE has been a consideration in this case although the review has not been informed of any further allegations or disclosures of sexual assault by other young people linked to this event.                                                             34 Ward H., Brown R., Hyde-Dryden G., (2014) Assessing Parental Capacity to Change When Children Are on The Edge of Care: An Overview of Current Research Evidence, Dfe    Page 36 of 57  125.  This type of abuse has over recent years attracted increasing media, public, policy and practitioner attention. It can be referred to as on street grooming, localised grooming and complex CSE.  Children can be sexually exploited by various groups who are neither related to the child or hold a position of trust. The abuse can take place in a wide variety of locations including vehicles, private houses and parks/beauty spots. Groups are defined as two or more offenders working together. The detection of children who are abused can be delayed and disclosure can be challenging especially for minority ethnic and vulnerable children. Victims can also be used in the recruitment and grooming process. Group based CSE is a pattern of abuse which includes distinct offences such as rape and sexual activity with a child. Systems should be adapted to improve the prevention, detection, investigation and prosecution of group based child sex offending.35  It requires multi-agency collaboration from a range of services to work with this issue and locally the Police Force has intelligence analysts working to identify this pattern of offending.    Learning Point: Group based CSE is a pattern of abuse which includes distinct offences such as rape and sexual activity with a child. Systems should be continually adapted to improve the prevention, detection, investigation and prosecution of group based child sex offending.   It requires multi-agency collaboration from a range of services to work with this issue and as well as the Police Force   126. The disruption of such activity requires ongoing vigilance and investigation across the population and is not the sole responsibility of one agency or professional group. Professional assumptions can be made that the child is a willing participant but should always be the victim, because of the power imbalance and potential or perceived threats.    Table 1.  Offender  Profile  (ages as of Jan 2016) Offence  Outcome of investigation on completion of the SCR 1 Male (21yrs) Sexual Touching NFA 2 Male (16 yrs.) Sexual Touching / witness intimidation Currently on bail. File with CPS 3 Male (22 yrs. 8 months) Incite a child to engage in sexual activity Investigation ongoing/ Arrested Apr 16 4 Male (11 years) Rape NFA 5 Male (16 years 7 months) Rape  NFA 6 Male (16 years) Rape Charge of rape authorised but male currently wanted on police national computer   127. Whilst there have been several criminal investigations ongoing there have been no convictions secured against the alleged offenders (see table 1). Several arrests have been levied against alleged offenders in respect of offences against Charlie and Sam. There have been significant challenges in respect to the identification of offenders due to language barriers, the number of aliases used by the alleged offenders and the vulnerability of the victims. There was advice that an intermediary should have been used to support communications with an alleged offender but this did not happen. The police learning summaries highlighted major concerns including time delays in allocating to an investigator, arranging a forensic medical, the coordination of strategy meetings, following advice and gaining information from key professionals. The police learning summary makes several positive learning points                                                            35 Brayley H., Cockbain E., JDiBrief-Crime Group Based Child Sexual Exploitation Summary 1. UCL Jill Dando Institute Downloaded 30.4.17 ucl.ac.uk    Page 37 of 57  and recommendations to improve practice. (see appendix 2) Disruption techniques are a central component for responding to CSE s should develop a disruption plan and establish relationships with other agencies to deliver it 36  Learning Point: Disruption techniques are a central component for responding to CSE. s or its partner agencies should review or develop a disruption plan and establish relationships with other agencies to deliver it.    4.4 CHARLIE: A CONCLUSION.  128. The review has provided conclusions throughout the narrative and analysis. It has considered in depth four significant events, during which Charlie was subject to a sexual assault and two alleged rapes in a 7-month period. The alleged rapes occurred whilst Charlie was subject to a child protection plan due to concerns about CSE.  A key consideration is whether the incidents could have been predicted and therefore prevented. The review has sought to learn, through the critical appraisal of the multi-agency information and through practitioner conversation, that had the information been systematically compiled and analysed could a prediction of harm been identified and the risk more effectively managed.  129. In October 2015, the first event it was understood that Charlie had a much older boyfriend which was a significant indicator of risk. She was a very vulnerable girl, with significant learning difficulties, from a disadvantaged minority ethnic group who was clearly disclosing she had a much older boyfriend. This should have prompted a joint response from the Local Authority and the police to at least identify the alleged boyfriend, plan disruption activity and undertake some preventative CSE work with Charlie. The response to leave this action for Education to manage with Charlie’s parents was not sufficient as this was not simply about managing a “boyfriend situation”. It should have been a joint response to prevent the sexual abuse of a child. It is of concern that the view of the Contact Centre would remain the same today although the CSE systems have developed significantly and this incident would be referred directly now into the multi-agency daily strategy discussion process.   130. In November 2015, there was a clear disclosure from Charlie that she had been subjected to a sexual assault by the same “boyfriend”. There is a lack of clarity as to when exactly this incident occurred with some professionals believing it was in the previous summer months.  The disclosure alone was significant and a very clear indicator that her parents were unable to keep her safe, therefore the previous strategy was unsuccessful. Universal services had an opportunity to undertake some early intervention work with Charlie to keep her safe and she engaged in one positive session. However, she did not access the drop-in session. There was a significant delay in the allocation of the investigation by the Constabulary, leading to a 6-week delay in the commencement of the joint investigation with Children’s Social Care. Children’s Social Care opened the case but there was a lack of clarity whether the case was being worked under the umbrella of child in need and a significant deficit in multi-agency planning to prevent further abuse and support the parents through an accurate assessment of their parenting capacity. There was in this period limited evidence of direct work with Charlie to try to keep her safe and a significant onus of responsibility placed on her parents to keep her safe without any effective assessment of their parenting capacity. The focus of intervention was directive work with the parents and the development of contracts which were meaningless given their language barriers, learning difficulties and literacy skills                                                              36 Paskell C., (2012) Tackling Child Sexual Exploitation, Helping Local Authorities to Develop Effective Responses Barnardo’s    Page 38 of 57  131. It is of concern that at this point the incident wasn’t perceived as a significant child protection risk, Charlie was clearly at risk of further sexual abuse and her parents whether by omission or commission struggled to protect her. The framework for managing cases under Section 17 should have been sufficient to encourage a robust assessment of needs leading to multi-agency planning and intervention to support and manage the risk for Charlie however this was not evident. It was clear from conversations that this case was not seen to be high risk, and there were cases that were much more concerning. There was no evidence during conversations that capacity was an issue although at the time the JTAI noted the social work caseloads to be very high. There is more confidence now that should a case present with similar features it would be managed more effectively through the improvements made to the CSE systems.  132. In May 2016, Charlie disclosed she had been raped on her way home from school by a different offender, another young person from her school. Whilst there is some conflict between multi-agency partners regarding the decision to allow her to walk home on that day, there was no prior information to indicate this offender was a risk to Charlie. There are always challenges when balancing the rights of a child to have some independence when the child requests or enforcing a plan on a child to be transported. There are however that the focus of intervention was directing the parents to keep the child safe, without a robust assessment of their capacity to undertake this task.   133. In July 2016, Charlie was raped during a missing from home event. The child protection plan was in place but there was a significant failure in sharing information regarding an earlier un-reported missing event. This led to a delay in the escalation of the case into legal proceedings and subsequent care orders. Charlie had to be removed after the incident.   134. There was an escalating picture of concern over the months however very limited direct work undertaken with Charlie to keep her safe, early help was not sufficiently evidence, the interventions with her parents was probably less robust because of the limitations of their capacity to keep her safe, the offender disruption work was ineffective due to the delays in the investigation process.      Page 39 of 57  SECTION 5: SAM THE SERIOUS CASE REVIEW   5.1 A PORTRAIT OF SAM.  135. Sam had lived in the United Kingdom for around 4 years prior to any safeguarding concerns being raised. She was born in Slovakia and her cultural heritage was Roma. Sam was the second youngest in a family of four children, having two adult half siblings and a sister 12 months younger than herself -Charlie. Practitioners involved in the provision of care to Sam described her as being thoughtful, affectionate, caring and loving. She could initially present as a quiet girl but had a good sense of humour and was affectionate. She was very close to her mother and her two elder half-siblings. Sam was protective of Charlie. She was perceived to be the leader of the two sisters, at times exhibiting some control over and manipulation of Charlie. Practitioners found her to be more guarded when sharing information, disclosing information only when she wanted a practitioner to know something. There were no known health concerns for Sam, she was seen infrequently for minor ailments by the general practitioner and had received all required immunisations.  136. Linguistically, Sam initially had difficulty speaking English but eventually became fluent. She could also speak three other languages. Her fluency in English resulted in her being used on occasions to interpret for family members. Physically, she was described as well presented with shiny hair, brown eyes and a love of glitzy jewelry. Sam was described as looking older than her years due to her dress and use of makeup. There were some additional concerns about Sam presenting as unkempt in school prior to her being placed in foster care.    137. When Sam commenced secondary education, she was a model pupil who appeared to enjoy school and had a diverse friendship group. When Charlie commenced at the same school 12 months later, Sam’s behaviour changed. She became disruptive but much less so than her sister. The school provided Sam with additional support through sessions with the counselling psychologist, EAL invention and a weekly outdoor intervention aimed at building resilience and self-esteem.   138. Academically, Sam had difficulties. Her reading age was assessed in September 2016 and was 5 years and 6 months. At this point in time, she had been attending secondary school for one year and had been in Local Authority care for around two months. Further assessment 5 months later identified her reading age was improving through the provision of accelerated reading and 1:1 multi-sensory teaching support.     139. Following a move to a new school, updated information indicates Sam’s reading age had improved to 7 years 1 month towards the end of Year 12. However, she faces significant challenges academically and requires additional support. Despite these challenges, Sam has settled well in her new school and is reported to be a lovely pupil who never complains about finding school work difficult and always tries her best.      140. Sam was placed in the same foster placement as her sister where she settled well and is enjoying the supervised contact with her mother. The contact arrangements include activities which enable Sam to retain her understanding of her cultural heritage. Sam’s presentation has become more in keeping with that of her peers since being accommodated.           Page 40 of 57   5.2 SAM: A BRIEF CASE SYNOPSIS.    141. Information in respect of Sam was limited and the risk of CSE she faced less well understood by practitioners who noted she was more guarded in sharing information than her sister, Charlie. Sam was only known to universal services prior to the escalation of concerns initially raised in relation to Charlie. The first concern raised about Sam was around three weeks prior to the initial case conference in February 2016. The school’s safeguarding lead advised the key social worker that inappropriate videos had been seen on Sam’s mobile phone.      142. The following day, education staff observed significant bruising to Sam’s legs for which differing explanations were given by the children and their parents. The school’s safeguarding lead made a CSE referral in respect of the bruising. A forensic medical examination was undertaken 2 days after the bruising had been identified. At this point, Sam had not made any disclosures and provided an accidental explanation for the bruises which was accepted by the examining doctor.  143. At the initial case conference, Sam was made subject to a child protection plan under the category of sexual harm due to the risk of CSE. Five days later, Sam disclosed in school that the bruises had been caused by an older man hitting her with a belt when she refused to do what he wanted. There were no further identified CSE incidents in respect of Sam. However, the ongoing concerns around the risk of CSE for both children, her vulnerability and her parent’s capacity to protect her from harm resulted in Sam being made subject to care proceedings at the same time as Charlie.    144. During the time line under review, Sam was used as an interpreter by her parents and by agencies on several occasions. Agencies also questioned Sam to try to clarify issues, for example, different disclosures by Charlie. There was evidence to suggest that her parents expected Sam to protect Charlie. Practitioners expressed a view that her parent’s language difficulties enabled Sam to manipulate her parents at times.      Page 41 of 57  SECTION 6: SAM: A CHRONOLOGICAL NARRATIVE & ANALYSIS OF SPECIFC EVENTS & THEMES.  145. This section will describe and analyse specific events and issues and the emerging themes from practice during the timeline of the review linking to the research question and terms of reference. The learning points, good practice and recommendations will be identified throughout the text.   6.1 SAM: THE MANAGEMENT OF INITIAL CONCERNS.  Event /Issue Links to terms of reference  Sam: Inappropriate videos found on mobile phone 1 Sam: Bruising to back of legs 1,2,4,5    146. Ahead of any concerns being raised specifically about Sam, a social worker had been allocated to work with the family due to the concerns raised for Charlie’s safety. At the beginning of January 2016, the key social worker undertook a single assessment of Sam. The outcome was for the case to be managed at the section 17, child in need threshold until the CSE risk had been investigated and until Charlie was receiving support services. There were no known concerns for Sam at that point. Sam herself advised the key social worker that she was not involved in her sister’s behaviours so didn’t know why she was being seen.  Whilst no concerns had been raised for Sam at that time she had significant vulnerabilities-only 12 years old, from a minority ethnic group known to be highly disadvantaged, living with parents who spoke and understood very little English, identified as requiring additional support services within school and with a sister only one year younger who had disclosed a sexual assault.  147. Sam: Inappropriate Videos Found on Mobile Phone. Towards the end of January 2016, the school’s safeguarding lead contacted the key social worker advising that inappropriate videos had been seen on Sam’s mobile phone. The safeguarding lead was advised to bring the phone to the next CIN Meeting and to hand it to the police. Feedback from the practitioners was this related to Sam having taken inappropriate pictures of Charlie on her mobile phone in the family home. After the phone had been seized the images were viewed by the police. The risk assessment outcome at the time was that this had been an isolated incident which did not warrant further action. It was understood that Sam had been coerced into taking the pictures by a third person on the phone and the incident was not perceived to pose an ongoing risk.  148. Sam: Bruising to the Back of Legs. The day after the inappropriate videos had been reported, the school’s safeguarding lead raised further concern for Sam and submitted a CSE referral to Children’s Services in accordance with local guidance at that time. Significant bruising had been observed on the back of Sam’s legs for which different explanations had been given by parents and the two sisters. Sam herself initially stated the bruising had resulted from Charlie pushing her down the stairs. Education staff were clearly concerned about the risk of CSE to Sam and followed relevant guidance.   Learning Point: The recently implemented CSE risk assessment tool was not embedded into practice at the time of this incident. This assessment tool enables a robust assessment of the level of risk of CSE. The current CSE agency referral process is through completion of a multi-agency referral form (hereafter known as MARF) which is forwarded to the Contact Centre where a CSE assessment tool is completed.  For cases, already open to Children’s Services, the key social worker completes the CSE assessment form and forwards it to the Contact Centre. Completed CSE forms and MARFs are forwarded by the Contact Centre to the MASH for prompt assessment within the daily strategy discussion processes. If the concerns are substantiated, the multi-agency CSE Assessment tool is completed, facilitating a thorough multi-agency understanding of both the CSE concern raised and the level of risk at an early   Page 42 of 57  point in a case. This process facilitates robust care planning.  Identified CSE cases are also subject to discussion and regular review at the monthly MACE meetings    This is expected practice.  149. Two days after this referral, Sam was seen for a forensic medical examination. The professionals accompanying her were a social worker (not the key social worker) and a Detective Constable from the CSE Team. Sam was examined primarily because Charlie had made an allegation of sexual abuse and there were concerns from agencies that both sisters were being sexually exploited. Sam herself had not made any allegations at this point. The outcome of the examination was neutral, which neither supported nor refuted sexual abuse/assault. Sam was screened for sexually transmitted infections and all the tests proved negative.    150. A review of the records relating to the examination identified the bruising to Sam’s legs had been clearly described and fully discussed. There was one large bruise and several smaller bruises. Sam gave a history of falling and hitting her leg on a rail and provided a full history to the bruises which was accepted as being consistent with the history presented. Around three weeks later and 5 days after the children had become subject to a child protection plan Sam made a disclosure in school.  She disclosed the bruises were because an adult male had attempted to kiss her and had beaten her with a belt when she refused. Charlie had been present at the time. Charlie disclosed they had been threatened by the men resulting in them being frightened to tell the truth. The school safeguarding lead shared this information at the first core group meeting held three days later.   Learning Point: The school safeguarding lead was proactive in ensuring these significant disclosures were shared with multi-agency partners at the first core group meeting. However, immediate sharing of this information with the police would have supported the criminal investigation. Sharing information promptly with the key social worker and the police would have provided more opportunity for a joint investigation and planning of the core group meeting.  This could have enhanced the efficacy of the first core group meeting and strengthened the outcome of the child protection plan.     151. Following the disclosure, the police commenced an investigation with the incident being deemed as “inciting a child to engage in sexual activity”. At the beginning of March 2016, both Sam and Charlie provided achieving best evidence interviews in relation to the incidents. The interview of Sam provided clarity on the incident resulting in the bruising. The alleged perpetrator was identified as a 33-year-old adult male who had made attempts to kiss Sam and then beaten her with a belt when she refused. The investigation continued. In July 2016 an emergency strategy meeting included a police update that the alleged perpetrator had been identified and was to be arrested. Police information suggested Sam had been involved in a relationship with another adult male. At the point of writing this report, the alleged perpetrator has not been charged in respect of this incident. The police learning summary indicates that Sam provided an extensive interview as a witness to the offences detailed against Charlie between June and November 2015.   152. It notes that Sam clearly provided information describing a cultural acceptance within their communities of the incidents that had occurred and that this significant information was not shared with multi-agency partners.  Since being removed into local authority care, Sam has provided further information about cultural norms including Roma gypsy marriages of young girls aged 11-12 years being “married” to older males with the parents of girls receiving a sum of money for this.     153. Practitioners were clear they did not understand the cultural background of the family, including cultural norms as shared by Sam.  Practitioners felt that an increased cultural competence would have facilitated more effective multi-agency working with the family and expressed a view that further support   Page 43 of 57  in relation to this complex area of practice is required. It was noted in the Children’s Services learning summary that an  task & finish group is currently considering the cultural competence of the workforce in safeguarding practice and actions required to enable practitioners to be responsive to the needs of specific communities. The use of language interpretation services is included within the remit of the task and finish group.   Learning Point: Practitioners working with the family were not aware of significant cultural norms that would have impacted on their understanding of risk when working with Sam, Charlie and their family. These norms potentially made it more difficult for the children to disclose. Understanding cultural norms would have informed the CSE risk assessment processes.      6.2 SAM: THE MANAGEMENT OF RISK THROUGH CHILD PROTECTION PLANNING.  Event /Issue Links to terms of reference  Sam: The Section 47 Investigation and Initial Case Conference  1, 2, ,5 Sam: Initial Core Group Meetings and Child Protection Planning  1,2,5 Sam: Child Protection Planning in Response to First Allegation of Rape by Charlie 1,2,3,4 Sam: Child Protection Planning Following MFH Incident for Charlie  1,2,3,4 Sam: Escalation of Risk and The Initiation of Care Proceedings 1,2,3,4,5  154. Section 4.3 of this report discusses the management of risk through child protection planning in respect of both Sam and Charlie and has therefore not been duplicated. The following sections provide further detail and analysis of the information relevant to Sam including concerns raised about her during this period. Reference is made to information about Charlie when appropriate.         155. Sam: The Section 47 Investigation and Initial Case Conference.  At the initial case conference in February 2016, the school was not represented but provided a report which highlighted concerns in respect of Sam including an 80% attendance. When Sam commenced at the secondary school there had been no concerns raised, she was reported as a “model pupil”. However, there had been a recent behavioural deterioration including truanting, ignoring instructions and some use of graffiti. There had been one recent incident of Sam not waiting for a Family Support Worker to escort her home. When Sam was located two hours later, she said she had been in detention, but this was found to be untrue.    156. Sam: Initial Core Group Meetings and Child Protection Planning.  At the point of the first core group meeting at the end of February, Sam was walking to and from school escorted by a family support worker. At the second core group meeting in the middle of March, it was agreed that Sam would commence walking to and from school alone after the Easter holidays with this being monitored. Information was then shared at the third core group meeting at the end of April that Sam had seen the alleged perpetrator whilst on a bus with her mother and auntie which had unsettled her. A decision was made that her parents would collect her from school each day.          Page 44 of 57  157. Sam: Child Protection Planning in Response to the First Allegation of Rape by Charlie.  At the beginning of May 2016, Charlie alleged she had been raped by a boy who attended the same school. The incident had occurred when Charlie and Sam were walking home through a park. This was the first day that Charlie had been allowed to make her own way home from school. Sam later disclosed attempting unsuccessfully to intervene. She informed the NSPCC CSP that a boy had grabbed Charlie and pulled her away, Sam had tried unsuccessfully to pull her back and she decided to run home to tell her mother. However, she became fearful of what her mother would say and instead went back to look for Charlie. When Sam found Charlie, and asked her if she was ok, her response was she didn’t want to talk about it and wanted to go home. The first review case conference was the next multi-agency meeting, held six days after Charlie’s rape disclosure.     158. Information shared about Sam included her school attendance was around 84% and there were concerns about her punctuality. There were no current behavioural concerns and she was making progress academically with additional support. She had initially stated that she wasn’t aware that her sister had made the rape allegation but later disclosed being too frightened to report it. Sam disclosed she was fearful of the alleged perpetrators of the abuse. However, she wanted to walk to and from school on her own not feeling at risk when alone. The outcome of the conference was that parents had done everything that had been asked of them, could understand the concerns and were able to protect their children. The child protection plan would remain in place due to the recent allegation of rape by Charlie which was community based.  159. Practitioner conversations highlighted the NSPCC CSP challenged the decision as to why the transport arrangements to and from school had been changed, without the agreement of the core group. The key social worker advised this had been an independent social work decision, with a view to progressing the child protection plan.    160. The fourth core group meeting was held at the end of May 2016. At this meeting, the NSPCC CSP questioned why Sam had been able to see an alleged perpetrator given the safety plan and raised the fact that the work undertaken with Sam would not yet have had a positive impact. It was this practitioner’s opinion that Sam was being allowed excessive independence. The key social worker agreed to advise mother to increase her supervision of Sam until the NSPCC CSP had undertaken further work with her.   161. Sam: Child Protection Planning Following MFH Incident for Charlie.  Charlie was found alone in a park at 2.40am one night in the middle of June 2016. The police learning summary notes that Sam conducted the conversation with the attending police officers on behalf of her parents after Charlie was returned home.    162. Sam: Escalation of Risk and The Initiation of Care Proceedings. At the beginning of July 2016, the SARS Practitioner working with Charlie notified the key social worker that she had disclosed being out with Sam on the previous Saturday night and that Sam had been drinking vodka. Sam had become very intoxicated and both girls had walked home in the dark. The following day, the NSPCC CSP for Sam sent a detailed email to the key social worker raising concerns about both children and requesting that these be raised at the forthcoming core group meeting. The key social worker subsequently contacted the NSPCC CSP to provide an update.       163. Two days after this home visit, Charlie escaped from the family home through a bedroom window and was reported missing by Sam who advised that she had reported Charlie missing because their parents didn’t speak English. The police learning summary notes that Sam conducted the conversation with the police officers who attended the home.        Page 45 of 57  164. The day after this MFH incident, Charlie disclosed in school that she had been raped the previous night.  In response to this incident, agreed actions included both children residing with their adult half-sister with a written agreement in place. Four days later, because of this agreement being breached, both children were placed in the care of the Local Authority through the securing of PPOs.           165. At the beginning of October 2016, a visit was undertaken by the key social worker from the care planning and court team. Sam and Charlie were spoken to alone. Charlie alleged she had been hit by a member of the extended family who was currently being assessed as a potential carer. This disclosure was explored further and Sam denied that it had happened. Towards the end of the timeline reviewed there were reports of challenges for both Sam and Charlie within school in relation to name calling, sexual comments mainly for Charlie, and harassment.    166. In conclusion, review of the information about Sam during this period has identified that- whilst no further specific CSE concerns were raised for her- evidence was emerging of the challenges she faced. These included attempting to protect Charlie by preventing her from going into the park, reporting Charlie as being missing and then communicating with attending police officers on her parent’s behalf, disclosing being fearful of alleged perpetrators and of parental responses to disclosures and there was also one reported incident of Sam drinking alcohol and walking home in the dark with Charlie. There were two occasions on which Sam disclosed seeing alleged perpetrators.               6.3 SAM: A PERSPECTIVE ON DIRECT WORK.   Event /Issue Links to terms of reference  NSPCC CSE service provision  5 Sam: Referral and allocation of her case  1,2 Sam: Assessment process 1,2,4 Sam: Interventions provided  1,2,4  167. NSPCC CSE Service Provision.  Single agency learning summaries had been requested for this SCR process. The NSPCC undertook a detailed internal management review (IMR) which was submitted instead of learning summaries. The conclusion of the IMR indicates the practice issues identified within the IMR, preceded the October 2016 revision of practice standards and the revised programme of self-assessment and practice improvements. These activities have addressed the lessons learnt.    168. The NSPCC provides the Protect and Respect service within the Local Authority. This service is provided to children who have been or are at risk of being sexually exploited. There are 3 levels of service available: prevention aimed at providing “keep safe” education, risk reduction aimed at children for whom CSE risk indicators have been identified and recovery aimed at children who have been safeguarded following being sexually exploited and require interventions to assist them in understanding what has happened. The service provides a 6-week assessment followed by tailored support, which can be offered for a period of up to 6 months.   Good Practice: The NSPCC provides a range of services to support children living in the Local Authority area who are at low or medium risk of CSE and preventative services. Recent service developments have included the provision of further training, the allocation of practitioners with relevant experience to the Protect and Respect service and the recent recruitment of an additional 3 CSPs specifically to undertake sexual exploitation work.                        169. The NSPCC service was offered to children at high risk of CSE prior to the implementation of the Pathway for Concerns of Child Exploitation. Since the implementation of this pathway towards the end   Page 46 of 57  of 2016, children at high risk of CSE are referred to the Protect Team within Targeted Youth Services for CSE focused intervention. The NSPCC Protect and Respect service is now offered to children at low or medium risk of CSE. These 2 services work collaboratively and are both represented at the daily multi-agency strategy discussions and the MACE meetings.   170. Case discussions at MACE meetings include consideration as to whether either the NSPCC or the Protect Team interventions would be beneficial. The single pathway for referral into these services is through discussion at MACE.   Learning Point: The MACE is dependent on robust MARF referrals and completed CSE and CSE Assessment tools to ensure that correct actions are agreed, including the identification of vulnerable children who would benefit from either NSPCC Protect and Respect service or Protect Team interventions. Therefore, it is vital that multi-agency practitioners:  fully understand their responsibilities in relation to CSE in light of the revised practice guidance including the Pathway for Concerns of Child Exploitation and   are competent in the identification, assessment and referral on of such cases.                         171. Sam: Referral and Allocation of Case. An NSPCC Team Manager attended the MACSE meeting at the beginning of February 2016, during which Charlie was discussed. An action from that meeting was for the NSPCC to contact the key social worker to discuss whether a service was required for both Charlie and Sam. Two days later, there was a telephone discussion between the key social worker and a duty NSPCC CSP about the identified concerns for Charlie and Sam. At that point, Sam had given verbal consent for a referral to be made to the Protect and Respect service. The formal referral from the key social worker was received 6 days later and Sam’s case opened pending allocation.   172. The time between the referral being received from Children’s Services and the allocation of Sam’s case was 27 days. During this time information was gathered and collated, including information gained through NSPCC attendance at the initial case conference and first core group meeting.  At the first core group meeting at the end of February the key social worker advised that it was unlikely that Sam or Charlie would engage with a male worker and it was agreed that individual female workers would be allocated. An NSPCC CSP was allocated to undertake the direct work with Sam two weeks later.   173. A CSP present at the practitioner event highlighted the use of individual practitioners made it very difficult to understand the whole picture in respect of the concerns about the children and their family. However, joint supervision had been received which had proved positive. Different NSPCC practitioners attended each of the MACSE meeting, the initial case conference and the first core group meeting. The allocated practitioners had not attended any of these meetings. An allocation supervision session was undertaken jointly with the allocated practitioners. This was facilitated by the team manager who had attended the MACSE meeting and included the NSPCC CSP who attended the first core group meeting. Additionally, one of the allocated practitioners had undertaken the telephone discussion with the key social worker. All available information was discussed and actions agreed to arrange an initial meeting with Sam and Charlie.          174. The NSPCC IMR highlights that “whilst different Practitioners became aware of different information between the case being referred and allocated…there was no management oversight during this time to develop a service perspective on the level of vulnerability and risk and the quality and efficacy of the child protection plan”.       175. Sam: Assessment Process. In the middle of March 2016, the allocated NSPCC CSP had a telephone discussion with a police officer in the CSE Team, to discuss whether it was possible to commence an assessment of Sam,   Page 47 of 57  given the ongoing police investigations. It was agreed this work could commence after Sam attended an identity parade.  At the beginning of April 2016, an initial home visit was undertaken by the allocated practitioners along with the interpreter employed by the school.  Both Sam and Charlie were seen along with their mother who spoke on behalf of father, as he wasn’t present. It was agreed that Sam would be seen weekly at school with the school interpreter initially. The work undertaken would include the planned assessment and interventions on keeping safe, grooming and internet safety. It was noted in the NSPCC records that an offer to undertake direct work with parents to support them in understanding the risks of CSE was also made at this visit. However, mother declined this saying they had been given a family support worker to support them in keeping the children safe. This resulted in direct work with parents being undertaken by a different agency. .  Learning Point: It could be hypothesised that the allocation of a separate practitioner to undertake the required direct work with parents might enable the children to more freely disclose issues to their allocated NSPCC CSPs. As individual NSPCC CSPs had been allocated to each child and a Children’s Services family support worker to work with parents, there were 3 Practitioners from 2 agencies undertaking direct work with family members. However, if the same Practitioner had undertaken the work with parents and with the children, then an improved understanding of risk could have been achieved through the collation and analysis of information within one service.                 176. Following this visit, the NSPCC CSP discussed the case in supervision and highlighted the interpreter was a member of the local community and this may impact on the girls being able to be open and honest with the workers. It was agreed that the NSPCC would seek to identify an alternative independent interpreter prior to the direct work commencing.  At the end of April 2016, the NSPCC CSP attended school to see Sam to explain why the direct work was delayed. Sam was off sick and the practitioner  visited the home to see her. Sam’s parents initially appeared unhappy for the practitioner to see her, indicating at the door that she was too unwell to be seen. Father mimed Sam was vomiting and had a high temperature. Sam was then seen at the door and the NSPCC CSP informed her of the rationale for the delay and another appointment would be arranged when she was feeling better.   Good Practice: The NSPCC CSP was very proactive in ensuring direct contact was made with Sam to check on her welfare and to update her.  177. The NSPCC CSP subsequently met with Sam in school, on 3 occasions during May 2016. At the first of these meetings, the need for an interpreter was discussed and agreement reached that the sessions would continue without an interpreter unless difficulties arose.   Good Practice: The NSPCC process in relation to securing the use of interpreters has now changed. The previous complicated internal procurement processes were identified as causing delays in undertaking direct work and the NSPCC is now able to secure this expertise from a professional agency recommended by the Local Authority.    178. At the second of these 3 sessions, Sam initially said nothing had happened during that week but then disclosed the alleged rape of Charlie on the way home from school, the preceding Wednesday. Sam informed the NSPCC CSP that her sister had disclosed this to her teacher at school 2 days later and that the key social worker had been to visit them that evening. Sam said she had overheard the discussion and she had been very angry. Sam understood what rape was, saying that it was forcing someone to have sex and she was aware that the alleged perpetrator attended her school. Sam was disappointed that Charlie didn’t disclose this to her on the day. The NSPCC CSP requested clarification as to why they had left school to go home alone. Sam said that her mother struggled to walk that far due to health problems and disclosed what had happened.      Page 48 of 57   179. After this session, the NSPCC CSP followed internal guidance in respect of receiving a disclosure of significant harm and sought advice and supervision. Actions were agreed including for the practitioner allocated to Charlie to clarify why agreed transport arrangements to and from school had been changed and for both allocated practitioners to develop a report for the review case conference. The report should include raising concerns about the parental capacity to protect the children and request clarification as to the assessment and of any work undertaken with the parents to build their capacity. It was subsequently clarified at the review case conference that the key social worker had decided to allow Sam and Charlie to make their own way to and from school.      180. During the third session Sam disclosed sometimes being upset in school because boys were calling her sister a ‘slag’ and this upset her and made her cry. She disclosed wanting to hurt them but said she wouldn’t do this. She also disclosed not being able to talk to her parents about her feelings or things that had happened. The NSPCC CSP clarified that the involved boys had been spoken to by the police. The documented assessment at that point was that Sam was primarily at risk regarding harassment, bullying and possible physical harm but there was no indication she was at risk sexually. Following this session, the NSPCC CSP contacted the key social worker by email to raise the concerns highlighted by her discussions with Sam and subsequently raised additional concerns at the fifth core group meeting 1 week later.   181. At the beginning of June 2016, the NSPCC CSP completed an Assessment Report. The assessment scores concluded that the risk of sexual exploitation for Sam was medium to low. However, the narrative identified the information which contributed to the scoring process was based on Sam’s self-reporting and there was evidence that Sam had been known to minimise events. As such it was possible the level of risk could be considerably higher. A decision was made to progress from assessment to intervention.   Good Practice: the NSPCC CSP undertook a thorough assessment of Sam and although the assessment scores indicated the risk was medium to low, exercised professional judgement in determining that it could be considerably higher given the evidence of Sam minimising events. Therefore, intervention was required.        182. Sam: Interventions. Between the beginning of June and the end of September 2016, the NSPCC CSP provided interventions to Sam at 7 sessions. A further session in the middle of June did not proceed due to Sam not being in school that day. Five of these sessions were undertaken after Sam had been placed in foster care. Interventions provided within these sessions included CSE prevention, self-esteem, map of the city including risky places and risky people, keep safe and understanding relationships, what is abuse and what is the law and consent. The practitioner recorded no new safeguarding concerns at 4 of these sessions and significant information was shared at 3 sessions.  183. At the session at the beginning of June 2016, Sam disclosed being fearful of repeated physical abuse if she was to meet the alleged perpetrator again. She disclosed that Charlie and herself had met the perpetrator of the alleged sexual assault against Charlie, on the street one day and he had asked if Charlie liked him. Sam said Charlie initially said ‘no’ but her initial contact with this alleged perpetrator had resulted from her answering ‘yes’ to the question previously hoping that this response would ‘get him to leave her alone'.     184. At the session held at the end of June, Sam discussed the police incident in which 2 males had been knocking on the door and threatening the family and said that this was why the family had moved to a new house. The NSPCC CSP contacted the key social worker by email after the session to ensure that the SW was aware of the incident.    Page 49 of 57   185. At the session held at the beginning of September, the discussions around the map of the city highlighted that the family’s new home was still very close to the alleged perpetrators and that Charlie and Sam were aware of where the alleged perpetrators lived. The NSPCC CSP advised the key social worker of this information by email and the police by telephone.   186. In conclusion, the information reviewed indicates that Sam did feel enabled to disclose her fears and worries within the direct sessions with the NSPCC CSP, that her voice was heard and that her perspectives were understood. Information was obtained which could have informed the risk assessment and child protection planning processes. The NSPCC CSP was proactive in sharing new information as it was disclosed. The NSPCC referral was received following discussion at a MACSE meeting in accordance with local guidance. However, prior to this referral being received there had already been a delay of 10 weeks between the initial referral in respect of Charlie being received by Children’s Services and the date of the MACSE meeting. NSPCC direct work with Sam did not commence for 8 weeks after receipt of the referral from the key social worker, resulting in there being an overall period of over 4 months between the initial referral to Children’s Services and the direct work commencing. Had this direct work commenced at an earlier point, information disclosed by Sam could potentially have enabled more robust risk assessment and child protection planning.  Information reviewed has identified that the CSP received regular supervision on the case and that the need to challenge the management of the case was discussed on several occasions. The CSP did raise concerns with the key social worker by email, by telephone and at multi-agency meetings and was persistent in raising concerns as they arose. However, the formal escalation process wasn’t utilised.    6.4 SAM: FURTHER ISSUES REQUIRING CONSIDERATION.            Event /Issue Links to terms of reference  Sam: Her role as an Interpreter    2  Sam: Her role within the family 1,2  187. Sam: Her Role as an Interpreter  Sam’s understanding of and fluency in English was very good and she was also fluent in 3 other languages. The understanding and use of English of both her parents was very poor, whilst Charlie could speak English but not as fluently as Sam. Practitioners advised that Sam was at times able to manipulate her parents given her fluency in English and that the sisters would speak in English at times so that their parents couldn’t understand their discussion.       188. There was significant information provided for the review indicating the children but particularly Sam, interpreted for their parents. The general practice learning summary indicated that both Sam and Charlie had been used to interpret for their mother during consultations.  A recommendation was included within this learning summary for general practitioners to use independent translators and not family members.   189. The information reviewed indicates that Sam was used to interpret by practitioners on several occasions. The police learning summary highlighted Sam was used by police officers as an interpreter on several occasions, including when they visited the home to see Charlie after she disclosed the alleged rape at the beginning of May and after Charlie had been MFH at the beginning of June. At the beginning of July, Sam contacted the police to report that Charlie had climbed through a window and left the house saying that she was contacting them because her parents were unable to do this. On this occasion, Sam also interpreted for the police patrol officers who visited the home after Charlie returned at 11pm.      Page 50 of 57  190. At the point of the initial case conference in February 2016, the conference chair recognised this was an issue and stressed the importance of not using children for whom there are safeguarding concerns as interpreters. Discussions at the Practitioner event highlighted the difficulties faced by frontline Practitioners in responding to the increasing requirements for the use of professional interpreters. This is particularly challenging in emergency and high-risk situations in which clear communication needs to be gained quickly to assess risk and determine timely and appropriate actions. The professional interpreter employed by the school was used whenever possible and all the practitioners who used this interpreter’s services reported her to be highly professional and trustworthy and that her support was invaluable.   Good Practice: Agencies used the same professional interpreter whenever possible to ensure consistency.  Good Practice:  The school interpreter provided a highly professional service which was invaluable to the involved agencies when working with a family for whom language barriers were a significant issue.      191. In conclusion, there is an increasing requirement for access to professional interpreters within multi-agency safeguarding practice. Agencies have differing commissioning arrangements in place to secure this expertise and there are particular challenges in urgent, high risk situations.   192. Sam: Role within the Family.  Sam’s role within her family was complicated. She enjoyed a close relationship with her mother but disclosed being unable to talk about incidents at home. Her relationship with her father appears to have been more distant and his involvement in her life limited. She was described as having a close relationship with her sister and practitioners highlighted that she could be both protective but also manipulative of Charlie. Sam adopted a parenting role in respect of Charlie at times. It was not understood whether she herself wanted to adopt this role due to knowing that her sister was vulnerable or whether she had been instructed by her parents to look after her sister.     193. Practitioners identified that Sam’s role as an interpreter for her parents afforded her a level of power within the family. Given that she was required to respond to issues on behalf of her parents including informing the police of Charlie going missing, a hypothesis could be that this role must also have caused her anxiety at times. The police learning summary noted that Sam was clear and coherent when interviewed in March 2016 and she did recognise risk. Her understanding of the risks is likely to have made her situation more difficult once the child protection plan and parental expectations were in place as-in all likelihood- she would have been aware that her parents may well be unable to meet the expectations on them.  194. In conclusion, Sam faced significant challenges within her home environment. At the age of only 12 years, she was aware that her sister was vulnerable and attempted to protect her whilst also at risk of CSE herself. In tandem with this, her parents faced multiple difficulties and proved unable to safeguard the children against the risk of CSE.                6.5 SAM: CONCLUSION.  Background Hazards known at the time of the initial case conference Situational Hazards known at the time   Page 51 of 57  Young child (age 12 years) Child from a disadvantaged minority ethnic community Streetwise yet emotionally immature Some additional support in school required English as a second language Additional responsibilities at home including interpreting for parents   Concern about parental capacity to protect Concerns that she may be at risk of CSE due to younger sister being known to be at risk of CSE having suffered an incident of sexual assault Deterioration in behaviour at school Concern about school attendance- 80% Strengths/protective factors known at the time  Dangers known at the time Loved by mother and family Large extended family school- diverse friendship group School- additional support provided including EAL interventions, literacy support and interventions to promote resilience and self-esteem      Significant bruising to backs of legs sustained- explanation of accidental causes had been accepted        195. The review has provided conclusions throughout the narrative and analysis.The information available in respect of Sam was limited and it was understood by involved practitioners that she was much more guarded than Charlie and less likely to disclose information. The information known at the point of the initial case conference in February 2016 is captured in the table above.  196. Two CSE concerns were raised specifically about Sam prior to the initial case conference, the first incident related to inappropriate images on her mobile phone and the second related to inflicted bruising to her legs after she refused to engage in sexual activity with an adult male. She was vulnerable given her age and family background and there were known CSE concerns in respect of her younger sibling. It should be noted that- despite her vulnerabilities- Sam was able to refuse the adult male’s attempts to kiss her in January 2016. There were no further specific CSE concerns raised in respect of Sam.     197. Sam was in her second year at secondary school when Charlie commenced there. During her first year, she had been a ‘model pupil’ presenting as happy and with a diverse friendship group. School staff had been proactive in recognising Sam’s vulnerabilities and providing additional support services including literacy support and interventions to promote her resilience and self-esteem. Education staff were very supportive and Sam did disclose several incidents and concerns.  198. What is notable about Sam is the fact that her behaviours in school deteriorated markedly after her sister commenced there. It can be hypothesised that these changes may have been linked to the point in time at which the CSE concerns commenced. The deterioration in her behaviour indicated that she was troubled and this would have had had a negative impact on her previous capacity to enjoy school and her friendships there.          199. Whilst the multi-agency planning was in relation to both children, the focus of professional intervention was on Charlie who was known to be highly vulnerable and at definite risk of CSE having disclosed being sexually assaulted in November 2015.   After the initial case conference, further information about Sam’s vulnerabilities and the difficulties within her life were emerging up to and after the initiation of care proceedings in July 2016.  Sam bore more responsibility than most children of her age. She acted as an interpreter for her parents and was also asked to interpret by multi-agency professionals on several occasions- usually in urgent situations when clarity was quickly required. There were occasions in which practitioners asked Sam for information to clarify issues including incidents disclosed by   Page 52 of 57  Charlie at which Sam was also present. Whilst this was understandable as clarity was required to inform risk assessments it was likely to have been challenging for Sam given her unwillingness to disclose information.    200. There were differing professional perspectives on the relationship between Sam and Charlie. At times Sam was very protective of her younger sister but it was also felt that Sam could manipulate Charlie. The police learning summary noted that Sam appeared to have been ‘put in charge ‘of Charlie but was sometimes unable to have any control over her sister.    201. A further challenge for Sam was highlighted by the police learning summary through her disclosure of a cultural acceptance of the behaviours exhibited by the alleged perpetrators. Additionally, she disclosed being unable to discuss incidents and concerns at home. These factors must have impacted on Sam’s willingness to disclose issues to practitioners and made her situation much more difficult.   There was a lot of fear in Sam’s life as evidenced through her disclosures about both fear of the alleged perpetrators and fear of telling the truth and getting into trouble with her parents. On the day that Charlie had allegedly been raped in a park, Sam disclosed that she started to run home to tell her mother but then turned back due fear of what her mother might say. Her fear of seeing the alleged perpetrators would have been significant given that they were members of the same small minority ethnic community and lived locally.    202. Further, Sam had to cope with the issues of harassment of her family and negative comments being made to her about Charlie in school. At the age of 12 years, Sam was facing many challenges within both her home and school environments. The initial delay in responding to the CSE concerns raised for Charlie in November 2015 resulted in belated multi-agency planning for both children. A single assessment was undertaken by the key social worker and education staff were proactive in supporting Sam in the school environment, however multi-agency planning through the child protection plan was not put in place for 3 months.   203. The effectiveness of the multi-agency child protection work in this case was then compromised by several issues including a perception that parents were willing and competent to protect the children, information sharing difficulties, and a lack of formal challenge by involved practitioners. The key practice issue identified for Sam was the significant delay in the direct work being commenced through which she had regular opportunities to discuss her fears and feelings and for her voice to be fully heard. Much earlier access to this support would have enabled Sam’s vulnerabilities to have been collated to inform risk assessment, child protection planning processes and determination of the multi-agency interventions required to fully support Sam at a very difficult time in her life.   204. Review of this case indicates that the multi-agency arrangements were not timely and appropriate in recognising and responding to the known risk of CSE for Sam. In relation to the research question, the parenting capacity limitations were not fully assessed and understood until after Sam had been removed from her parents’ care and delays in progressing the case including direct work impacted negatively on the understanding of risk in the case including the understanding of risk by the children.  This case was being managed at the time of the JTAI Inspection process and this report highlights the key changes that have been made to practice since then through the JTAI action plan.      205. Key changes identified include the fact that the case would now be allocated within the police very promptly following referral facilitating a timely joint investigation and multi-agency response. The implementation of the CSE Assessment tool has enabled an increased understanding of the level of risk in a case at an early point and this tool is regularly reviewed and updated within the MACE meetings, the remit of which includes identifying concerns about the progress of cases and escalating any such concerns. Whilst there have been significant improvements made in the system to manage cases when children are at risk of sexual abuse and exploitation there was some evidence that these   Page 53 of 57  changes have not fully converted into front line practice with evidence that cases would be managed the same way.           6.6 Addendum to SCR: CONVERSATIONS WITH CHARLIE, SAM AND THEIR MOTHER    1. During the process of this Serious Case Review there were regular discussions between the SCB, the Independent Reviewers and the Social Worker regarding the children and their parent’s participation in the review process. Due to the traumatic impact of the children’s experience, the criminal investigations and the need for the children to settle in their placement the conversations could not be undertaken until after the completion of the review. Their father declined to be involved in the process, although their mother agreed to feedback to him.  2. Individual conversations were held with Charlie and Sam and their mother, who were all supported by a Social Worker, with whom they had a good relationship. An interpreter, also well known to the mother and children was present, in case there were difficulties in communications. Their foster carer sat outside the room and was not involved in the conversations. She was briefed and accompanied the children home. The mother and children did not express a desire to read the serious case review but considered this may be something they may be interested in in the future. At the end of the conversations each child and their mother were provided with details of how they could make further contributions to the review through their foster carer or social worker.  3. Charlie’s Participation;  These were Charlie’s main comments about what helped her and what might have helped her better;  “In the first secondary school the teacher who sat beside me in school, who gave me extra support really helped me.  Now I am supported by a support worker who supports a group of children. I much preferred the 1:1 support as I needed help with reading and other work.”  “I came to this country at around 7 years of age, I didn’t like my first primary school. I got support in a group but would have preferred 1:1 support.”  “It wasn’t easy to make friends at my first secondary school, there was lots of bullies, so I fought back, I could go to a room to keep me safe and take a friend which I regularly did - there is no bullies at the secondary school I am at now, I have lots of friends, go to a youth club and am able to do my work in school.”  “I ran away from school because I couldn’t manage the work and other children were not being nice (bullying) and no one could have stopped me from leaving.”   “The worker from SARS really helped me. I could talk about my thoughts and still see her every week, I feel better after I have spoken to her. My foster carer is good to talk to as well. When I lived at home with my family it would have been good to have someone to talk to as well and ask loads of questions. I used to talk to one teacher in school which was good.”  “When I saw the police they only sometimes used an interpreter, but there was no interpreter when they took at statement which would have made it easier.”  “In the hospital the staff were kind, told me what would happen and asked me if it was ok. There was always an interpreter. There was toys and books and a television which were OK to.”    Page 54 of 57  “I like being with my foster carer she is funny, but I also like to see my mum, dad and other family members. If children come to this country and go into foster care, it would be better if the bedrooms were bigger, but I like having my own bedroom too.”  4. Sam’s Participation;  These were Sam’s main comments about what helped her and what might have helped her better;  “When I came to this country I had no support at first, except for other children who helped me in school. Sometimes we were taken out of class to do small group work in primary school… children struggle to learn the language and do work when they come to this country.”  “I was happy in primary school, but terrified when I went to secondary school. I quickly adjusted and had extra English classes in secondary school.”  “The NSPCC helped me a lot, they went over and explained a lot of things, they gave me a lot of ideas to keep safe. Really helpful… It would have been good to have their help much earlier. They understood what was happening”  “Bullying and name calling a problem… teachers would talk to children, but they still struggled.”  “At the time of the incidents, everyone knew in school what was happening, but now they don’t…its better… but I liked my previous secondary school which had more children with different and cultures… it was just lovely. and that school had the nicest teacher …School was very helpful, when you were upset you could go and talk to someone in a little room.”  “I wasn’t used to talking to social workers, but now its much easier but it would have been helpful to always have an interpreter. It was scary talking to the police, but they used an interpreter sometimes. A lot of stuff was going on and it could be confusing. not sure what they wanted … sometimes they explained and other times they didn’t explain…. I didn’t mind acting as an interpreter for mum, but it could be difficult.”  “Staff were kind in the hospital, I felt ok and the playroom made you feel better. More activities for young people would have been good.”  “Foster carer is lovely but contact can be difficult due to lack of interpreter.  Life is difficult away from my family but happy with my foster carer too… I would want to go and live back with my family in the future.”  5. In summary the children’s perspective is very powerful. They made many significant comments about what had been helpful and their experience of professional support was generally extremely positive. During the timeline of the assaults it was evident the only regular external support was from one teacher with whom both children could communicate. This is an area of practice that could be strengthened. Both children clearly identified the benefits in respect to ongoing work, NSPCC for Sam and SARS for Charlie with the SARS practitioner continuing to have weekly input, but this work did not begin until much later in the timeline of events. The children also clearly identified the benefits of support provided by their foster carer. The children were also able to discuss the benefits of an interpreter, that sometimes an interpreter was not used and that Sam was used as an interpreter which could be difficult. A significant feature was the children’s experience of being bullied, which was contrasted with current experience in an education environment where there was no bullying. Contact with family remains an important feature their lives, although both children feel very settled in foster care.   Key Learning   Page 55 of 57   Sam identified the language and barriers to learning when children migrate into this country, learning the language as well as learning can be difficult.  Charlie and Sam have benefitted from the long-term intervention with SARS or the NSPCC, however this these interventions were not available at the time of the incidents of sexual abuse.  The children highlighted the inconsistencies and benefits of good interpreting services.  Bullying was recognised to be a persistent issue in the school environment, especially at the time of the incidents.   Charlie and Sam had a lot of positive engagement with multiagency professionals during the period under review.   6. Mother’s Participation;  The children’s mother’s main comments about what helped her and what might have been helped more are documented below;  “Our family came to this country as migrants and had a place to live immediately as they were supported by a family member who had lived here for 12 months. The children learnt English quickly and had extra lessons in school.”  “When we came to this country we needed more help with the language as this is the biggest obstacle. English classes for adults are not easily available. The Job Centre had a program, but this ended 2 years ago due to a lack of funding.”  “Generally, schools used family members to interpret. Police generally used an interpreter except in emergencies.”  “When the concerns started it was good that social services tried to help. The support worker helped ... there would be no such help in our home country… home visits were good and there was always an interpreter when a social worker visited.”  “I always understood what was happening, even if my family interpreted.”  “The support worker was good providing practical situations and the work on real life stories read to mum helped her to relate to their story. I had enough support.”   “Attendance at meetings. Generally helpful. I gained new information not known before. I found agencies sharing information helpful. It helped mum and dad’s relationship as dad was able to understand their concerns.”  “The written agreements were always explained with an interpreter present. They were read part by part and explained fully by the social worker and then the interpreter updated mum on each issue. My adult child understands written English and could read them in between visits if needed Only the court documents were translated, but not written agreements, case conference minutes or LAC documents. I would have liked to have them in my own language.”   “The expectations of me were manageable. I knew things could go badly if the plan wasn’t followed. Overall, it was helpful, and I learned a lot from the process. I had enough information about the court proceedings.”    Page 56 of 57  “I went with my children to be examined at the hospital, it was traumatic as I knew the girls were scared. Everything was fully explained by an interpreter. Everyone was very friendly, smiley, explained and gave the girls time.”  “I feel the police investigation has stalled, not had any information. This is difficult.”  “I am happy my children are in a safe place but would like to see them more. I think there is nothing that needs changing. Social Care is more structured and better resourced than our home country. People can learn a lot from it as I have done, including about parenting. Its hard to let your children be cared for by someone else. However, they are safe and happy.”  7. To summarise Charlie and Sam’s mother provided an extremely positive experience of her involvement with multiagency services. She highlighted a lack of feedback in respect of the criminal investigation, that it would have been beneficial to have a range of documents translated into her own language and the challenges in securing adult learning opportunities locally to learn English  Key Learning   Is the process to feedback the outcome of criminal investigations to children’s parents sufficiently robust?  There is a significant local community for this minority group therefore the system should be able to translate documents into the family’s first language.  There appears to be a deficit of local adult learning opportunities to learn English.      Page 57 of 57  APPENDIX 1: BIBLIOGRAPHY.  1. Bedford A., (2015). Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the Experiences of Children A, B, C, D, E, and F. Approved by the SCB February 26th, 2015. 2. Brayley H., Cockbain E., JD I Brief-Crime Group Based Child Sexual Exploitation Summary 1. UCL Jill Dando Institute Downloaded 30.4.17 ucl.ac.uk  3. Brown P., Scullion L., Martin P., (2013) Migrant Roma in the United Kingdom Population Size and Experience of Local Authorities And Partners, Final Report, University of Salford  4. DfE (2017) Child Sexual Exploitation. Definition and a Guide for practitioners, Local Leaders and Decision Makers Working to Protect Children from Child Sexual Exploitation. Crown Copyright 2017. 5.  DH (2000) Framework for the Assessment of Children in Need and their Families, London The Stationary Office.  6. EHRC (2016) Research England’s most disadvantaged groups: Gypsies, Travellers and Roma, is England Fairer? Review spotlight report. Equality and Human Rights Commission. 7. Evans J (2010) Not Present and Not Correct: Understanding and Preventing School Exclusions. Barnardo’s   8. HM Government (2015) Working Together to Safeguard Children, a Guide to Inter Agency Working to Safeguard and Promote the Welfare of Children. Crown Copyright.  9. Hurley B., Baptiste M-J., Pande S (2015) Free to Move, Invisible to Care, Coordination and Accountability towards Romanian Unaccompanied Minors’ Saftey. NSPCC, ICARUS, European Union. 10. Integrated Early Help Strategy: handbook for all Schools, April 2014 11. Janta B., Harte E (2016) Education of migrant children Education policy responses for the inclusion of migrant children in Europe. RAND Europe, downloaded 18.4.17  12. Kirkman E, K Melrose K (2014) Clinical Judgement and Decision-Making in Children’s Social Work: An Analysis of the ‘Front Door’ System, Research Report, April 2014, The Behavioural Insights Team, DFE. 13. NHS Choices (2015) Post –Traumatic Stress Disorder(PTSD). RCPSYCH (2015) Traumatic Stress in Children: Information for Parents, Carers and Anyone Who Works with Young People.  14. Perry B D. (2007) Stress, Trauma and Post-Traumatic Stress Disorders in Children - An Introduction, The Child Trauma Academy. 15. NSPCC People whose first language is not English: learning from case reviews Summary of risk factors and learning for improved practice around people whose first language is not English- accessed 01.05.17 nspcc.org.uk 16. Orgovanova Klara, Roma in Slovakia. Downloaded 29.4.2017 Slovakia.org 17. Paskell C., (2012) Tackling Child Sexual Exploitation, Helping Local Authorities to Develop Effective Responses Barnardo’s  18. Safeguarding Children and Young People from Sexual Exploitation: Supplementary Guidance to Working Together to Safeguard Children (DCSF, 2009). 19. SCIE Learning Together to Safeguard Children: A Systems Model for Serious Case Reviews. 20. Sweeney S., Mathews K.; (2017) Friends, Families and Travelers a Guide for Professionals Working with Gypsies, Roma and Travelers in Children’s Services, FFT. 21. Ward H., Brown R., Hyde-Dryden G., (2014) Assessing Parental Capacity to Change When Children Are on The Edge of Care: An Overview of Current Research Evidence, Dfe. 22. Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. 