Sexual abuse of a girl between the ages 10-16 years old. Child N disclosed the abuse to a mental health worker in September 2015 at age 19-years-old. Perpetrator convicted of multiple offences against her. Family is white British. Child N lived with her mother and older sister. Maternal history of: foster care; mental health problems; attempted suicides. Child Protection Plan initiated for both siblings for emotional abuse in 2007 due to concerns about multiple men in the home, and Child N being collected from school by different men; stepped down to Child in Need Plan and closed in 2008. Child N known to multiple agencies. Child N's sexual abuse was not identified; several professionals aware of her sexual relationship with an older man. Learning includes: need to reduce thresholds for intervention in complex cases involving neglect; need for professional curiosity and challenge; using historical information, including timelines, can help build a true picture, especially in neglect cases; a multi-disciplinary and/or multi-agency approach is good practice; need to 'think family'; need to consider sexual abuse when very young children self-harm or have injuries to intimate areas; perpetrator confession should be acted on. Uses a hybrid Individual Agency Review and Learning Review methodology. No recommendations. Considerations for the board include ensuring: all practitioners understand the indicators for neglect and are trained to do this effectively; guidance for sexual abuse, including the threshold guidance, is robust and understood; Child Protection Plans are outcome focused; all agencies escalate concerns and use a case resolution protocol appropriately.
      
 Title:  Serious case review: ‘Child N’. LSCB: Devon Safeguarding Children Board Author: Louise Newbury Date of publication: 2019  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                       Serious Case Review ‘Child N’ November 2018    Report Author Louise Newbury 2 | P a g e  Serious Case Review ‘Child N’  Overview Report    Contents INTRODUCTION Page Background to this review 5 The review process 5 Scope of this review 6 Methodology 7 CHAPTER 1 Family Background 8 CHAPTER 2 Timeline of key events 8 CHAPTER 3 Analysis 15 CHAPTER 4 Summary and Conclusion 33 Learning Points 34 Considerations for the DCFP 35 GLOSSARY AND APPENDIX Appendix 1 – Glossary of terms 37 Appendix 2 – Participating agencies 38 Appendix 3 – Documents consulted 39 3 | P a g e  INTRODUCTION   Background to this Serious Case Review  1 This serious care review (SCR) involves a young person who at the age of 19 disclosed to her mental health worker that she had been sexually abused as a child over several years between the ages of 10 and 16, by a man 10 years her senior. This man has since been convicted of multiple offences against her and has received a lengthy custodial sentence. 2 As a child, she was known to multiple agencies including health, mental health, Police and Children’s Social Care and was the subject of both a Child In Need and Child Protection Plan at times including during the time of her sexual abuse, yet her sexual abuse was not identified. 3 As a result of her sexual abuse, this young person has suffered significant mental health problems including several serious self-harm attempts, behavioural issues resulting in very limited school attendance and educational attainment, and ongoing health problems. 4 This young person was living with her parents and older sister. To protect their privacy, names have been changed and the young person will be known as child N, her sister as P and her parents as Mr and Mrs Q. Her assailant will be known as Mr R.   The Review Process  5 When a child dies or is seriously hurt and the family are receiving services from child care agencies, the Local Safeguarding Children Board (LSCB)1 has to consider whether a Serious Case Review (SCR) should be carried out. 6 The Devon Safeguarding Children Board, now known as the Devon Children and Families Partnership (DCFP) under the arrangements of Regulation 5 of the Local Safeguarding Children Boards Regulations, 2006, decided that in Child     1 See appendix 1- glossary of terms 4 | P a g e  N’s case, the criteria were met for a SCR. The Chair of the DCFP confirmed this and notiﬁcation of the decision was made to the Department of Education. 7 The purpose of the Review is:  To establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result; and As a consequence, to improve interagency working and better safeguard and promote the welfare of children.   Scope of this review  8 The review covers the period from N’s birth to when she was 18 years old. It follows the government guidance on Serious Case Reviews within Working Together to Safeguard Children (2015, page 75); however given that this review is being carried out a number of years after the abuse took place, it was felt unlikely that professionals involved at the time are still in post. The assumption was also that agencies’ understanding of child sexual abuse and child sexual exploitation and their practice in response to this form of abuse has also improved significantly in that period of time. 9 The Serious Case Review subgroup were therefore keen to understand in what ways practice has improved in Devon and to receive assurances from agencies that opportunities to identify child sexual abuse and appropriately intervene that were missed in relation to N, would not be missed today. They also wanted to understand what support enabled N to disclose the abuse when she was an adult, in order to ensure the right environment is in place to facilitate disclosure. In particular they wanted to find out what promotes early disclosure, and what helps practitioners to hear and recognise disclosure in such cases. 5 | P a g e  Methodology  10 A Serious Case Review Group was convened with appropriate independent representation from partner agencies and decided that the case met criteria for a Serious Case Review. Chronologies were obtained from agencies involved and collated into a joint chronology. After collation of chronologies, the Serious Case Review Group devised the following 6 key lines of enquiry: a. There is evidence that practitioners failed to recognise indicators of neglect, physical abuse, sexual abuse and/or sexual exploitation. How are organisations assuring themselves and the DFCP that practitioners are robust in their identification of and assessment of the risk of abuse? b. Are there barriers, individual or organisational – preventing professionals from identifying and acting on these indicators? If so what actions are taken or need to be taken to mitigate against these? c. Is there evidence that Child N disclosed or attempted to disclose abuse as a child and if so, why was this missed by professionals? d. How do professionals facilitate disclosure? What skills are needed by professionals dealing with children at different stages of development to facilitate this? e. To what extent do professionals recognise grooming (of children and professionals) and understand how this inhibits disclosure. f. To what extent do professionals understand the links (including coexistence) between neglect, CSA and CSE? 11 The SCR Group decided to use a hybrid Individual Agency Review and Learning Review methodology, focusing on key points in time where there were missed opportunities for identification and intervention. Agencies were tasked to provide an agency review that addressed these areas and also to compare how (if) services have changed since the time period of the assaults and provide assurance through analysis of their current services that practice has improved. Action plans were requested to address any identified gaps. 12 An Independent Reviewer was appointed. A shared learning event was held in April 2018, with over fifty practitioners representing Police, Education, Health 6 | P a g e  and Voluntary agencies, to draw out key points of learning from the agency reports, and to identify any additional current organisational barriers or opportunities leading to improved practice today. 13 In addition, some policy documents from agencies and national research documents of relevance to the issues of the Review were consulted. All the documents consulted are listed in Appendix 3. 14 N and her family were informed that the review was to take place. They were invited to take part in the review, and meet with the Independent Reviewer, but they declined contact.   CHAPTER 1  Family background  1.1 N was the second child born to Mr and Mrs Q. Her sister P was four years older. The family are of white British ethnicity and English is their first language. They are not known to have any particular religious identity. 1.2 Mrs Q’s mother died when she was an infant and she was in Foster Care from the age of 5 until 16. She had an ongoing, although reportedly difficult relationship with her Foster Carers. 1.3 Mr and Mrs Q separated when N was age 2. Mrs Q had long standing mental health needs and was under Mental Health services for many years. Several episodes of overdose are found within the clinical record. After separation from Mr Q, Mrs Q had several male partners living in the home, some of whom were a cause for concern regarding inappropriate behaviour towards the children and domestic abuse. 1.4 Mr Q continued to have ongoing contact with the children, visiting them several times a week. The relationship between Mr and Mrs Q appeared amiable. 1.5 From the age of 8 to 12, N’s older sister P became increasingly difficult to manage. Her school attendance fell, she developed mental health concerns and she was the subject of five referrals to Children’s Social Care during this time. In 2007, at the age of 14, P was made the subject of a Child Protection Plan 7 | P a g e  under the category of emotional abuse. This plan moved to a Child In Need basis in December 2007 and she remained a Child In Need until July 2008. 1.6 In September 2009, P was pregnant at the age of 16. The father of her baby was age 17. He and his older cousin Mr R (age 22) were found to be living in the attic of the family home in January 2009. They both had a criminal background and were felt by Police to be unsuitable males to be living with N and P.   CHAPTER 2  Timeline of key events  Date Age Event Agency May 1998 1 year Torn fraenum2, bruised lip and gum Health Visitor (HV) Nov 1999 2 years Child not brought to developmental review despite concerns regarding speech development 6 months previously HV March 2000 2 years Parents separate  March 2000 2 years Child referred to Paediatrics at local hospital for Encopresis (faecal soiling). Settles once starts nursery. Noted to have dental caries, poor diet, poor speech and poor growth. HV/ Hospital/ Nursery May 2001 4 years Behavioural change, extreme aggression. Mother later reports she is ‘full of bruises’. GP/ Hospital Feb 2002 4 years Onset  of  stammering  and  bedwetting,  then recurrent urinary tract infections – later felt to be Hospital      2Fraenum– small piece of joining tissue between upper lip and gum 8 | P a g e     cystitis3. Failed to respond to preventative antibiotic therapy. Later found to have duplex kidney4. Unusual symptoms, negative urine tests.  May 2004 7 years A and E attendance with bruising to inner thigh and injury to ‘vagina’ having fallen off swivel chair. Hospital Aug 2004 7 years Over familiar behaviour noted with mother’s new partner by child N and her sister. Strategy meeting. Plan for monitoring by school nurse. CSC Children’s Social Care (CSC) / GP /HV Nov 2004 7 years Safe work5 to start (both girls). Felt not to be child protection issue as partner had left home, but still in contact with mother CSC June 2005 8 years CAMHS (Child and Adolescent Mental Health Services) referral for behaviour concerns. CAMHS question Child Sexual Abuse in view of recurrent urinary symptoms. GP/ CAMHS 2007 10 years Assaults commence according to disclosure  March 2007 9 years Sister, P, made subject to Child In Need plan due to  poor  school  attendance  and  absence  of CSC      3 Cystitis – a inflammation of the bladder wall, not always caused by infection, may also be caused by irritation or trauma 4 Duplex kidney – kidney with two drainage systems rather than one. Can be associated with infections. 5  Safe Work-  a programme of intervention with a child, teaching them about safe relationships with adults. 9 | P a g e     boundaries in the home – no plan made for child N.  May 2007 10 years Referral to Children’s Social Care as male with risk to children in contact with child N’s mother. Initial assessment and section 476 enquiry results in child protection meeting. CSC/ Police/ Health May 2007 10 years Child Protection meeting: multiple men in home, child N being collected from school by different men. Child Protection Plan initiated for emotional abuse for child P and likely emotional abuse for N. Poor home conditions and mother’s mental health needs including overdose noted by core group. Stepped down to Child In Need in December 2007 and closed July 2008. CSC Dec 2008 11 years Behavioural concerns and distress related to multiple overdoses by mother and older sister P noted by school – referred to CAMHS. N not wanting to leave mother alone. CAMHS referred to CSC. CAMHS closes case after initial meeting with N and her mother independently. N discloses to CAMHS that domestic violence in home by mother’s partner, and that he has assaulted her. CSC and Police assessment of N’s allegation, then case closed without further action. CAMHS/  CSC/ Police Jan 2009 11 years S18 search (a search of the home after any arrest under  section  18  of  the  Police  and  Criminal Police/ CSC      6 Section 47 enquiry – an investigation that takes place when Children’s Social Care have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. 10 | P a g e     Activity Act) – home found to be ‘disgustingly filthy’ + 2 x ‘undesirables’ in home – living in attic. These were child P’s boyfriend and his older cousin who was child N’s abuser. Initial Assessment started by Children’s Social Care then not progressed  Feb 2009 11 years Bruise to cheek, referred to Children’s Social Care by school for assessment. Poor attendance at school – 34%. Behavioural problems. Referred back to CAMHS. Police/ Education /CSC Feb 2009 11 years Attended GP surgery with heavy periods – given Norethisterone7 tablets. Attended with mother’s partner who was under influence of alcohol. GP April 2009 11 years Dressing ‘provocatively’, untreated Urinary Tract Infection. Concern she could be sexually active. CAMHS/ CSC April 2009 11 years Mr R tells Probation Officer that he has a 15-year- old girlfriend with whom he has a sexual relationship. Names child N. Probation Officer refers to Children’s Social Care and is told that a Child Protection Conference will be held. CSC/ Probation April 2009 11 years Overdose. Not felt to be suicidal. Noted to be mixing with much older men. CAMHS say they can’t do therapeutic work as home life unstable. CAMHS/ Hospital June 2009 12 years Social Worker tells Probation Officer that the allegation of sexual relationship between X and Mr C is false and was made up by X’s mother and that there is no suggestion of any sexual contact. CSC/ Probation     7 Norethisterone is a hormone treatment given to stop periods 11 | P a g e   July 2009 12 years Seen weekly by GP with headaches and urinary symptoms. GP July 2009 12 years Overdose. Felt to be due to situational issues. For CAMHS follow up. CAMHS/ Hospital July 2009 12 years Child protection meeting (ICPC) - onto a Child Protection Plan for emotional harm. Sister P is pregnant at age 16 with one of men previously identified as living in attic in Jan 2009. N not attending school and mixing with people older than her. Going out at night with persons unknown. CSC/  Education  /Health March 2010 12 years Child Protection Plan ends, step down to Child In Need Plan (ended December 2010). N told Social Worker that she had had sex with a young man (Jamie) and another young person said that N was seeing an ‘older man’. CSC/  Health/ Education April 2010 13 years Overdose. Anxious regarding counselling sessions ending and not wanting to return to school. Closed to CAMHS May 2010. Hosp/ CAMHS Sept 2010 13 years Chlamydia screening Health Nov 2010 13 years Not attending school. Anxiety in crowds. Self- harm – boyfriend stopped her (age 14). Referred to CAMHS for initial assessment GP/ CAMHS Jan 2011 13 years Anonymous report to Police that P’s boyfriend had sold N to a drug dealer. Intelligence received that N and Mr R have been in a relationship since 1/1/11. Referral to Police and CSC, ABE8 interview –   no   disclosure   of   sexual   contact.   Core Police/ CSC      8  ABE interview – interview under Achieving Best Evidence arrangements (video recorded interview) 12 | P a g e     assessment shows a number of other concerns but no further involvement.  Feb 2011 13 years Police called to domestic incident at Mr R’s house – evident N in a relationship with Mr R age 23. N’s mother said she was unable to prevent the relationship so took her to see him. Bail conditions for incident include Mr R to have no contact with N. Disclosure by Mr R’s mother that N claims she has had a termination of pregnancy. This is later denied by parents. N says her period was late and she did a pregnancy test which was negative. She later denies sexual contact between herself and Mr R. No further action by Police or Children’s Social Care as information felt to be insufficient for disruption legal activities. Police/ CSC March 2011 13 years Mr R found drinking in a public place with N in breach of bail conditions. Mr R arrested. No further action. Police April 2011 14 years Mr R first investigated for possession of indecent photographs of children. Lengthy process to court –arrested initially July 2011, bailed but failed to attend interview repeatedly and arrested in June 2012. October 2012 (18 months later), CPS made charging decision and court appearance December 2012 where found guilty. Sentenced January 2013 for custodial sentence and given a Sex Offenders notice. Police/  Crown Prosecuti on Service (CPS) May 2011 14 years Mr R again discloses relationship with N to Probation Officer. Enquiry to MASH9 but no onward referral to CSC. Police investigate – N CSC/      9 MASH – multiagency safeguarding hub 13 | P a g e     denies  sexual  relationship.  Probation  contact school nurse to arrange contraception for N. Probation /Police/ School Nurse June 2011 14 years Mr R seen with N in public place simulating sex. No further action. Police Aug 2011 14 years Mr R found in N’s bedroom wearing no top by Police seeking him for another matter. Appeared he had spent night with N. On bail for possession of indecent images of children. Referral to CSC and joint visit with Police. Decision for Core Assessment and subsequent Child In Need Plan.  Jan 2012 14 years Mr R and N have argument. Police called. Mother admits N has contraceptive implant and items of ‘provocative’ underwear found in N’s bedroom. Mother not protective during argument. Information sent to MASH. No further action by MASH or CSC. Police/ MASH Feb 2012 14 years Food aversion Hosp/CA MHS Sept 2013 15 years Chronic pain referral Hosp 2013- 2015 15-18 years Miscarriage age 17, overdose, mental health concerns, domestic violence, and repeated health concerns with urinary problems. CAMHS, Police, GP Sept 15 18 Discloses abuse to Adult Mental Health worker in April and then Police in Sept 2015 Adult Mental Health services/ Police      14 | P a g e  CHAPTER 3  Analysis  3.1 Each agency produced an Individual Agency Report, looking at the key time points and identifying strengths and weaknesses in relation to N’s management. They were then tasked to provide evidence of current practice and whether the same strengths and weaknesses apply to practice today. 3.2 Identified strengths in relation to N’s management included:  The consistent and extensive support provided by N’s adult mental health worker, which included attending Police interviews with her.  The sensitive and victim centred approach taken by the Police after N’s disclosure, again with consistency of worker.  3.3 Identified weaknesses in N’s management included:  Failure to recognise multiple indicators of neglect.  Failure to recognise indicators or physical abuse, sexual abuse and sexual exploitation. A lack of appreciation of the co-existence of forms of harm.  A lack of including family associates and regular visitors to the home in a ‘think family’ approach. Failure to truly appreciate adolescent risk in the context of neglect  Organisational barriers to disclosure including multiple changes of staff and a lack of staff ‘hearing’ disclosure  Poor supervision of individual workers.  A lack of escalation when interagency difficulties were identified.  Procedure based rather than outcome-based planning within child protection procedures. Poor information sharing and working together in the context of complex and multiple risks. 3.4 In view of the length of time since many of the events occurred in this review, agencies were asked to provide evidence of where they are now in relation to 15 | P a g e  the key lines of enquiry, both within their written reports and through the practitioner event. 3.5 This analysis is presented here with reference to the key lines of enquiry.    a. There is evidence that practitioners failed to recognise indicators of neglect, physical abuse, sexual abuse and/or sexual exploitation. How are organisations assuring themselves and the DFCP that practitioners are robust in their identification of and assessment of the risk of abuse? 3.6 Agencies identified multiple opportunities to recognised indicators of all these forms of abuse in this case. Key points included: 3.7 Missed indicators of neglect including dental decay at a very young age, a requirement for behavioural modification under a year of age and delayed development including speech and social delay. She also had failed health appointments, poor linear growth, and rapid toilet training once at nursery, yet inability to achieve continence whilst still at home. She had behavioural problems and school refusal. Poor home conditions were identified by several agencies. Multiple men were known to be visiting the home and picking N up from school. Mother was seen to be taking N to her abuser’s home and she failing to intervene during an altercation between N and her abuser. 3.8 Missed indicators of physical abuse including torn fraenum and facial injuries at a young age, allegation of assault by mother’s partner and facial bruising at the age of 11. 3.9 Missed indicators of sexual abuse including recurrent urinary infections from a young age with a lack of response to treatment, sexualised behaviour with her mother’s partner, a disclosure that she had a sexual relationship at the age of 12 and taking a Chlamydia screen and a pregnancy test at the age of 13. 3.10 In addition, further indicators of sexual abuse and exploitation included an anonymous disclosure of her being ’sold’ to a drug dealer at age 13 and her long-known association with her abuser including his living in her home from age 10. She was also found to have ‘provocative’ underwear found in her bedroom and a disclosure she had a contraceptive implant at age 14. In   16 | P a g e  addition, a disclosure was made by her abuser to his probation officer that he was in a sexual relationship with her, made when N was only age 12. 3.11 Agencies were clear that there have been significant improvements in education and processes. All agencies have shown evidence that they have in place policies and procedures for safeguarding children, which are in line with the DCFP Procedures. All information in these procedures is based on ‘Working Together’ principles. 3.12 There has been a particular focus on neglect in Devon over the past year. In December 2017, the DCFP held its annual conference, on neglect. At the conference, they launched the new neglect strategy and toolkit. There was good representation from all agencies, including those involved in this review. Further training is expected across agencies on the use of the toolkit and the Graded Care Profile 2. Health services have additional guidance on some specific indicators of neglect, such as children not brought for appointments. 3.13 This is all very recent however, and it is possible that practice is not yet embedded. It will be important to ensure that all agencies have an understanding of this work and how it applies to their practice. There is optimism amongst agency representatives that the lack of recognition and triangulation of neglect plus other possible forms of abuse would not happen now.       3.14 Since the publication of the independent enquiry into Child Sexual Exploitation (CSE) in Rotherham in 2014, the focus amongst many agencies and safeguarding boards nationally has been the detection and management of CSE. This has led to considerable improvements since the time when N suffered her abuse - in both knowledge about CSE and how to disrupt the perpetrator’s activities in order to protect the victim. The same rigor however does not seem The DCFP should consider assuring themselves that practitioners from all agencies understand the indicators for neglect. They may wish to assure themselves that practitioners are confident in the use of the neglect strategy and toolkit. 17 | P a g e  to have been applied to Child Sexual Abuse (CSA) as a whole. DCFP however appear to be ahead of many other regions. In 2016 they set up a Child Sexual Abuse Task and Finish Group following publication of the Serious Case Review CN11 in January 2016, and in light of the Children’s Commissioners’ report on Child Sexual Abuse. 3.15 The DCFP have a well-established CSE subgroup, and partners have made significant changes to practice over the last 2 years. The Devon and Cornwall Police PEEL report of 2016 highlighted that Police had made improvements in its response to and management of child sexual exploitation, rolled out training across the force, introduced CSE champions and their awareness of CSE was high. Since then, the Police have trained most of their frontline practitioners in CSE in 2017 and CSE training including advice on disruption powers is now incorporated into generic safeguarding training. 3.16 The 2013 Ofsted inspection of Devon Children’s Social Care found ‘the current arrangements to respond to the needs of children and young people who are at risk of child sexual exploitation (CSE)... are not sufficiently robust. Inspectors identified a number of cases where the risks of CSE had not been considered or identified: consequently, children and young people are not adequately protected’. The subsequent Ofsted 2015 inspection reported notable progress, including risk assessment, management oversight and the extent to which the individual experiences of children are identified and considered. Policies, procedures and training are informed by the Rotheram enquiry of 2014, the Oxford Serious Case Review10 in 2015 and the Bristol Serious Case Review11 report of 2016. 3.17 Health services staff attend DCFP generic level 3 safeguarding training in which CSE is included.      10 The Oxford Serious Case Review 2015 into CSE in Oxfordshire– OSCB.org.uk/wp- content/uploads/SCR-into-CSE-in-Oxfordshire-FINAL-FOR-WEBSITE.pdf 11 The Operation Brooke Serious Case Review Bristol 2016 - bristolsafeguarding.org/media/1213/brooke-overview.pdf 18 | P a g e  3.18 For all agencies, there is a CSE risk tool providing guidance on defining, assessing and managing CSE. There are also a number of  independent organisations providing support and advice including: • The REACH service (Reducing Exploitation and Absence from Care or Home) includes one to one support for young people to help them recognise exploitation and to build on existing strengths to develop coping and keeping safe strategies. They also work with professionals offering support for cases and perform Return Home Interviews for missing children and young people. • CHECKPOINT (the equivalent service to REACH for Torbay), who also work with young people who have been sexually exploited in a similar way with one to one support. • There are MACSE (Missing and Child Sexual Exploitation) forums in Devon. These are multiagency meetings which share information regarding children and young people who are particularly vulnerable to being sexually exploited or trafficked. The aim is the prevention, protection and disruption of CSE and to ensure these children and young people are safeguarded. • JACAT (Journey after Child Abuse) is a child centred service which provides in depth psychological support to children and young people who have been abused. They provide consultation, co-working, training, group work, direct and indirect work. • The SARC (Sexual Advice Referral Centre) in Exeter provides crisis worker support, forensic examinations, sexual health information and referral and follow up emotional support to both children and young people who have been the victims of sexual abuse and assault. For children they also provide a clinic service for historical abuse. 3.19 The DCFP Child Sexual Abuse Task and Finish Group was set up in 2016 as a formal sub-group of the safeguarding board. Many other Safeguarding Boards still have no specific CSA subgroup. They have reviewed internal agency and DCFP training on CSA, they have conducted a benchmarking exercise of staff awareness and confidence in the recognition of CSA, and developed a toolkit 19 | P a g e  including the use of one minute guides and the use of the Brook tool12 for recognition of Child Sexual Abuse. They also determined several key performance indicators (KPIs) to monitor the impact of their plan. Unfortunately, whilst professionals indicated that they felt confident in recognising CSA, analysis of the KPIs last year showed little impact, and the number of children subject to a child protection plan for Child Sexual Abuse remains low in Devon. The CSA subgroup remains active and is now under new leadership with a new focus. 3.20 In the MASH, all staff have undergone CSA training, and managers from REACH offer regular consultations and workshops in relation to CSE. When practitioners working in Children’s Social Care (in the Initial Response team) were asked about CSA, a culture of empowerment was evident for staff, with managers supporting ground staff in confidence around dealing with possible CSA in families. 3.21 North Devon Healthcare Trust, who run the self-testing services for Chlamydia screening, have changed their policies since N took her test in order to better pick up cases of CSA and CSE. It is now their policy for any child under the age of 16 to be phoned with the result of their test, regardless of the result. Fraser competency is assessed, and a risk assessment carried out depending on age. This includes talking about emergency contraception, offering an opportunity to attend a setting, and if age 13-14 then contact is made with the safeguarding team and a safeguarding assessment takes place. 3.22 As part of this Serious Case Review, the social work team performed a dip sample audit of current cases under Children’s Social Care where children are subject to Child Protection Plans for Child Sexual Abuse (CSA). They found good examples of manager oversight and assessment in these cases. Of course, these are cases where CSA has been identified, we do not know about cases such as this one where there are indicators of CSA but no formal identification has been made.      12 The Brook Sexual Behaviours Traffic Light Tool – www.brook.org.uk 20 | P a g e  b. Are there barriers – individual or organisational – preventing professionals from identifying and acting on these indicators? If so what actions are taken or need to be taken to mitigate against these? 3.23 Concerns still remain regarding identification of child sexual abuse, as a very low number of children are subject to Child Protection Plans for Child Sexual Abuse in Devon (in 2017, 2.8% of all children were subject to CP plans). This compares to a national average in 2017 of 4.4% of children on a Child Protection Plan and 6.4 % of children on a Child In Need Plan. 3.24 The current barriers to recognition of sexual abuse and exploitation appear still to be a lack of knowledge regarding symptoms and signs, and a reliance upon verbal disclosure - as was seen in this case. Although there has been considerable investment in resources and guidance for Child Sexual Exploitation over the last few years, a comparable investment has not been made in resources and guidance for Child Sexual Abuse. 3.25 It is important to ensure practitioners have up to date knowledge and good quality, easily accessible guidance relating to Child Sexual Abuse.     3.26 In this case, further identified barriers to identifying and acting upon indicators of abuse, appear to be a lack of information sharing and joint working in such complex cases as this. Examples of gaps in information sharing include: a) Although Probation shared information by telephone with Children’s Social Care, they were not aware from this conversation of N’s true age. b) As there was no written communication, the significance of Mr R disclosing to a professional that their relationship was sexual may have been missed. The DCFP should ensure that guidance relating to Child Sexual Abuse, including that within Threshold Guidance, is robust and easily understood. They should consider assuring themselves that practitioners in all agencies are adequately trained and able to recognise and manage cases of Child Sexual Abuse in Devon. They may wish to consider developing a Child Sexual Abuse strategy as part of this. 21 | P a g e  c) The early health information from hospital and Health Visitor does not seem to have been taken into account when N was assessed in 2007 for emotional abuse. d) The hospital did not seem to have appreciated the full background of Mrs Q’s antenatal problems with mental health and other risk factors for neglect. e) The GP notification of the sexualised behaviour in the waiting room which was appropriately shared with Children’s Social Care, does not seem to have been taken into account when CAMHS queried CSA in view of her urinary infections. f) The possibility of CSA, raised by CAMHS to the GP, does not seem to have been shared with the hospital or Children’s Social Care.  g) The Police do not appear to have been informed about Mr R having disclosed that his relationship with N was sexual – this may have informed their subsequent management when faced with the pair being together in various settings. h) The risks of Mr R being investigated for possession of indecent images of children does not appear to have been shared with health, CAMHS, or Children’s Social Care until he was found in N’s bedroom in August 2011. 3.27 It is possible that if N had remained on an early help pathway between periods of Child Protection Planning, that the channels of communication between agencies would have been easier, as regular face to face meetings (team around the child or TAC meetings) would have occurred between the family and all professionals looking after N. Face to face meetings such as strategy meetings or team around the child meetings with all those involved with the child (even in a satellite manner such as the Probation) is by far the best way of ensuring information is adequately shared and risk assessed by all agencies, with multiagency engagement in planning. If this had happened in this case, it is possible that identification and termination of the abuse could have happened much earlier. 22 | P a g e  3.28 In addition, the use of the Early Help and TAC electronic recording process (meeting minutes and an Early Help Plan) can help clarify the information which is shared, and ensure all information is held in a place that all professionals can access. 3.29 It is important that methods of recording safeguarding information about children and young people are secure, yet available to other professionals if needed. The CP-IS (NHS Child protection information sharing system) system of information sharing has been adopted in Devon, currently involving the hospital and Children’s Social Care, though there are problems with its roll-out and it is not yet functional. 3.30 A highlighted problem has been retention of safeguarding records within schools. Both schools had destroyed or lost their safeguarding records regarding N. This has been a highlighted area recently within education, and most schools are now using online safeguarding data storage such as CPOMS13. There is now clear guidance regarding record keeping and the secure transfer of files between schools in a secure way, and this was highlighted in one of the recent Education ‘one-minute guides’ used by schools. 3.31 Training in record keeping is planned for health staff working in Community Paediatrics and Child and Adolescent Mental Health (CAMHS) in May and June 2018. 3.32 The use of the MASH as a means of sharing information between agencies at the point of contact has had positive outcomes for children. In January 2018, over 70 strategy meetings took place via the MASH, with 100% of cases having feedback to practitioners. 3.33 In N’s case, information gathered in previous assessments was not carried forwards. There was little consideration of historical factors and information became lost within the record. The use of chronologies and timelines is helpful       13 CPOMS – safeguarding and child protection software for schools – an online system to record and monitor child protection concerns in pupils. 23 | P a g e  in such complex cases and is recommended within the new practice standards for Children’s Social Care.  3.34 Children assessed by Children’s Social Care now have their assessment recorded on a Single Assessment template. The template contains embedded guidance which highlights that the assessment, conclusions and plan should be considered within a strengths based perspective and give close consideration to the personal, family and community resource available to the family and the need to target strengths and develop resilience. 3.35 The need for plans to become more outcome focused to drive purposeful interventions and improve outcomes for children has been highlighted as one of the top 10 areas for improvement in the Social Care Improvement plan for 2017/18 and has been made a priority for improvement in the forthcoming year.         c. Is there evidence that Child N disclosed or attempted to disclose abuse as a child and if so, why was this missed by professionals? 3.36 N had numerous interactions with practitioners in health, CAMHS, Children’s Social Care, education and Police but did not disclose verbally and directly her sexual abuse until she was an adult. She said herself that she lied about her relationship with Mr R to practitioners as she loved him and also feared she would not be believed if she told the truth. 3.37 N’s fear about not being believed was likely to be related to the fact that she had previous experience of disclosure leading to no action: The DCFP may wish to assure themselves that Child Protection Plans are outcome focused and drive purposeful interventions and improve outcomes for children and their families. The DCFP may wish to assure themselves that there are standards within organisations regarding safeguarding record keeping and that such standards include guidance on retention of records, clarity of record keeping, and accessibility. 24 | P a g e  • She disclosed in 2008 that her mother’s partner had assaulted her. • She disclosed that she was having sex at the age of 12 to a social worker. • She disclosed at the age of 12 to another young person that she was ‘seeing an older man’. • She said to her GP at the age of 13 that she self-harmed but was stopped by her ‘boyfriend’. • She disclosed that her overdose in 2010 was due to her worries about CAMHS input stopping, yet it still ceased. • She said in 2011 that she had taken a pregnancy test yet when she said their relationship was non-sexual this was not challenged. 3.38 We also know that at times she was told to lie to cover up abuse – such as when she disclosed about Mum’s partner assaulting her and later retracted her allegation. 3.39 Mr R was well known to the Police and his dealings with them may have coloured her interaction with the Police. He appears to have exhibited considerable control over her, evidenced by the fact that N’s relationship with Mr R had ended, and he had moved out of area, by the time she finally disclosed her abuse to her mental health worker in 2015. We know that victims of abuse in childhood often disclose only when they feel safe, and often only as adults. Mr R having moved out of the area may have allowed N to feel safe enough to disclose. 3.40 The appointment where N disclosed, was her first appointment with an adult mental health services worker – the change in approach from professionals working with children and those working with adults may have encouraged her to disclose. Her mental health worker also saw her at her home at this appointment, rather than in hospital. The change in venue may have added to her feeling safe enough to disclose her abuse. 3.41 Frequent changes of professional may have impacted on N’s ability to disclose. N had multiple changes of mental health worker when under CAMHS. She frequently had short action intervention and then was discharged again, sometimes after only one appointment. In total she went in and out of CAMHS services six times. She did have one long period of 9 sessions with one worker however and still made no disclosure. Her eventual disclosure was at her first 25 | P a g e  appointment with her adult mental health worker; however, this time the same worker then worked with her for over a year, until she herself felt ready to disengage with the service. 3.42 Medical appointments and hospital admissions focussed on N’s medical needs. She was rarely seen on her own without her mother. This may have been a barrier to disclosure. 3.43 Services often provided very separate care packages to N. Little face to face liaison took place between professionals, except for the episodes of statutory intervention within a child protection plan. When N did finally disclose to her Mental Health Worker, this individual travelled with N to see the Police and enabled her to forge a trusting relationship with the investigating officer, leading to further disclosure of her abuse. 3.44 Good quality supervision and interagency planning at the Early Help level can help facilitate disclosure even when changes of practitioner are necessary in services with a high turnover of staff, or patients are moved in and out of services. 3.45 Good planning is needed for transfer from one professional to another. Children’s Social Care are about to launch a case transfer policy, which includes principles of case transfer including that children and young people should experience the least number of transitions during their contact with Children’s Social Care.      d. How do professionals facilitate disclosure? What skills are needed by professionals dealing with children at different stages of development to facilitate this? 3.46 Agencies were asked specifically how they facilitate disclosure today, both in the Independent Agency Reviews and in the practitioner learning event. Devon The DCFP may wish to assure themselves that all agencies facilitate disclosure through consistent involvement of practitioners and good interagency sharing of information in all cases but particularly in those identified as high risk of abuse. 26 | P a g e  and Cornwall Police now have specific workers within the Police Force and good links with third sector agencies who can work over a long period with children and young people at risk. They are of the opinion that should N have presented today, the Youth Intervention Officer for her area would have become involved. The links with agencies such as SPACE14, Checkpoint and REACH enable workers to form trusted bonds with such young people. 3.47 In all agencies there is an increased awareness of the need to hear the voice of the child, both individually and in planning services. 3.48 Disclosure may happen at any age, to any professional. It is important that all staff know how to handle disclosure when it is made. Agencies identified that skills such as child focussed interviewing, the use of age appropriate references and language, and the importance of acting upon disclosure were vital to facilitate disclosure. Accurate recording of disclosure was also highlighted as an important skill.       e. To what extent do professionals recognise grooming (of children and professionals) and understand how this inhibits disclosure? 3.49 All agencies identified a risk of grooming of both children and professionals in complex cases such as this. Grooming of children was felt to be a particular problem for adolescents. 3.50 In this case, both N and her family showed signs of being groomed by Mr R and his cousin Mr S, including the men living in the family home, and N’s mother taking her to visit Mr R at his mother’s house.       14  SPACE (formerly the Devon Youth Service) has 8 youth centres within Devon, offering a range of services for Young People.   The DCFP may wish to assure themselves that all agencies train staff to facilitate disclosure at all ages from young children to adolescents. 27 | P a g e  3.51 There is also evidence of grooming of professionals in this case. When Mr R disclosed a sexual relationship with a 15-year-old to his probation worker (N was actually only 12 at the time), although there was a referral made to Children’s Social Care, no referral was made to the Police at the time. Although health and social care professionals found considerable evidence of neglect, there was frequently a lack of challenge made to the family. When N showed signs of mental ill health and distress at a young age, attribution was made to her difficult home life and the abuse she was suffering was not discovered. N was made subject to a Child Protection Plan twice with multiagency involvement, however both times the plan was ended with it recorded that there were no ongoing concerns and changes had been sustained. Between both plans however and after the second plan, N continued to have significant problems and her abuse was ongoing throughout this period. 3.52 It is recognised by professionals that N’s grooming by Mr R, together with possible grooming by Mr R and the family of professionals inhibited N’s disclosure. It is understood that to prevent this happening in future, grooming must be recognised and actively disrupted. To facilitate this, it is recognised that a culture of professional challenge and scrutiny is necessary. Where these were missing in this case, this led to drift and a delay in disclosure and resolution for N. 3.53 Since this case, a  formal escalation, or case resolution policy has been instituted within Devon. The policy is clear and concise and user friendly. If it had been in force at the time, the problems escalating concern regarding N’s care could have been resolved, leading to her abuse being recognised much sooner. 3.54 Audits within Children’s Social Care have continued to show a need for improvement in management and supervision. In order to tackle this, both practice standards and the supervision policy have been updated in 2017. Within this new policy, each child open to the supervisee should be the subject of supervision at least every 4 weeks, and the template for recording supervision includes prompts to ensure elements such as the child’s voice and experience are regularly considered. 28 | P a g e  3.55 Within the Police, there has been an increase in scrutiny and supervision of cases for safeguarding issues. With the development of the MASH and the central safeguarding team, all new Police cases involving children are now scrutinised daily. Internal reflective learning panels are timetabled throughout the year to critically examine the investigation of safeguarding offences. Multiagency case audits also take place and identify areas for development and facilitate the sharing of good practice. Direct supervision of cases takes place by the first line supervisor and complex cases are reviewed weekly by the Senior Management Team. 3.56 Within Health, all referrals to MASH are now quality assured both by community and hospital-based services. There are supervision policies within all health agencies and audit details of supervision by the community trust shows a clear understanding of concerning factors in both the child and their adults and carers. Within the hospital, safeguarding supervision has been embedded within the working culture, particularly of high risk areas such as Midwifery, Paediatrics and the Emergency Department. Peer Review also takes place for clinicians involved directly with safeguarding cases. 3.57 Probation are midway through a major organisational re-structure, resulting in increased recruitment of operational staff and increased capacity of front line workers and managers. Management spans of control are being reduced, enabling more frequent supervision of staff and performance data reports are being produced as a further check to ensure the right cases including child safeguarding cases are discussed and monitored. In addition, staff supervision templates are being revised to ensure safeguarding cases are identified as a standing agenda item in supervision. 3.58 Within the voluntary agencies involved in this case, there is an excellent supervision structure, including weekly case meetings as well as individual supervision. 3.59 Within Education, there is more difficulty. SWDA, the provider of out of school education provision, where the most vulnerable children often receive help, identify that they have an ongoing need for supervision. This is not provided currently due to limited resources. Within one school, internal supervision is performed informally, and they also have some external supervision from the 29 | P a g e  early help for mental health team. There appears to be no formal supervision however in either school contacted. This is an ongoing gap.          3.60 There are in addition several initiatives taking place in Devon where possible perpetrators of grooming may be identified. In particular, the ‘think family’ approach, which has been adopted by most of the partner agencies may aid identification. The acute hospital board have been particularly helpful in ensuring their staff use this approach. Devon and Cornwall Police use their ViST (vulnerability screening tool) to record all contacts where children are present. They are all reviewed by the central safeguarding team, who decide which cases need further information to be shared with partner agencies, or a child protection referral. 3.61 The MACSE forum considers perpetrators as well as victims of exploitation and today it is likely that Mr R would have come to their attention, further enhancing the response provided to N. 3.62 Community Health services also operate a ‘think family’ approach. In this case, N’s father received little attention or focus in investigation or planning. The increased use of genograms and considering the wider family and associates is vital in such cases. 3.63 The co-location of services in the MASH enhances the ‘think family’ approach. The close working relationships with Police, Health and Children’s Social Care allows for the consideration of the wider family and associates. The DCFP may wish to assure themselves that all agencies escalate concerns when needed and are aware of and use the DCFP case resolution protocol appropriately. The DCFP may wish to assure themselves that all agencies have appropriate policies and practice with regards to safeguarding supervision. They may wish to consider holding a themed audit of supervision. 30 | P a g e  3.64 Audit themes continue however to highlight the need to work with fathers and men in families.     f. To  what  extent  do  professionals  understand  the  links  (including coexistence) between neglect, CSA and CSE? 3.65 Several agencies identified a possible lack of understanding by professionals of the links between neglect, CSA and CSE. There appears to be a lack of research in this area, particularly in adolescents. 3.66 All adolescents may exhibit risky behaviour. In a safe and supportive environment, this leads to exploration of boundaries and is an essential part of development. In the context of neglect, or other abusive environments, then normal risk-taking behaviour can rapidly escalate and become damaging. In the case of N, she had suffered long standing neglect, and therefore was very vulnerable to all forms of exploitation and dangerous behaviour. 3.67 N was already exhibiting this by the age of 12, when she was known to be going out at night with persons unknown, associating with people older than her and possibly taking part in sexual activity. In addition, it is possible that N suffered sexual abuse at a young age, so this further impacted on her knowledge of healthy relationships. She was not in school so was removed from her peer norms and their experiences at the same age. Her role models in her sister and mother were not ideal and so she was at further risk of mental health problems and risk-taking behaviour in the form of overdose. 3.68 N’s vulnerabilities and particular risks as an adolescent appear to have been lost in the attempts to safeguard her. They should have led to an up-regulation of the early concerns regarding her relationships and lifestyle. Any relationship with Mr R, be it sexual or non-sexual should have been very concerning in view of  his  age  difference  and  criminal  behaviours  in  addition  to  her  other The DCFP may wish to assure themselves that practitioners consider the whole family and associates in the assessment and management of child protection cases. They may wish to assure themselves that there are effective ways of working between children’s, young peoples and adult services in the families most at risk. 31 | P a g e  vulnerabilities and a focus on changing the underlying risk factors should have taken priority. 3.69 A reflection of the lack of understanding of co-existence of risk is that there was an assumption that mother could protect N, despite evidence to the contrary.  At times, agencies withdrew intervention citing these risk factors as a barrier (such as CAMHS withdrawing care due to an unstable home environment). 3.70 The risks associated with neglect can become compounded further as in this case. N’s out of school provision relied on her remaining under mental health services, as it was provided on a health basis. When her CAMHS care was withdrawn as it was felt her home life was too turbulent, her out of school provision was also withdrawn, leaving her extremely isolated and vulnerable in the community. She cited withdrawal of services as the reason for one of her episodes of self-harm. Her vulnerability factors which were cited as her reasons for not receiving care should have led to increased support not a reduction in care for such a vulnerable adolescent. 3.71 Many of N’s long-term problems are likely to be not only due to her sexual abuse, but also due to her neglect. This has had a definite impact on her development and educational attainment. Her mental health problems are likely to be due to a mixture of her longstanding abuse and her lack of emotional development secondary to neglect. These are pervasive and lifelong conditions brought about by a combination of her neglect and sexual abuse. 3.72 The additional risks conferred from long standing neglect should be taken into account, and this is included in both the CSE and Neglect toolkits. There is evidence of excellent partnership working with a focus on adolescent risk within the MASH, within Multiagency Risk Conferences (MARACs) and within the MACSE forums. There are also a number of excellent providers of support to adolescents within Devon such as Young Devon, who have around 140 staff operating in more than two dozen locations across the county. 3.73 The provision for management of adolescent risk today appears very different from that present at the time that N suffered her abuse; however, some of the risks now are different too. It may be that agencies wish to broaden the remit 32 | P a g e  of their sexual exploitation forums to include other forms of adolescent risk such as other types of exploitation.         CHAPTER 4  Summary and conclusions  4.1 N was 19 years old when she disclosed that between the ages of 10 and 14, she was sexually abused by a man 10 years her senior. 4.2 N was known to many agencies both before and during her abuse, and she had two periods of being subject to a Child Protection Plan. 4.3 N did not disclose her abuse until she was out of contact with her abuser and had a stable therapeutic relationship with a mental health worker. 4.4 N suffered longstanding neglect; opportunities to pick this up at a young age were missed by several agencies. 4.5 N had multiple symptoms and indicators of possible sexual abuse, there were missed opportunities to recognise this by several agencies. 4.6 When sexual abuse was considered, the lack of a disclosure meant that concerns were dismissed. The DCFP should assure themselves that partners are moving from a sole focus on CSE to a wider remit of all forms of exploitation faced by young people. They may wish to assure themselves that organisations providing support to adolescents are appropriately funded and that pathways for access and collaboration are secure. The DCFP may wish to assure themselves that practitioners receive specific training on the co-existence and indeed increased risk of other forms of abuse such as such as sexual abuse and exploitation when neglect is identified. They may wish to ensure that these risks are identified and assessed appropriately within the neglect and CSE toolkits. 33 | P a g e  4.7 A confession of sexual contact by the abuser to his Probation worker was dismissed when information by N and her family was given that no sexual contact had taken place. 4.8 N tried to call for help, by self-harming including taking overdoses, seeing her GP frequently with low grade concerns, and giving clues regarding sexual activity even whilst denying it during dealings with professionals. She claimed she was sexually active to professionals (but with a child of her own age). 4.9 Professional  curiosity  was  absent  from  many  of  N’s  interactions  with professionals.  4.10 N has suffered long term complications with her emotional and physical health due to her neglect and sexual abuse 4.11 In most of these areas, agencies within Devon have shown considerable improvements in practice, especially with regards to Child Sexual Exploitation.      Learning Points  4.11 In complex cases where multiple classes of risk occur, the presence of neglect should reduce thresholds for intervention in other areas. 4.12 In order to disclose, children and young people need consistent contact with trusted professionals but may still not disclose until they are certain they are safe from their abuser. 4.13 Children and young people who are the victims of childhood sexual abuse and exploitation may not recognise themselves as victims and may actively mislead professionals investigating the case. This is because sometimes they feel that they are to blame for the abuse, and also because children often do not want to see harm or punishment coming to the perpetrator, especially if a care giver, or if they perceive themselves as being in a relationship with the abuser. Abusers are also often good at silencing their child victims. Professional curiosity and challenge needs to be applied in these situations. The DCFP should consider the best way of disseminating the learning from this SCR, so that it reaches as many practitioners as possible. 34 | P a g e  4.14 In some child protection cases, particularly in neglect cases, it is important to use historical information to build up the true picture and fully assess for progress long term against goals. 4.15 Children who fail to attend school need a multiagency approach to investigation and management of their non-attendance. 4.16 Children who self-harm at a very young age, need a multidisciplinary approach to investigation and management of their self-harm. The possibility of sexual or other child abuse should be considered. 4.17 Children with injuries to intimate areas should be assessed for the possibility of sexual abuse. 4.18 Poor quality of supervision leads to drift and poor outcomes for children.  4.19 Adolescents with risky behaviour benefit from a multiagency approach to management of their problems. 4.20 Perpetrator confession, especially to trusted professionals, should be held as the highest level of evidence for child protection investigations, in line with disclosure by the child. 4.21 Interagency working within the MASH facilitates high quality investigation and positive outcomes for children.   Considerations for the board  The DCFP should consider assuring themselves that practitioners from all agencies understand the indicators for neglect. They may wish to assure themselves that practitioners are confident in the use of the neglect strategy and toolkit. The DCFP should ensure that guidance relating to Child Sexual Abuse, including that within Threshold Guidance, is robust and easily understood. They should consider assuring themselves that practitioners in all agencies are adequately trained and able to recognise and manage cases of child sexual abuse in Devon. They may wish to consider developing a child sexual abuse strategy as part of this. The DCFP may wish to assure themselves that there are standards within organisations regarding safeguarding record keeping and that such standards include guidance on retention of records, clarity of record keeping, and accessibility. 35 | P a g e  The DCFP may wish to assure themselves that Child Protection Plans are outcome focussed and drive purposeful interventions and improve outcomes for children and their families. The DCFP may wish to assure themselves that all agencies facilitate disclosure through appropriate training, consistent involvement of practitioners and good interagency sharing of information in all cases but particularly in those identified as high risk of abuse. The DCFP may wish to assure themselves that all agencies have appropriate policies and practice with regards to safeguarding supervision. They may wish to consider holding a themed audit of supervision. The DCFP may wish to assure themselves that all agencies escalate concerns when needed and are aware of and use the DCFP case resolution protocol appropriately. The DCFP may wish assure themselves that practitioners are aware of the whole family and associates in assessments and management of child protection cases. They may wish to assure themselves that there are effective ways of working between children’s, young peoples and adult services in the families most at risk. The DCFP should assure themselves that partners are moving from a sole focus on CSE to a wider remit of all forms of exploitation faced by Young People. They may wish to assure themselves that organisations providing support to adolescents are appropriately funded and that pathways for access and collaboration are secure. The DCFP may wish to assure themselves that practitioners receive specific training on the co-existence and indeed increased risk of other forms of abuse such as such as sexual abuse and exploitation when neglect is identified. They may wish to ensure that these risks are identified and assessed appropriately within the Neglect and CSE toolkits. The DCFP should consider the best way of disseminating the learning from this SCR, so that it reaches as many practitioners as possible. 36 | P a g e  APPENDIX 1 – Glossary of terms  LSCB (DCFP) The LSCB is the Local Safeguarding Children Board, known in Devon as the Devon Children’s and Family Partnership (DCFP). This is a board made up of senior representatives of the organisations who have contact with children including Children’s Social Care, Police, health and education. It was a recommendation of section 13 of the Children Act 2004, that such a board should be established in each area. Serious Case Review Group This is a group of senior managers from across all agencies, whose role is to oversee the SCR process, advise the Independent Reviewer on local issues and ensure the quality of the report. Some members of the Group will ensure any recommendations from the Review are followed up with an action plan. Child Protection Case Conference A meeting of professionals such as teachers or social workers and a family to discuss a case and determine how best to safeguard a child and promote their welfare. This may be held following an investigation under section 47 of the Children Act 1989 (a child protection investigation). Child Protection Plan An outcome from conference, which assesses the likelihood of the child suffering harm and looks at ways that the child can be protected. Professionals decide upon short and long term aims to reduce the likelihood of harm and clarify people’s responsibilities and actions to be taken, together with outlining ways of monitoring and evaluating progress. Child In Need Plan When it is decided that a child is unlikely to achieve or maintain a reasonable standard of health or development without the provision of services from the Local Authority, then the child is registered as a Child in Need. This may be as step-down from a Child Protection Plan, or may be the outcome from a child protection investigation and a Case Conference. This is under section 17 of the Children Act 1989. A Child in Need plan sets out what works well, what support is required and why and which agencies will provide the required services. It also outlines what the expected outcomes are and what the timeframe of the plan is. 37 | P a g e  APPENDIX 2 – Participating agencies  Devon and Cornwall Police Devon Children’s Social Care Devon Multiagency Safeguarding Hub (MASH) National Probation Service Virgin Care Ltd – CAMHS, Health Visiting, School Nursing1  South West Ambulance Services NHS Trust North Devon Healthcare Trust  Torbay and South Devon NHS Foundation Trust Devon Doctors (out of hours GP services) GP Surgery  Devon Partnership NHS trust (adult mental health services) Teignbridge Housing (Young Devon) Education (including education other than at school service)                                                            1 Virgin Care Limited were involved in the review but were not the provider of childrens community health services during the period under review. 38 | P a g e  APPENDIX 4   Documents consulted   Devon Neglect Strategy   Devon Case Resolution Protocol   UK Government official statistics – characteristics of children in need 2016-2017  https://www.gov.uk/government/statistics/characteristics-of-children-in-need-2016-  to-2017   NSPCC child sexual abuse facts and statistics 2017:  https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual-  abuse/sexual-abuse-facts-statistics/   Working Together to Safeguard Children 2018  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach  ment_da/file722305/Working_Together_To_Safeguard_Children_-_Guide.pdf   DCFP Annual Report 2016-2017  https://www.devonchildrenandfamiliespartnership.org.uk/uncategorized/annual-  report-2016-2017/   NSPCC – How safe are our children? 2018 