Life-threatening injuries to a 17-year-old boy. Riley was hit by a car and assaulted by the driver. Learning includes: recognise and reflect on cumulative risk, including parenting history and adverse childhood experiences; the need for active communication between agencies involved in assessing need; undertake joint assessments to ensure all needs are identified; see a child's behaviour as their way of communicating and be reflective about what the behaviour could be telling us; use language that recognises a child's behaviour as a means of communication; recognise the impacts of neglect and trauma, understanding how this can manifest in adolescence; not overloading a child with referrals/workers but considering what needs to be prioritised and who is the best person to deliver; understanding a child's needs, and being needs led rather than service led; practitioners work together to respond to multiple needs such as underlying learning needs and child protection concerns; creativity about where and how appointments take place to maximise engagement and attendance. Recommendations include: a review of children who have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs; explore the use of a communication passport which can be reviewed at key stages in a child's life, so all agencies understand the strategies needed to engage with a child with additional needs; consider the partnership's approach to adolescents receiving hospital treatment.
      
    Serious Case Review No: 2022/C9665  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1  Local Child Safeguarding Practice Review Riley (August 2022)     2 Case Synopsis  Riley was 17 years old when he was hit by a car and suffered significant life-threatening injuries. After hitting Riley with the car, the driver exited the vehicle and assaulted Riley before driving away. Riley was found with a quantity of cannabis on his person and later admitted to having taken this from a cannabis farm before being followed and attacked by the perpetrator of the incident. Riley suffered a fractured eye socket and a perforated pancreas. He initially refused to engage with the necessary treatment for his injuries, however, has since made a good recovery. Longer term impact will not be known until further assessments can be undertaken. Riley is currently refusing to have these assessments.   Riley is the eldest child. He has two younger half-siblings whose father is step-father to Riley. Riley’s biological father is currently in prison and Riley has no contact with him. At the time of the incident Riley was living in supported accommodation. This had been sourced by the Local Authority in the months prior to the incident following Riley being arrested and bail conditions stipulating that he could not enter his parental address; due to being involved in stealing a neighbour’s car.   Riley was open to children’s social care on a child in need basis at the time of the incident, had a number of missing from home episodes and had been recently referred to MACE (Multi-Agency Child Exploitation) Hub.   Rapid Review  Whilst the Rapid Review into the serious incident was able to gather the facts of the case and identify potential opportunities for improvements to safeguard and promote the welfare of children, it was felt that further learning could be identified through taking a long-term perspective on Riley’s life to better understand his needs, how these were identified and responded to, and how these impacted upon the vulnerability and risk in adolescence.    Review Methodology  This Local Child Safeguarding Practice Review was undertaken in two parts. Part one took a long-term perspective on Riley’s life, learning needs and how agencies supported him throughout childhood. This took the form of a deep dive analysis of records and in depth look at a chronology of Riley’s full history of involvement with services; to answer specific questions set by the Rapid Review.    Part two was facilitated through an appreciative enquiry approach. A focus group with frontline practitioners and a learning event with managers and strategic leads were undertaken. These events focussed upon the child’s journey, voice and perspective. They examined Riley’s lived experience through a lens of best practice, to support systemic learning and practice improvement.    3 PART ONE    The Long-Term Perspective on service involvement with Riley  Riley first became known to services when he was three years of age. He had suffered accidental ingestion of turps and a thermal burn to his leg from hair tongs which had been followed up by the health-visiting service. A school nurse referral was made following concern for Riley’s growth and weight loss which resulted in a referral to the paediatric team, however, Riley was not taken to the appointment by Mother.  There was further involvement from services when Riley was six years of age. There was a domestic incident in which Mother’s partner set fire to Mother’s belongings in the garden and Police and the Fire Brigade attended the property. Mother’s partner was arrested but later returned to the family home.   When Riley was aged 8, Mother requested help from services due to struggling with his behaviour at home and Riley expressing to his Mother that he wanted to kill himself. The family were supported via Early Help for approximately a year. Riley underwent an educational psychology assessment which showed that his cognitive age was significantly lower than his chronological age. ADHD and Autism assessments were undertaken but were unsubstantiated. He received a diagnosis of Dyspraxia and sensory processing disorder at age 9. He struggled to access mainstream curriculum and attended a specialist school part time alongside his mainstream school. He was reported to have difficulty sleeping and a low appetite.  The case transferred from Early Help to the Children’s Disability Team when Riley was aged 9; this was to support Mother with direct payments. Riley spent time living with grandmother as support for Mother (approximately twice per month), supported by the direct payment. Riley was open to the Children’s Disabilities Team for seven years and closed to them approximately 8 months prior to the incident which led to this review being undertaken. A referral was made to TEWV for anger management support for Riley. Riley was taken to three of the five sessions by Mother. During one of these sessions, he expressed that he wished he was dead.   There were further Domestic Abuse incidents reported between Mother and Step-Father when Riley was 10 and 11 years old. In one such incident, Mother was physically assaulted and both Mother and Step-Father had been intoxicated at the time. Due to the case already been open to the disability team, the incident was passed on to the worker who undertook a home visit during which Mother expressed that she had left her partner.   School made a referral to CAMHS due to deterioration in Riley’s behaviour at school. CAMHS reported no assessed mental health need but felt that the mainstream school was not right for Riley.  Riley transitioned to a specialist secondary school. Riley was re-allocated to the LD CAMHS team who undertook an initial home visit, followed by a number of ineffective visits and cancelled appointments by Mother resulting in discharge from the service.    4 School reported concerns with Riley’s behaviour and Riley received a number of fixed term exclusions. His school attendance dipped and he was spending time during school hours out in the community with friends. At age 13 he was located by Police during the school day at local shops and was found to be in possession of a knife. He worked with Youth Offending for a period of time and was reported to have engaged well. A further referral was made to CAMHS due to concerns around behaviours and suspected ADHD. An assessment was completed with Riley who expressed that he finds it hard at school due to not understanding and that he also does not ask for help. Due to no evidence of a Learning Disability, LD CAMHS allocated a Primary Mental Health Worker (PMHW) for assessment, however Mother did not engage in taking Riley to the initial assessment.   At age 14, Riley’s behaviours both in and out of school escalated. He started to smoke cannabis and spend more time out with friends; with reports of anti-social behaviour. Riley was located by Police in the early hours of the morning with peers who had been reported missing by their parents. School and Riley himself reported that he was often angry and unable to control his emotions. A referral was made to Domestic Abuse Services for anger management support for Riley, however, Riley was not brought to appointments and attempts to contact Mother were unsuccessful; therefore, Riley was discharged from the service without receiving support.   When Riley was 15, there was a further domestic abuse incident in which Step-Father had attacked Mother and Riley was head butted when he had tried to intervene. A strategy and Section 47 enquiries were undertaken which concluded this to be an isolated incident and Riley continued to be supported by the Disabilities Team on a Child in Need basis. Riley spent more time living with Grandmother.   At the age of 16 he was arrested for assaulting his girlfriend during an argument over money for cannabis. Riley was reported to be suffering with mental health issues and suicidal thoughts. Domestic Abuse services attempted to contact Riley but telephone contacts were unsuccessful. Substance misuse services also tried to make contact with Riley but this was unsuccessful. Riley started attending college.  Riley was closed to the disability team just prior to his 17th birthday. It was felt that the direct payments were no longer required. Two months following the case closure, a disclosure was made in school by Riley’s half-sister. The disclosure was in relation to a domestic abuse incident in which Step-father had assaulted Mother in front of the children and threatened to kill Riley. A strategy and Section 47 enquiries were undertaken by the Safeguarding Assessment and Support (SAS) team, resulting in Riley and his half-siblings being supported on a Child in Need basis.   Riley’s behaviours escalated further. Riley began to disengage from college. He was arrested on a number of occasions (breaking into cars, threatening someone, smashing windows at home, burglary) and was rumoured to be involved in other criminal activity (setting fire to a car, hitting someone with a hammer) although this was not proved.  There were numerous missing episodes and Riley was discussed at the VEMT (Vulnerable, Exploited, Missing and Trafficked) meetings due to hitting the 3 missing episodes in 90 days trigger. Youth Justice Service attempted to work with Riley; with some examples of good engagement. Riley assaulted staff at placement and he displayed an increase in anger and frustration. He was referred to MACE (new VEMT arrangements) shortly prior   5 to the serious incident but was considered not to be at risk from exploitation as there was no new intelligence or information to indicate exploitation and it was felt that his needs could be met through his robust CIN plan which was overseen by his Social Worker and his core group of practitioners.   Key Questions posed by the Rapid Review  1. What were the child’s early emerging needs, how were these assessed and met? Did need change over time and were assessments and interventions responsive to this?  On the face of it, the only need Riley had was support with his behaviour and the difficulty mum had in managing this behaviour. However, a review of Riley’s life journey through the combined chronology, shows a different picture. There are incidents of domestic abuse and early indicators of possible concerns re: supervision of Riley by mother (at a very early age) which were not explored. There is no evidence of a holistic assessment being undertaken to review previous history to understand lived experience.   Practitioners responded to mothers request for support in relation to Riley’s behaviours without exploring further what was happening for Riley.   There appears that there was no-one who knew all of Riley’s needs; as practitioners were looking at only their bit of the system. Prior to 2020 (the point when Safeguarding team got involved) practitioners across the system did not talk to each other to triangulate information. There was a cycle of referrals for assessment for Riley’s behaviour and then either non engagement by Mother or assessment findings not shared with the wider workforce.   There was an additional complication of self-reporting and this becoming fact. There are records stating Riley had ADHD but then TEWV records state that he did not have ADHD or ASD and no learning disability.  However, the EHC plan states that Educational Psychologist assesses cognition as low and extremely low. There is no evidence of multi-agency discussions to bring all this together to fully understand Riley’s needs.   In conclusion: The information collected indicates that the child’s early emerging needs were not properly assessed and therefore not met. Assessments undertaken were single agency with limited sharing of information across agencies to understand Riley’s lived experiences. This was the position throughout Riley’s early childhood.    2. What was the child’s lived experience? How did these shape his childhood?  Riley’s Lived Experience has been set out below (this has been taken from his records)    6         7         8       9    Riley’s lived experience can only be seen when all the chronologies have been combined (this indicates that combined chronologies are a powerful tool to understand a child’s journey). In isolation each practitioner did not have a full view of Riley’s life.  It is felt by all those involved in this review that Riley’s lived experience has shaped his childhood and subsequent decisions he has made in his teenage years. Once the combined chronology was completed, Riley’s voice was very loud in telling us at every point of his life that he didn’t understand what was wrong with him and that no-one helped him. The review group felt that Riley’s experiences shaped his later years as follows:  Not understanding why he was struggling at schools and as a result disengaged from education  Listening to people saying he was the problem which has translated into self-blaming and internalising that he is the problem   Not understanding why he feels as he does and self-medicating with drugs  Witness to domestic abuse and has subsequently been a perpetrator of domestic abuse  Multiple needs that have not been met which has subsequently made Riley vulnerable to exploitation   In conclusion: Riley’s behaviours and response to situations are as a result of his childhood experiences. Practitioners needed to work together to assess Riley’s needs and work together to understand what support he needed to meet his needs. It is important at this stage that expertise across the system worked together to identify needs.        10   3.  Were there early indications of risk and vulnerability? How were these responded to in order to reduce harm? (From 2010 -2018)  There were early indicators such as domestic abuse and lack of supervision that, at the time, should have been more robustly reviewed. It is unclear (due to length of time since these incidents) whether this was further explored however there is no indication of follow up and a curiosity to know more.  It is assumed by the lack of interventions in the records that workers were not curious to explore Riley’s lived experience.   Practitioners very quickly decided that Riley’s learning and behavioural needs were the main issue and therefore everyone saw this case through that lens.     Domestic abuse incidents appear throughout Riley’s life however there does not appear to be further exploration of this in terms of impact on Riley and no understanding of the impact of this DA on mum and her ability to be available for Riley.   Education, Health and Care plan and Speech and Language service records show that Riley has communication needs and there were strategies set out in the records that would help to communicate with Riley. However, there is no evidence that this was discussed with practitioners working with Riley such as Early Help worker therefore it is unknown if Riley understood what was being said to him.   There were numerous assessments started, across organisations, however it is not clear how many of these were completed or shared. There were a number of times when mother did not take Riley to appointments which is a potential early indication of concern.  It does not appear at this stage that organisations shared this information to understand if this was a significant concern.  It feels a missed opportunity that everyone’s efforts at this early stage in Riley’s life were focused on Riley being the problem however there was never a joint understanding of Riley’s needs across the workforce.    It is also evident through this period of time that there were no discussions with Dad/stepdad. The review group understand that Riley’s Dad was in prison at this point however there is no exploration of the impact of this in Riley’s life. There is also no exploration with stepdad about his involvement/ relationship with Riley. This should have been fully explored in all assessments.   Riley and his family were supported by the Children with Disabilities Team through this period. Records show that the focus was on the family accessing direct payments. There does not appear to have been any exploration about what family life looked like for Riley, parenting capacity and the impact of domestic abuse.   In conclusion: There were definitely early indications of vulnerability such as domestic abuse incidents, possible lack of supervision, early signs of neglect and these were not sufficiently explored or addressed to reduce harm.     11  4. How well was the child’s learning needs understood by those working with Riley and his family? Was this taken into account in practitioners’ engagement of him and work tailored accordingly?  There is a mixed picture across organisations of what Riley’s needs were at the time and continue up to today. Self-reporting by Mother is accepted by some practitioners, educational psychologist indicated low to extremely low cognitive ability however TEWV records show Riley did not have a learning disability.   It is also clear in the records that Riley is accepting the view that something is wrong with him and feels helpless and hopeless to know what to do and starts to self-blame. Reflecting on this when reviewing the whole chronology indicates a self-fulfilling prophecy of a young boy behaving in a way that is “expected” of him.   There was no multi-agency discussion held to understand the full picture. It is expected that the team around Riley would discuss the difference in opinions in relation to Riley’s needs alongside the wider needs of Riley and family and agree the best plan to support Riley.   The EHC review process may have been a useful mechanism to have the discussion about Riley’s wider needs however social care and health input is limited with the focus being on education.    In conclusion: it is evident in the records that workers did not understand Riley’s learning needs. There was one Speech and Language assessment that indicated some strategies to use with Riley however it does not appear from the records that this was shared with the wider system to enable workers to engage with Riley in a meaningful way.    5. To what extent did practitioners understand and intervene in Riley’s early indicators of vulnerability, particularly to exploitation (2018 – 2019)? What impact, if any, did this have to divert him from harm? What else could have been considered?  Riley’s early indicators of vulnerability can be seen as early as age three. There are potentially multiple vulnerabilities which includes neglect, domestic abuse and learning needs. One of these in isolation would potentially impact on a young child however the cumulative effect of all of these with little evidence of effective multi-agency intervention is highly likely to lead to an increase in vulnerability to exploitation.    As Riley grew up, records show that he was increasingly labelled as troublesome. It is important that we reframe our response to children and young people that present with challenging behaviour. This behaviour is often a way for them to communicate their emotions, and needs to be explored to understand the child/ young persons lived experience. The review group reflected that the use of language by professions is incredibly important as children will internalise this and this will become their narrative as they grow up.     12 There is evidence that practitioners tried to better understand Riley’s needs in 2018 /2019/ 2020 which had a mixed response which is likely due to the trauma he has suffered throughout his childhood.  In conclusion: the review shows that practitioners (in 2018/2019) tried to engage with Riley during this time but they did not have an understanding of Riley’s childhood or is learning needs and therefore saw him through “troublesome lens”.  This means that any potential support/ intervention was ineffective due to a lack of understanding of Riley’s needs.   6. Learning Difficulty / Disability –   Do agencies and practitioners working with children and young people have a sound working knowledge of characteristics and associated potential impact of a diagnosis of learning difficulties versus learning disabilities?  How did they manifest in this case and how can practitioners tailor their work with young people at risk of exploitation to respond to their learning needs?  What are the most meaningful and effective ways of engaging young people with a  learning need at risk of exploitation  What would be the impact of tailored assessment, intervention and management of risk and vulnerability? What would we see that is different?  It is evident that practitioners are using learning difficulty and learning disability interchangeably without knowing the difference. However, when identifying and responding to a child’s needs do we need to be labelling to meet need? The IQ difference between a learning difficulty and disability can be negligible and only defines access to services instead of helping us understand how to meet a child’s needs.   This highlights the need for a needs led response instead of label/diagnosis. Once learning needs are identified there needs to be an agreement about the best strategies to use to support a child/ young person. On this occasion some strategies were identified but the lack of a multi-agency plan meant that these were not used consistently.   It is clear that Riley has some learning needs and if practitioners had understood this there may have been a way to understand his lived experience. However, practitioners didn’t look at the wider issues which would have been impacting on Riley. It is likely Riley’s behaviour in his early years was a combination of people not listening to him and seeing traumatic events such as Domestic Abuse incidents. Domestic Abuse, although a feature through the chronology, was not considered. In this case there was a need for a holistic assessment with all Riley’s needs explored and then a multi-agency plan to ensure we could meet these needs.   Interestingly Riley was referred to and attended anger management sessions. Reflecting on Riley’s voice within the review indicates it is highly likely Riley was feeling frustrated that no-one was helping him. In addition, Riley had learning needs that were not clear. On reflection, it is not surprising Riley would feel anger however an exploration of what Riley’s lived experience was would have probably been more appropriate than a referral to anger management.    In conclusion: In this case the workforce did not have a full understanding of Riley’s needs and therefore did not know how to engage with Riley. However it appears that the workforce were expecting a “diagnosis” to enable them to support Riley. It is clear from Riley’s voice that he just wanted people to listen to him and understand what his life looked like.    13 7. Early Indicators of Vulnerability to Exploitation   To what extent did practitioners understand and intervene in Riley’s early indicators of vulnerability, particularly to exploitation?   What lessons can be learned from the effectiveness and efficiency of the Contextual Safeguarding system and agency response; in order to inform continuing developments to the safeguarding system moving forwards?  As stated above there were indicators of vulnerabilities for Riley at a very early age. All responses seem to have been that Riley was troublesome without an understanding that Riley was traumatised through his early life experiences.   He told us that he was struggling to make friends at primary school which extended into secondary school. Based on the multiple vulnerabilities that were evident it is highly likely that Riley would have struggled to maintain relationships which may have made him a target to exploitation.   In conclusion: As indicated throughout this review the lived experience of Riley in his childhood has made him vulnerable to poor outcomes. This may not have been exploitation but his vulnerabilities made him at more risk from harm than his peers. These early vulnerabilities were not considered as he grew up and therefore not addressed to reduce his risk to exploitation.   8. Escalating Indicators of Exploitation    To what extent did practitioners understand and intervene in Riley’s escalating indicators of exploitation (2020 – 2022)? What impact, if any, did this have to divert him from harm? What else could have been considered?  What lessons can be learned for the effectiveness and development of the local area’s response to Contextual Safeguarding to inform and optimise the safeguarding system moving forwards? (This is to go beyond the date of the incident to include the potential links between Riley’s exploitation and how he responds to treatment and the response of services to this).  There is evidence within the chronology and in discussions with practitioners that there were concerns about Riley’s escalating challenging behaviours and needs. This appears to have increased anxiety across the workforce and resulted in numerous referrals being made to “specialist services”. At one point (Sept 2021) Riley was expected to work with:   Social Worker,   Family Support Worker,   Substance Misuse Worker,   Youth Justice Service Worker,   Forensic CAMHS,   One Stop Shop,   Domestic Abuse services,   YJS Speech and Language Therapist    AFOS clinical psychologist.  This must have felt overwhelming and Riley stated very clearly that he doesn’t know what everyone does and doesn’t understand why they all want to work with him. He says at this point that no-one listened to him before. This also needs to be considered in the context that Riley has learning needs and that he has a cognitive age of 11; so it is unclear what his understanding was.     14 This was discussed within the review group and it was highlighted that the two allocated social workers and family support worker developed a highly effective way of engaging with Riley. They developed an ongoing relationship with Riley and they ensured that Riley was supported to access the services that are set out above (many of these were required under the court order that Riley was subject to at this time).  This is good practice and should be adopted when working with young people.   There was also an email group set up specifically to share information on an immediate basis. This allowed all practitioners who were involved to share the risks and the plan. This is an area of good practice and is now being undertaken for young people at risk of exploitation through the MACE.   There is one occasion when Riley opened up to a YJS worker and this seemed to be a good opportunity to build a relationship to start to work with Riley to reduce the risks. However this happened just before the incident and, unfortunately, could not be sustained after his treatment. This interaction showed that Riley was upset, scared, and wanted help and if this model of one worker had been further developed earlier this may have improved the chances of Riley engaging and thus reducing his risks.   Another example of good practice was the interaction between Speech and Language Therapist (YJS) and Riley. Riley engaged and this was a positive intervention however on reflection, it is unfortunate that this came too late. This type of interaction should have taken place earlier in his life to prevent the risks associated with exploitation.   In addition, services were not “going to” Riley. He was expected to respond to workers on their terms. A number of agencies only used telephone contact however this was not successful, but they kept trying resulting in closing the case as they could not contact.   There was an increase in in Riley’s aggression from August 2021. The review group reflected on this and although there wasn’t one specific incident workers thought it was likely linked to the substances Riley was now using. In addition, the social worker reflected that a young person had been moved out of area which left a gap in the group that were leading the criminal activity. It is likely that Riley then filled that gap. This led to a discussion within the group of the importance of mapping all the young people collectively to try and understand the interaction of these groups. It was acknowledged that this has now started within the MACE and is expected practice.   A significant event for Riley at this time was when his girlfriend miscarried, and Riley’s aggression further increased. Workers were very respectful of the girl’s family’s wishes and Riley’s wishes at this point and workers backed off allowing them time together. However due to the subsequent incident being only a week after, there hasn’t been any specific work with Riley about this loss. It is likely that this will have significant emotional impact on Riley.  It is evident in reviewing the notes from the incident (Dec 2021 until Feb 2022) that there was no shared understanding of Riley’s learning needs which meant that there was a delay in understanding how his needs could be meet in relation to his treatment. The records are very robust throughout this period however it is clear that there was a delay in deciding if he had capacity. Discussions took   15 place across 12 days until he was deemed not to have capacity to make medical decisions. If there were records that set out some of the strategies outlined by speech and language services in his earlier life this may have prevented some of his distress at the hospital   It is also evident through the records and discussion with the review group that the joint work between children’s social care and the Foundation Trust safeguarding team was excellent. However the review group raised a number of concerns across this period of time which were contributing factors to Riley not receiving the treatment he needed:  Riley being placed on an adult ward without understanding his needs  shifts changes of nurses with no time to understand Riley’s needs  delay in transfer to Hospital 2 due to Riley contracting COVID  a significant lack of communication between the Hospital 1 and Hospital 2  Hospital 2 allowing Riley to leave without transferring back to Hospital 1 and allowing him to leave with Oramorph when he was known to have substance misuse issues. There was also no follow up re: ongoing assessment required to monitor effectiveness of treatment. This has resulted in Riley not wanting to engage with any health assessments which could be placing him at ongoing risk.   In conclusion: Practitioners at this stage were working together to try to support Riley. However this was without the full knowledge of Riley’s needs/ childhood experiences and therefore ended up being reactive rather than proactive. Riley’s perception was that services had not supported him in the past therefore why would they help now therefore making it more difficult to engage with him. In future it would be beneficial for MACE to review childhood experiences to understand why a young person is behaving in a certain way and putting themselves at risk.    RILEYS VOICE   Riley was spoken to via phone to get ask him about the support he had been offered and whether he felt it had helped him. Riley was happy to talk about his experiences and was engaging to speak to. He said:  “I knew something was wrong with me but no-one told me what it was. School helped me as they gave me a one to one. I went to CAMHS a couple of times but it didn’t make any difference. Everyone thought I was a naughty boy.”  When asked about domestic abuse he had witnessed he said “no-one asked me. Every boyfriend my mum had there was violence and I couldn’t help my mum. They would be taken away and then come back the next day.”  When asked about drugs he said “I use weed as it makes me calm and makes me sleep.”  Riley stated that he felt “what I have seen has made me.” (when he discussed his past)     16 Riley commented on being in hospital saying “there were loads of really ill people with cancer in there and didn’t have time for me.”  MUM’S VOICE  Mum was spoken to for a short time via phone and her response stated:  “I never got any support from anyone. I had to fight for help with Riley’s behaviours and I never got any help. I remember he had one psychological assessment but nothing came of it and no support.”  RECOMMENDATIONS:  MAIN RECOMMENDATION 1  Reflecting on this case it is highly likely that there are other “Riley’s” that will be at risk of exploitation if we do not intervene early. In order to prevent similar cases, it is recommended that the partnership undertakes reviews of all children that have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs.  In addition, there are two further supplementary recommendations:   Recommendation 2:  Explore the use of a communication passport which can be reviewed at key stages in a child’s life, so all agencies understand the strategies needed to engage with child/ young person with additional needs  Recommendation 3: Consider the partnership’s approach to adolescents receiving hospital treatment   This review covered a significant period of time in order to understand Riley’s lived experience. This means that there has likely been a change in practice since that time. It is therefore proposed that the partnership assures itself that practice has improved and includes:    1. The use of combined chronologies in multi-agency meetings  2. Children with disabilities workers fully understand safeguarding concerns in all cases and act as appropriate to safeguard children  3. Assessments take into account all vulnerabilities at the earliest opportunity – ensuring the Right Support at the Right Time 4. Agencies work together to understand the needs of a child and the strategies needed to work with them if they have learning needs. Ensure this is clearly recorded in all agency records.  5. Workforce to understand that children/ young people with challenging behaviour are usually trying to communicate with us and we need to find a way to understand their lived experience to ensure we can meet need. 6. Workforce know that learning needs can be a risk for young people to be exploited and the team around a child/ young person with learning needs consider this within their planning 7. “Was not brought” policies are robust and implemented effectively    17  PART TWO  Systemic Learning and Practice Improvement  Two sessions were held to review this case through Riley’s voice as it appeared through the chronology that the system did not always respond to what he was telling those around him. We explored Riley’s life journey from age 3 to the present day through an appreciative enquiry approach and discussed what best practice we would expect to see at each stage of his life. (Please note that practice may have changed since Riley’s early childhood and many elements of best practice set out below will already be in place).   There were three themes identified within these discussions which are set out below:   Identifying Need Best practice in identifying need would be a workforce that was professionally curious. The workforce will be looking at all children’s and family’s needs including parenting capacity in the context of their history. Workers would listen intently to children and young people to understand what life feels and looks like to them and ensure that children and young people voice is valued.  Workers would understand that children’s behaviour is a way for them to communicate. Workers would keep checking in with children and young people to ensure that assessments are dynamic as needs change. If there were concerns raised about any learning needs workers would work with specialists to understand these needs and the strategies needed to engage with these children would be recorded.   Best assessments are based on a positive relationships with child and family and recognise the importance of valuing the time needed to build these relationships; acknowledging that assessments need to be timely but not to the detriment of quality. Practitioners should seek to:   recognise and reflect on cumulative risk including parenting history, ACEs   actively communicate between agencies involved in assessing need  undertake joint assessments to ensure identifying all needs   see a child’s behaviour as their way of communicating and be reflective about what the behaviour could be telling us   be mindful of and use verbal and language that recognises the behaviour as a means of communicating; ensuring the child is seen as troubled rather than troublesome   be curious about the context / root causes behind presenting issues  recognising the cumulative impact of neglect on a child and the impact of trauma on brain development; understanding how this can manifest in adolescence       18 Responding to Need  Best practice in responding to need involves, in the first instance, building effective relationships with both the child and family but also within the team around. Practitioners who communicate effectively with each other to ensure that everyone understands the bigger picture and knows about changes as they occur are more informed and able to make more effective evidenced-based decisions. Children / young people and their families who own their plans and understand what practitioners are going to do to support, but also what their responsibilities are, are more likely to engage with the plan and to make the changes required. Organisations that do not have organisational silos enable true multi-agency working and ensure that the most appropriate worker (that family most engages with) supports the family; with specialist services supporting the worker. This maximises trusted relationships leading to more successful engagement and intervention.   A workforce that understands that a child’s behaviour is a way for them to communicate with us is more in tune to early indicators of vulnerability and does not see children/ young people as troublesome but actively seeks the reasons why they are behaving in a certain way in order to match response to need. A workforce that fully understands the impact of trauma (such as Domestic Abuse) on brain development and how this may affect learning needs are more able to respond effectively to need.   Support is based on meeting needs rather than a label or diagnosis. Learning needs and the way to engage children with these needs are shared across the multi-agency team around to ensure that we are working with children in a way that they can access.    Substance misuse and mental health services work together to develop shared plans to support young people to improve their emotional wellbeing and reduce their substance misuse.    Practitioners should seek to:   • place high importance on relationships - allowing themselves time to build trusted relationships with a child and family • where child is not brought to appointments, be creative in how and where these are offered to maximise possibility of engagement in these (assertive outreach) and explore the barriers for parents not attending  • co-ordinate the Team Around – not overloading a child with referrals / workers but considering what needs to be prioritised and who is the best person to deliver • quality assessment rationale to evidence when not able to meet timescales. • understanding needs - be needs led rather than service led • Joint Working – workers working together to be able to respond to multiple needs such as underlying learning needs and child protection concerns       19 Meaningful and Effective Engagement Best practice in meaningful and effective engagement means that the workforce is creative, innovative and persistent in engaging with children, young people and their families. It is built on the development of positive relationships which can take time however we commit to that approach.  Workers work together across organisational boundaries to ensure that the right people are supporting the child and young person. The workforce work together as a multi-agency team around the family to identify the worker that has the best relationship with child and family. “Was not brought” processes are robust and workers tirelessly follow up if children are not brought for appointments and escalate as required. Cases are not closed for non-engagement and workers seek support from the team around to support engagement.  The child knows we listen to them and act on what they say and we also feedback to child/ young person to ensure that they understand why we have done something. Practitioners should seek to: • Be creative about where and how appointments take place to maximise possibility of engagement and attendance • Be up to date / creative when working with / engaging young people and have appropriate systems / resources / technology (Snap Chat) in place to talk to children in the way they prefer  • The team around are consistent in their approach to engage young people and regularly review this to adapt their approach to meet the needs of the young person    Summary The initial focus for this review was to look at the way that partners across the system worked together when a child is identified at risk from exploitation. However it was clear once Riley’s life was explored that Riley’s potential exploitation was inextricably linked to his childhood experiences.  Riley has additional needs and witnessed and was subject to domestic abuse. These needs were not met and these experiences shaped Riley as he grew up and ultimately became at risk of exploitation.  It is important that the workforce understand the importance of understanding a child’s lived experience to ensure that children are supported at the earliest opportunity. This will reduce the risk of children being at risk of exploitation as they become adolescents. The workforce must also be aware that a child with additional needs is at a potential greater risk than those of their peers.   