Chronic neglect, physical and sexual abuse of eight siblings and three older half siblings perpetrated by their parents and one sibling. Both parents and the oldest sibling of their relationship were convicted and sentenced for sexual offences and neglect. Initial case review commissioned in 2016 and covered a period of 26 years involving six Local Authority areas; reviewed in 2019 to focus on home area partner agencies and services responsible for the family from 2005-2015. Children were removed on Care Orders in 2007 but sexual abuse continued to be perpetrated by their parents and an older sibling. Two criminal investigations - the first in 2007 did not progress; the second concluded with charges and a trial in 2017. Ethnicity or nationality not stated. Learning includes: the impact of securing evidence in criminal proceedings and safeguarding children; mothers as sexual abusers of their children and the impact of disguised compliance by parents; the level of knowledge, skills and training available to practitioners on child sexual abuse within the family; the continuing need for escalation and professional challenge by practitioners; the historical and current issues around the retention of records; the central role of the Independent Reviewing Officer (IRO) needs to be recognised when there are a number of children within a family in different placements; and children not brought to medical appointments. Recommendations are provided under the following themes: child sexual abuse investigation processes and management oversight; professional escalation and challenge; training and professional development for front line practitioners; and information sharing.
      
    Serious Case Review No:  2021/C8678  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.   Classification: OFFICIAL-SENSITIVE  1  Classification: OFFICIAL-SENSITIVE            Serious Case Review Anonymous Family REVIEW REPORT   Independent Reviewer: Alex Walters                Classification: OFFICIAL-SENSITIVE  2  Classification: OFFICIAL-SENSITIVE  CONTENTS Item Page  Introduction    3  Process for conducting the review   4  Relevant background information prior to the timeframe under review and brief summary of engagement   5-6  Children’s perspectives   6-7  Brief summary of engagement with agencies 2005-7 and learning points    7-10  Summary of engagement 2007-2015 and key learning points  10-13   Conclusion, learning and analysis   13-16   Effective Practice    17    Recommendations   17-18        Classification: OFFICIAL-SENSITIVE  3  Classification: OFFICIAL-SENSITIVE 1. Introduction 1.1 This Serious Case Review (SCR) was originally commissioned by the Independent Chair of the Local Safeguarding Children Board (LSCB) in September 2016. An SCR Panel was established, and an Independent Reviewer was appointed in February 2017. The scope of the initial review covered a time period of 26 years and involved six different Local Authority areas. The SCR process was hindered by the significant gaps in information from numerous agencies that were involved with the family over this lengthy time period, by the delay in producing agency reports of sufficient quality and by having 3 different SCR Panel Chairs and a high turnover of members of the SCR Panel  1.2 In August 2019 the three statutory partners of the Local Safeguarding Children Partnership, established under the new Children and Social Work Act 2017 legislation, which replaced the previous LSCB, reviewed the final draft SCR report. It was considered that it demonstrated hindsight bias, there were significant gaps in the information available from Local Authorities, schools, community health services, CAFCASS and GPs and assumptions and conclusions had been drawn in the absence of triangulated evidence which made the subsequent evaluation of practice difficult.  1.3 As a result it was agreed by the three Statutory partners to commission another Independent Reviewer to review the scope of the SCR and produce a report that although using material in the first report was more proportionate, focussed on the key learning for practitioners and also engaged with practitioners and the adult victims which had not been previously undertaken. Alex Walters was formally commissioned in September 19 and revised the scope, which was agreed by the Statutory Partners in October 19 and which focussed on the period of time the home area partner agencies and services were responsible for the family from 2005-2015- Appendix A 1.4 This SCR involves a family of eleven children – eight siblings and three older half siblings with a twenty-three-year age range. The family moved within six different Local Authority areas throughout the country and the children have been subject to chronic neglect, physical abuse and sexual abuse perpetrated by their parents and the oldest sibling of their relationship. The children were removed on Care Orders in 2007 but sexual abuse continued to be perpetrated by their parents and an older sibling. The allegations of sexual abuse resulted in two criminal investigations – the first was initiated in 2007 but did not progress further. The second concluded with charges and a trial in 2017 where both parents and the oldest sibling of their relationship were convicted and sentenced for sexual offences and neglect. Mother received a custodial sentence for the neglect of two of her eldest children and failing to protect her children from sexual abuse.  Father received a significant custodial sentence for the neglect of the children and the rape of one child. The oldest sibling had pleaded guilty to some of these offences and received a significant custodial sentence (later reduced on appeal) for offences of rape and sexual assault of four children.  Classification: OFFICIAL-SENSITIVE  4  Classification: OFFICIAL-SENSITIVE  2. Process for conducting the Serious Case Review 2.1 The Local Safeguarding Children Partnership recognised the criteria for undertaking a SCR was met and there was potential to learn lessons from this review regarding the way that agencies work together in the local area to safeguard children. It was agreed in the revised scope that the timeframe under review would be from 2005-2015. This covers the time period from when the family moved back to the home area and care proceedings were instigated in 2007 and then the period after the removal of the children from home and how further abuse of the children by the parents and elder sibling took place. Relevant information on historical involvement with the family by agencies where available, prior to these dates was also considered, 2.2 Agency reports had been provided from a large number of agencies primarily involved with the children after they came into care in 2007. They all identify learning, and areas of effective practice.  Further information and clarification were subsequently sought by the Independent Reviewer through follow up e mail exchange.   2.3 A central component of the SCR process is understanding the perspective of front-line practitioners and the opportunities and challenges about the 'system' within which they work to analyse why incidents occurred and the contributory factors rather than just what occurred. A key element of the methodology was therefore the learning event for front line practitioners. It was held on 6/12/2019 and involved 5 practitioners who considered key themes identified by the Independent Reviewer, and the perspectives and opinions of all those practitioners involved at the time were discussed at the event and have significantly informed this SCR report.   2.4 The contribution of family members is an important part of the review process and learning.  It was agreed that the children involved in the criminal proceedings would be informed of the SCR process and invited to participate and meet with the Independent Reviewer.  As a result, two of the children who are now adults met separately with the Independent Reviewer and their views and perspectives were most helpful and highly valued by the reviewer in identifying improvements and are incorporated into the review and its recommendations. Neither had given evidence in the criminal proceedings and it is recognised that their perspectives can only represent their own experience and views and not that of all the children. In addition, the Independent Reviewer had a most helpful discussion with the adoptive mother of the youngest two children who had expressed a wish to contribute to the review.  Her contribution and desire that there should be learning from her child’s experience have also reinforced the recommendations from this review. Classification: OFFICIAL-SENSITIVE  5  Classification: OFFICIAL-SENSITIVE 3. Relevant background information 1989-2005 prior to the timeframe under review  1989-1994 3.1 The family comprises mother and father who have eight children, mother also has three older children from previous relationships. Historically, there had been concerns around the three elder children and the Local Authority in the area they were living had instigated care proceedings in the late eighties. The concerns related to severe levels of neglect and physical abuse and sexualised behaviour shown by the children. A Care Order was granted and although the original care plan had been permanency outside the family home, this was later changed following residential assessment to a phased rehabilitation home to mother and subsequently her new partner and father of the following eight children. The rationale and context for this decision making is outside the scope of this Serious Case Review but it is clear that there were a number of contextual reasons which may have influenced and led to this decision by professionals which was sanctioned by the Family Court. It would appear that these three elder children subsequently returned to Local Authority care in their mid teens and there is little evidence they were perceived as children who had suffered significant adverse childhood experiences. 1994-2005. 3.2. During this period the family lived in five different Local Authority areas and moved within those areas numerous times. Although recording is incomplete and limited there was evidence of concerns raised by schools, education welfare officers, police and neighbours about the three older boys who were involved in criminal activity and were reported missing from home but there appears to have been limited response or consideration of them or the younger children. The oldest child presented as homeless and in need of permanent accommodation and support by children’s services and was accommodated under the supported lodgings scheme at the age of 16. The second and third oldest children were also temporarily accommodated, as they were unwilling to return home, alleging that mother and father had beaten them. The report of physical abuse was not picked up.  There were reports of domestic violence between mother and father and father left the household for periods, apparently taking his oldest child with him on at least some occasions.  3.3 It also appears that there were a number of concerns noted by health visitors (HV) as they attempted to complete new birth visits for the youngest children.  There were nine ‘no access’ attempted visits for one child. None of the children appear to have had immunisations, children were not brought to appointments and when visited the home is described as chaotic to the point where the HV is unable to carry out her assessment.   It is not clear whether the condition of the home was ever assessed by other professionals who visited the family. It is not clear that any of these concerns were shared with social care.  3.4 There were periods when the children were subject to Child Protection plans in other Local Authority areas in 2000-2003 but there was little evidence that any of the concerns around the children resulted in any significant intervention. The changes in Classification: OFFICIAL-SENSITIVE  6  Classification: OFFICIAL-SENSITIVE residence meant that there was a disjointed engagement with services, and the family was less visible.  Allegations were not fully investigated or the records now available do not indicate whether action was taken.  3.5 Overall this period reveals a continuing pattern of concerns, domestic violence, neglect of the children and offending behaviour.  A common feature appears to be unreasonable demands on the children by their parents to undertake physical tasks (such as housework) – with the implication that this was used as a means of punishment or control.    4. Children’s perspectives  4.1 As a result of the contact made through the local Police, two of the adult children indicated a wish to meet with the Independent Reviewer. The first was one of the three older children and he had clearly undertaken a great deal of reflection on his family experience. His perspective was clear that the decision to return the older three children home had led to a poor outcome for himself in that the neglect and abuse continued for them as well as for the subsequent children in the family. He felt he had told a number of professionals about the abuse he was experiencing but there had been no active response. He was however positive about the placement facilitated by Children’s Social Care in supported lodgings when aged 16. He left the family home at that point and essentially now has no contact with any family members. He additionally raised the issue of how he frequently spent hours in waiting rooms –often at police stations and that the literature he read on offending behaviour appeared to reinforce the view that the child was “bad” and that once labelled this will inevitably lead to a life of crime/abuse. There is I believe an increasing recognition from practitioners in all agencies that children’s behaviour often simply reflects their home and parenting experience and should be considered in this light.   4.2 The second adult child who met with the independent reviewer was one of the younger three children and had comparatively experienced a more stable placement history in that he remained with the same foster carers following removal from the birth family at the age of eight. This had been a positive experience and he also benefitted from a stable constructive education. His reflections were that his parents had been determined to undermine the placements and manipulate the children to return home.  He understood that they used disguised compliance with professionals and were determined to maintain family secrets. His memory of his family home was one of chaos and a dirty environment with few boundaries where the children had nominal bedrooms but didn’t know where they would sleep that night. He has had some recent contact with both parents and described them blaming the other or their extended families. The therapy arranged for him had not been at the right time and he felt his foster father had had to fight agencies to agree the funding, but he had subsequently been unable to make best use of this as a child, although he is receiving therapy now. When asked about what could have been done differently by agencies, he felt that Classification: OFFICIAL-SENSITIVE  7  Classification: OFFICIAL-SENSITIVE there was nothing that would have raised awareness given the entrenched determined behaviour of his parents.  4.3. Adoptive mother’s perspective. The youngest two children were adopted in 2009 and the second youngest made a number of disclosures alleging sexual abuse by family members, which were investigated by the local police force. The criminal process involved video interviews being undertaken of the eight-year-old child. The outcome of the criminal proceedings were significantly delayed and ultimately resulted in a decision not to pursue prosecution. In the interim the family were advised not to discuss the abuse with the child or to pursue therapy, which clearly had an adverse effect on the child as well as the natural nurturing, required in a newly adoptive family as the mother described her parenting as therefore feeling “artificial”. The initial video interviews were undertaken by male police officers despite a request for female officers.  The child’s social worker was told at the point of interview that she couldn’t attend despite the child’s request as she had not been ABE (Achieving Best Evidence) trained. After the final interview the Police officer said in the hearing of the child that the evidence was “vague”.  The impact of this process was that the child was left feeling that she hadn’t been believed and that some commitments made to her and the family had not been kept. The adoptive mother felt that there had been positive experiences but that their families experience of the criminal investigation process had been damaging and she hoped that approaches to child victims had significantly improved over the last 11 years. This perspective is clearly reflected in the recommendations of this review.    5.Brief summary of engagement with agencies 2005-7 and learning points 5.1 The family moved into the home area in January 2005 although the older three children were adults and no longer living at home. Throughout 2005 there were concerns raised from local schools that suggested possible sexual and physical abuse. One child disclosed to a teacher that they had woken up and found the eldest sibling on top of them and had also seen this sibling lying on top of another younger sibling. Another child disclosed that they often had to put this child’s nappy back on and pull up their pyjamas at night.  The school was rightly concerned and made a referral to social care.  A social worker attempted to make a home visit without success.  Enquiries were made with other agencies including police, health visitor (HV) and GP. The HV and GP reported no concerns, although there was already a worrying pattern of “Was Not Brought” (WNB) for health appointments for many of the children but these were not picked up as indicating possible safeguarding concerns.  5.2 An initial assessment was completed but made no reference to the previous disclosures by the children or the expressed concerns about sexual abuse.  The focus was rather on health, education and housing. It is not clear that the children were seen or spoken to individually and the case was closed.   Classification: OFFICIAL-SENSITIVE  8  Classification: OFFICIAL-SENSITIVE Learning point  5.3 There would appear to have been an initial limited response to a complex family situation, which presented significant risks of sexual, physical abuse and neglect where experienced and skilled judgement was required. Although there was clear history of allegations and disclosures of sexual and physical abuse and neglect it was only with the oversight of a new manager that some of these assumptions were challenged and examined more critically.  5.4 There followed further notifications from schools of concerns about damage, threats to teachers, violence and nuisance.  One child made a threat of suicide if sent home from school (which resulted in a CAMHs referral as it was regarded as a purely health issue), and the school reported continuing concerns over aggressive behaviour resulting in exclusions. One school reported another child defecating on the floor of the toilets. Social care records note that the eldest sibling was seen by CAMHs for signs of depression and anxiety and one child was seen for ADHD and sleep problems. A behavioural psychologist raised concerns about behaviours and stated that sexual abuse should be considered. There is no corresponding health record of these referrals, although they may have been made as a result of GP consultations.  This was a missed opportunity for an assessment. The new manager of the social care team in 2006 said that she found that the team saw their role as supporting and advocating on behalf of families for other agencies such as education and housing.    5.5 The case was subsequently reallocated for detailed assessment and to consider the history of sexual abuse and mother and father’s ability to manage the children in late 2006.  This was an appropriate management review of the case, and the first time there is any mention of the previous history on the file, but there had already been significant drift and delay since the initial concerns. The eldest sibling disclosed to the social worker that their aunt and cousin had sexually abused him.  At a further home visit the following day three siblings then made further allegations of sexual abuse by their eldest sibling.   5.6 The disclosures resulted in a joint investigation by Children’s Services and the Police and a Strategy Meeting was held the following day, which was just before the Christmas holiday period. The perpetrators are recorded as maternal aunt, her son, maternal grandmother, and the eldest sibling. It is clear there was detailed and serious discussion about the best way of planning to protect the children.  There was concern that removal of the children, or just the eldest sibling immediately before a holiday period might inhibit the children making further disclosures. The minutes of the meeting show that mother’s limited motivation or ability to protect her children from risks both outside and within the immediate family was identified. It was important to understand a full picture of the nature of the risks, not just for prosecution but to make future safeguarding provisions for a large number of children – possibly involving the wider extended family of cousins who were potentially also at risk. Immediate removal of the children could have had the likely effect of making the children feel punished for talking. If the eldest sibling alone was removed, having opened up about the rape by the cousin, this was felt to be likely to silence the children and might have taken the Classification: OFFICIAL-SENSITIVE  9  Classification: OFFICIAL-SENSITIVE accountability away from mother. Having only one working day left before the holiday period may have also been a factor in deciding not to attempt to accommodate the eight children immediately.  5.7 The legal advice was that the threshold was not met for an Emergency Protection Order (EPO) due to the chronic nature of the concerns.  The advice appears to have been particularly mindful of the ruling from Justice Munby of the high test to achieve immediate removal that there was forensic evidence of immediate, life threatening harm to a child (X Council v B 2006).  At this stage the disclosures did not include the parents and there was no forensic evidence.  This was not to underplay the seriousness of the concerns but reflected case law in acute situations.   A further strategy meeting and Legal Planning meeting took place in early January 2007. The advice was to proceed to planned care proceedings where the test for removal, at an interim stage was seen as appropriate to the presenting evidence.    5.8 Forensic medical examinations of the children did not take place immediately and took place over several days.   These did not provide clear evidence of sexual abuse except for one child, although there was concern about the emotional harm that the children might have suffered. It was felt the children’s disclosures were symptomatic of challenging behaviour.  There is no record of any substantive challenge to these findings and this view undoubtedly contributed to the uncertainty about how to manage the risks faced by the children.  5.9 There was also an additional delay between the February and March 2007 court dates as court appointed guardians from CAFCASS wanted to meet with the children before making recommendations.  This was in theory best practice, and the guardian recommended removal, but it did add to the delay. The Care Order on all eight children was granted on 2.3.2007.  Learning points  5.10 This approach to care proceedings, however, did not reflect the significant history of allegations or more robustly challenge whether the children remained at risk while in the care of their parents.  Given the number and extent of the disclosures involving family members that had been made, this advice might have been challenged by the Local Authority. It is also significant to note that the focus was very much on the disclosures of sexual abuse within the immediate and extended family which did not reflect the significant existing evidence of chronic neglect. This reflects the perspective at that time that chronic neglect was not seen, prioritised or responded to by practitioners working in child protection in the way it is approached today. This was a key point of learning raised by practitioners at the learning event.   5.11 The Strategy Meetings had recognised that there were inconsistencies in mother’s accounts.  However, there appears to have been no overt consideration of the extent to which mother already knew of the allegations or might be a perpetrator or colluding with the abuse by others. There is research that highlights the reluctance of workers to recognise that women can also be abusers, and also of the complex psychological Classification: OFFICIAL-SENSITIVE  10  Classification: OFFICIAL-SENSITIVE effects this can have on both perpetrators and workers1. The deflection of attention from the parents by alleging abuse by a wider circle of people was a frequent feature of this and subsequent investigation of allegations and disclosures. The practitioners also described mother as very charming and very skilled in the features of what we now recognise as disguised compliance.  5.12 It was also a considerable task to prepare the written evidence to ensure that when the matter was heard by the court everything was in place for Interim Care Orders and that Care Plans for removal were approved. This resource issue was recognised by the local Children’s services management and an experienced worker was employed to manage the case, and her evidence and care planning work along with other team members were of an excellent standard. The practitioners that met with the Independent Reviewer also reinforced the significance of the workload in relation to eight children in finding and supporting placements, facilitating contact with parents and between all the children, responding to further disclosures and preparing chronologies and evidence for care proceedings. This task was additionally hindered by the need to locate historical files for the older three children made challenging by changes to the local government boundary areas in the late 1990’s. It is known that files were not effectively managed with no centralised system and resulted in key missing information.  5.13 The local police force had initiated an operation to gather evidence and the parents were not regarded as suspects.  There was a tension between the urgency of protecting the children and removing them from an unsafe and neglectful situation, and the desire to have a strong evidence base for allowing further disclosures and evidence for possible prosecution.  This was a difficult balance to strike and there is evidence that practitioners and managers were aware of these dilemmas but underestimated the extent to which the parents were displaying disguised compliance and were seeking to manipulate both professionals and the children.   6. Summary of engagement 2007- 2015 and learning points  6.1 Following removal of the children from the family home three children continued to make disclosures that they had been abused historically by two of their siblings and also by their mother. Immediately after the children were removed, police and social care were contacted by the family about the children withdrawing their statements and some of the children telephoned the police to say they had lied, and the allegations were untrue. It would appear that whilst there were multi-agency meetings, the criminal case was not reopened in fear of jeopardising the family court process. The Police and Children’s Services discussed a possible criminal investigation for neglect against                                                            1 Early literature on sexual abuse often suggested abuse against children by women was unbelievable and, even if real, less harmful than when perpetrated by men. Despite this, females are capable of sexually abusing children, with very damaging results. In a recent US study (McLeod, 2015), one out of every five child sexual abuse cases validated by child protection had a female as the main offender of the abuse. The types of sexual abuse females can commit on children is not limited to touching and fondling and is significantly underreported in both the US and UK.  Classification: OFFICIAL-SENSITIVE  11  Classification: OFFICIAL-SENSITIVE mother and father. The local police force sought advice from the Crown Prosecution Service, however the police report was filed still pending access to third party material and no appropriate action was taken.   Learning points  6.2 This episode illustrates the difficult decisions and choices that were faced by professionals in managing the case.  A series of serious disclosures and allegations were made, and although there were significant delays in collating and responding to these, it would appear that most of the risks were recognised. Caution about the impact on the children, but also anxiety about gathering evidence, resulted in a drawn-out process which may well have allowed perpetrators to pressure the children into retracting allegations and certainly left them exposed to further abuse.  There appears a lack of challenge to advice from legal and medical services.  6.3 The local police force Agency Report contains a very fair but critical review of how the operation was conducted.  This is a positive and good example of scrutiny applied to previous practice and demonstrates learning and improvement from past events.  In the early stages of the investigation there was regular liaison between managers and better recording of meetings and decisions.  However, the investigation lost momentum and recording became infrequent and the rationale around decisions was lost.   Contact arrangements  6.4 Following their removal from home the children were placed in different care settings although the youngest two were placed together and subsequently adopted. Over the next 9 years at least a further four children began to make a series of disclosures of sexual abuse relating to both parents and the eldest sibling. There is considerable evidence that the parents sought to disrupt the care arrangements and attempted to exercise control over the children where they could.  6.5 The arrangements for contact were in the legal and practice context of the expectation that the Local Authority as corporate parent should promote contact between parents and children. The local Children’s Services were aware of the risks and difficulties that this presented and had made these concerns clear to mother and father.  Contact arrangements were to be supervised and recorded, and the notes of these sessions are thorough and comprehensive.  When care orders were granted the younger five children were subject to Section 34(4), which meant they had no further contact with their parents, but they could have contact with their older siblings.  The three older children were subject to Section 34(2), which provided for limited contact with their parents, supervised and in a neutral location.  Despite these unusually restrictive arrangements the parents continued to undermine the placements for the older three children, and it is clear that abuse and exploitation continued over the following years.    Classification: OFFICIAL-SENSITIVE  12  Classification: OFFICIAL-SENSITIVE 6.6 The parents contested the care proceedings, which meant that there was continuing court action and the disclosure of information between the parties.  This was a significant background to the care management and planning for the children. Children’s Services were clearly aware of these risks. The older children regularly went missing from their placements and returned home to their parents, and in addition they were passing on messages to the younger children from their parents that included permission, indeed encouragement, to disrupt their placements.  There was anticipation of the extent to which mother and father were able to continue controlling their children even though they were in care.  For example, the assessment for one child recorded that:  “The severity and frequency of the sexual abuse were understood and recorded and formed the basis of successful applications for the removal and then full care orders for these children.  The risks of continuing contact with parents were recognised, and in seeking to use legal powers to restrict contact and enforce recovery, the local Children’s Services was assertive in attempting to protect the children. However, it is not clear that there were consistent strategies to implement or enforce the restrictions that the court had granted.   Concerns about managing contact were raised by reviewing officers and by placements. Individual practitioners were concerned about the trauma experienced by the children and, where this is recorded, appear to have dealt sensitively and professionally with the complex and challenging needs of the children. Carers and staff in placements appear to have worked hard to sustain relationships of care and support for children who were often troubled, angry, displaying sexualised and harmful behaviours, and difficult to manage. These are considerable achievements in the face of an extremely challenging set of concerns.”  6.7 However parental determination and the use of social media (particularly Facebook) and mobile phones which were hidden or difficult to restrict or control, meant that the children continued to be subject to coercion and pressure from their parents.  The parents even moved to a new house in another Local Authority to be closer to one child’s placement, which made it easier to encourage absconding, and resulted in repeated opportunities for abuse by her family and others.    Learning point  6.8 Despite the best efforts of all professionals, it is not clear if there was a full understanding of the grooming behaviour that the parents had exercised, and the conflicted nature of the children’s relationships with their abusers. It is clear that despite considerable efforts, and recognition of the continuing risks posed by their parents, there were not consistently successful arrangements to protect and support these children. Specific applications to court were made to try to strengthen the ability of the local authority to oversee and restrict contact, but it was difficult to enforce this in the face of repeated absconding, access to social media, hidden mobile phones and disruption of placements.   It is not clear that the placement providers were consistently consulted and involved with the management of risk or the decision making over how to manage this complex and challenging behaviour.  Parents continued to exploit any lack of joined up working between agencies and were adept in subverting attempts to Classification: OFFICIAL-SENSITIVE  13  Classification: OFFICIAL-SENSITIVE keep the children safe. It would appear that the response of agencies who should have been building up and analysing a complex picture was to respond to each incident as it occurred and to rely too often on single agency investigation of individual incidents.  6.9 The second police operation was initiated when one child contacted the local police force in 2013 for the first time and made disclosures of rape and sexual abuse by an older sibling.  Following this, further disclosures were made by another two children against the same sibling, and by one child against Father. The local police force became aware of disclosures made by another child in another Police area, about recent and non-recent rape and sexual assault by the parents and the elder sibling.  Two children alleged that their mother was complicit in the offences and a perpetrator in her own right. Two of the eldest children also contacted the local police force and made disclosures of physical abuse and neglect at the hands of mother and father.  As a result of these disclosures and the subsequent investigation over a four-year period charges were authorised and came to trial. The creation of the operation team by the police able to investigate and make the links of evidence and testimony across the family resulted in a successful prosecution of perpetrators of serious offences against these children.   Learning point  6.10 The conclusion in this report emphasizes the extent to which sexualised behaviour, regular sexual assault and rape were normalised in these children’s experience over a long period. Subsequent knowledge of children who go missing has developed the understanding of how grooming and coercion can subvert other loyalties, ties and relationships. Children may have been seen as very difficult creating their own risks rather than as vulnerable and a victim of abuse. It is still a challenge to recognise and intervene in sexual abuse within the family where, as in this case, there is considerable disguised compliance and manipulative behaviour by perpetrators. The extent of sexual exploitation, grooming and persistent and repeated abuse that occurred within the family setting is extreme and therefore was challenging for professionals to recognise, name and have the confidence to respond to.  In this context it is understandable that there was a wish to have firm evidence to allow the investigation and prosecution of the perpetrators.   7. Conclusion, learning and analysis 7.1 Highly sexualised and harmful behaviour was normalised within this family from a very early stage, and successive children were born into situations where abuse and neglect were already established. Neglect overcrowded and poor housing conditions, poverty and criminal behaviour were significant features as well as sexual and physical abuse. The family were difficult to engage; often distrustful of agencies; and there is strong evidence that mother and father deliberately sought to undermine and disrupt the work of agencies, practitioners and carers, using the children as means to achieve this.  The parents displayed disguised compliance and successfully deflected examination of their roles in permitting and perpetrating abuse. This happened both before, and after, the removal of the children from their care.   Classification: OFFICIAL-SENSITIVE  14  Classification: OFFICIAL-SENSITIVE 7.2 The case illustrates the complexity of dealing with a series of disclosures, over an extended time from different children, some of which were subsequently withdrawn or modified, and the challenge of striking the right balance between the duty to safeguard and the opportunity to gather evidence and secure prosecution for the crimes believed to have been committed.  7.3 The focus of the SCR must be on what can be learnt for the future, strengthening and improving services, and identifying learning from this case to improve multi-agency working, about confronting the complex challenges of intrafamilial sexual abuse and disguised compliance from perpetrators, about sharing information more consistently, and about placing a primacy on the safety of vulnerable children.  There are also some important lessons for the oversight and management of complex investigations in a multi-agency environment.  Key learning relates to: • The impact of securing evidence in criminal proceedings and safeguarding children • Mothers as sexual abusers of their children and the impact of disguised compliance by parents • The level of knowledge/skills and training available to practitioners on Child Sexual Abuse within the family. • The continuing need for escalation and professional challenge by practitioners • The historical and current issues around the retention of records.  • The impact of continuing contact between the children and with parents post 2007 which resulted in further abuse and the impact of social media to facilitate this • The need to ensure sufficient resource by partners to large scale criminal investigations • The central role of the IRO needs to be recognised when there are a number of children within a family in different placements • Children “not brought” to medical appointments   Mother as a sexually abusive parent 7.4 During the police operations, mother as a possible sexual abuser did not seem a prominent concern. This may have been due to societal attitudes to female sexual offending: that women, particularly mothers, are incapable of committing sexual offences. Even experienced Child Protection professionals have often adopted that thinking (Denov, 2003)2. Practitioners must be mindful of the existence of maternal sexual abuse. Although estimated reports of its prevalence vary greatly, it is widely agreed that children find it much harder to report sexual abuse by a mother figure than by other abusers3 (a finding that appears to be supported by the disclosure history of                                                            2 Denov, M. S. (2003). The myth of innocence: sexual scripts and the recognition of child sexual abuse by female perpetrators. Journal of Sex Research, 40(3), 303-314. 3 Horvath et al (2017) “It’s a lonely journey” A Rapid Evidence Assessment on interfamilial child sexual abuse, Office of the Children’s Commissioner. Classification: OFFICIAL-SENSITIVE  15  Classification: OFFICIAL-SENSITIVE the family). This risk should be in the minds of professionals when making assessments about the protective factor of a mother, and her involvement as a supporting role in an investigation (Recommendation 8)  The balance between investigation and safeguarding 7.5 It is clear that all agencies were working with significant gaps in information partly due to the long history of involvement with this family across many local authority areas and the lack of continuity in engagement.  A key learning point is the need to balance the desire to secure evidence with continuing risks this may present for victims. At various times this balance was contested between agencies, and the processes for obtaining evidence were in any case not always timely or thorough.   In the decisions about the removal of the children there was an anxiety that immediate removal might preclude further disclosures.  This decision needed to be set against the recognition of the extent to which the children were already groomed into compliance with their abuse. Additional learning relates to the need to pro-actively manage the likelihood of further disclosures and for there to be strategic oversight and coordination of disclosures particularly when covering a number of different Local Authority and Police Force areas. (Recommendations 1, 3 and 5)  Challenge, Escalation and Deference to professional opinions 7.6 From the earliest stages of this case there are examples where there was not sufficient challenge made to professional opinions from those practitioners or agencies who held a different view. Multi-agency arrangements need to provide clear processes for supporting appropriate challenge and for resolving professional disagreements when these occur. It is not clear what challenge was made to the medical opinion that the children had not been sexually abused.   Legal advice was cautious about the prospect of securing court approval for removal of the children, but this was not sufficiently challenged by police or social care.  7.7 Examinations and video interviews were not always arranged promptly which meant that the evidence for abuse was not gathered in a robust or timely fashion.  Agencies did not always challenge when investigations were not followed up or completed, although it is clear that in relation to one placement, they raised these concerns with police and Children’s Services on a regular basis and on occasions formally and in writing.  (Recommendation 7)  Training, development and professional expertise- “think the unthinkable” 7.8 This review illustrates considerable historical gaps in practitioner knowledge, confidence and skills in dealing with complex sexual abuse.  Practice has changed and been strengthened in the intervening years, and there is much greater understanding of the processes of grooming, coercion and control used by perpetrators including within families and also of the need to support victims. However recent Joint Targeted Inspections of child sexual abuse in the family environment demonstrate that this form of abuse can often be hidden and the effects of abuse on children can materialise in Classification: OFFICIAL-SENSITIVE  16  Classification: OFFICIAL-SENSITIVE different ways, which is best described as ‘behaviour is the voice’. Practitioners involved at the time recognised the need to “think the unthinkable”. (Recommendation 8 and 9)  Management oversight of complex cases  7.9 Throughout this case there is evidence that strategy meetings between multi-agency partners to consider how to progress child protection inquiries were not always held were not always recorded, and the decisions not always shared with all relevant partners.  Many were conducted as phone conversations rather than as face to face meetings where complex and changing information could be properly shared and discussed.  In some cases, providers and schools who had significant and relevant insights were not invited.  It is also clear that the respective responsibilities of host and placing authorities, and of different police forces were unclear, which compounded the fragmentation of response and the lack of information sharing that can been seen in this case.  7.10 There are frequent examples by agencies of actions not followed through, further inquiries not completed, agreed actions not undertaken, and also a lack of clear recording on what actions were expected.  This presents a systemic challenge as it is difficult to see the reasons for such a repeating pattern.  There is some sense that the scale, severity and persistency of the abuse suffered by these children became overwhelming for those working on the case. (Recommendations 2, 4 and 6)  Voice of the Child – responding to individual needs 7.11 The individual voices of the children are only recorded intermittently through this case.  There are a number of occasions when different children tried to voice their concerns. However, the children were not always seen individually, their files are sometimes cut and pasted between siblings and there was little recognition of the changing needs of the children as the family grew and as exploitation, neglect and abuse moved down the successive children.  (Recommendation 8)  Information and recording 7.12 This case has numerous examples of poor recording practice across agencies and gaps in the information shared.  Throughout the case, as well as for the Review, it has proved impossible to access complete records.  Files have been difficult to retrieve or have been found to be missing. This significantly affected the informed basis on which decisions about the case could be made – the previous history was just not visible.  The social care managers who took over responsibility in 2006 commented on the lack of information available to them – they needed to “put the pieces of the jigsaw together”.   It would also appear that some information was not saved on electronic files because it was seen as confidential. It clearly proved difficult and time consuming to retrieve files across numerous local areas relating to the early history of the family.  The fact that they moved to several different areas throughout the country made this even more complex.  Although this was particular challenge for social care files, there are also issues about missing information from CAFCASS and the police.  (Recommendations 10, 11, 12) Classification: OFFICIAL-SENSITIVE  17  Classification: OFFICIAL-SENSITIVE  8. Effective practice that had a positive impact.  8.1. The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered effective and supports good outcomes for children. Good practice from professionals has been recognised and this includes the concerted focussed response by the local Children’s social care to the allegations in 2006 from the children and the resource and approach to the application for care orders, placement finding and supervised contact for these eight children. Having met with the practitioners the emotional impact of this family on them and the work undertaken was significant and still resonates to this day. The Police response from 2013 resulting in the trial in 2017 was significant, focussed, well resourced and well led and resulted in successful prosecutions. There is also evidence of a residential placement supporting and advocating purposefully for one child. 9. Recommendations 9.1 The Review concludes with recommendations to the newly created Local Safeguarding Children Partnership (LSCP), which build on the recommendations and actions already identified for learning by single agencies during the process of researching their involvement in this case. In a number of cases, actions have already been taken to improve arrangements/systems.  9.2 The following additional recommendations are provided under overall themes to ensure that LSCP and its partner agencies are confident that any other areas are addressed and that the LSCP is able to monitor progress. Theme One- Child sexual abuse investigation processes and management oversight 1. LSCP should consider whether for the most complex cases there should be oversight by the statutory partners to monitor progress, address barriers and ensure sufficient resource. 2. LSCP should ensure that where children in suspected child sexual abuse cases within the family are considered too vulnerable to support a criminal investigation this should be regularly reviewed by the Police and Children’s Social Care. 3. The role of Independent Reviewing Officers to act as a champion for the child, and to ensure that the full range of information about the whole family circumstances is used to coordinate planning, should be reinforced. 4. LSCP should review supervision arrangements in partner agencies through the Section 11 audit process to establish that there are robust arrangements for handling complex cases. 5. LSCP should conduct an audit of strategy meetings attendance, recording and decision-making involving cases of sexual abuse  Classification: OFFICIAL-SENSITIVE  18  Classification: OFFICIAL-SENSITIVE 6. LSCP should ensure where large disclosure applications are made that there is a protocol between key agencies to ensure information is shared in a timely appropriate manner.  Theme Two - Professional escalation and challenge  7. LSCP should review and raise awareness of its professional escalation procedure.  Theme Three - Training /professional development for front line practitioners  8. LSCP should conduct an audit of training and CPD provision across agencies looking at the following areas to ensure that there is a comprehensive and up-to-date offer to address professional and multi-agency competencies in working with: • The challenges of large families (over 5 children) • Intrafamilial sexual abuse where siblings may be both victims and perpetrators • The role of women as perpetrators and facilitators of sexual abuse • How to support and manage disclosure from victims, especially of long-term and persistent abuse • To ensure active consideration of the voice of children • The impact and management of social media on contact and placement arrangements where this leads to increased risks of abuse  9. LSCP should undertake specific training and support for practitioners around disguised compliance by parents particularly around child sexual abuse in the family environment and incorporate key messages from recent research reports.  Theme Four- Information sharing  10. The Local Authority should identify contingency plans in conjunction with other local authorities in the area for the secure storage and retrieval of remaining paper files.  11. LSCP should ensure the retention policy for all school safeguarding records should be reviewed and secure arrangements for records relating to schools which have become academies confirmed  12. LSCP should request all agencies provide assurance that all current case files contain closing summaries and records of decisions.  Alex Walters – July 2020 