In August 2020 a 15-year-old male was involved in a stabbing incident. This was the third knife-related event which he had been connected to in 2020. He had already been subject of 'child protection plans' for over 2.5 years and during his early teenage years, there had been numerous safeguarding or other referrals involving his family. Recommendations include: the Partnership should compare the findings of this CSPR with findings emerging from other comparable cases, identify commonalities and develop priorities for the local Partnership, including in particular the capacity in the local network to recognise and address identified need for therapeutic trauma-related responses via Child and Adolescent Mental Health Services; take all necessary steps so as to be able to offer the Safeguarding Partnership an assurance that uncompleted tasks such as home visits to those subject of a child protection plan are detected and recorded at review conferences; those responsible for chairing functions such as child protection conferences have the knowledge and professional confidence to escalate serious service delivery failures of the sort observed in this case; and the police service should review and refresh its expectations of police- imposed conditional bail in cases where there is an extensive history of violence.
      
 Title:  Child safeguarding practice review (CSPR): ‘C84’. LSCB: Torbay Safeguarding Children Partnership Author: Fergus Smith Date of publication: 2021  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.                                                                                                                                                                                                   TORBAY SAFEGUARDING CHILDREN PARTNERSHIP  CHILD SAFEGUARDING PRACTICE REVIEW (CSPR)     ‘C84’   FERGUS SMITH  29.07.21                                                                                  CAE                                                                   1                             1 INTRODUCTION  1.1 TRIGGER FOR CHILD SAFEGUARDING PRACTICE REVIEW  1.1.1 In late August 2020, C84 (a then 15 year old male of unrecorded heritage resident in Paignton with his mother and siblings) was involved in a stabbing incident. It was the 3rd knife-related event to which he had been connected in 2020. C84 had already been subject of ‘child protection plans’ for over 2.5 years and during his early teenage years, there had been numerous safeguarding or other referrals involving his family. Initial concerns had been in relation to domestic violence between mother and her then partner. C84’s behaviour had escalated into engagement with drugs and displaying more aggression. 1.1.2 In response to the latest incident, Care Proceedings were initiated on C84 and his siblings. Regulator Ofsted and the National Child Safeguarding Practice Panel were notified of the above context and a decision reached at the local ‘Rapid Review Meeting’ on 09.09.20, that an independently conducted CSPR was required. 1.2 PURPOSE, SCOPE & CONDUCT OF REVIEW 1.2.1 The purpose of this CSPR focusing primarily on the period 2018 to September 2020 and which was completed between March and June 2021, has been to review the following lines of enquiry: • C84’s background / experiences: multi-agency case recording to identify pre-existing information, identifying the complexity of C84’s ‘lived experience’, establishing his opportunities to articulate that by means of engagement with local services, evaluating effectiveness of multi-agency engagement and progress of child protection planning / review / core groups • Acknowledgment of good practice • Responses to ‘missing episodes’: establishing quality and timeliness and whether all relevant lines of enquiry were properly and fully pursued and risks effectively managed • Responses to offending behaviours: how actions and assessment of risk was shared and understood  • Supervision and oversight: how actions and assessment of risk was shared and understood  • Safeguarding Practice: establishing how safeguarding concerns including criminal exploitation were identified, recorded and responded to (including use of ‘Professional Escalation’ policy, evaluating timeliness and effectiveness of information sharing between agencies and reviewing this against local and national guidance on safeguarding policy / procedure - including ‘missing & child exploitation (MACE) meetings, missing strategy discussions and child sexual exploitation (CSE) vulnerability checklist,                                                                               CAE                                                       2                                       designated safeguarding lead responsibilities and safeguarding training  • Overall effectiveness: analysis of reasons why services / intervention appear to have had little impact upon outcomes for C84   • Criminal exploitation: establishing quality / timeliness of responses to criminal exploitation and whether all relevant risks / lines of enquiry were identified and fully pursued, evaluating multi-agency response to C84 as a perpetrator and victim of exploitation and evaluating responses to abuse / exploitation in terms of lessons learned from other Torbay Safeguarding Children Partnership (TSCP) 1.2.2 The key purpose of the review is to prevent future similar harm and learn lessons so as to further safeguard and promote the welfare of children. It has been based upon information derived from: • A merged chronology and a large number of additional documents provided on request by Torbay’s Safeguarding Children Partnership (TSCP) • Consultation events for practitioners and managers   1.2.3 The author was advised and supported at 4 panel meetings by representatives of Health (Clinical Commissioning Group and Primary Care), Torbay Children’s Social Care (Looked After Children, Local Authority Designated Officer (LADO) and Independent Reviewing Officer (IRO) Services), Education, Youth Offending Service and Devon and Cornwall Police. 1.3 FAMILY STRUCTURE & INVOLVEMENT                                                                                                                               1.3.1 His mother and C84 himself were informed of this review and invited by means of hand-delivered letters, to contribute. The author completed a phone interview with a very articulate and co-operative mother and her views have been incorporated into this final draft. C84 also agreed to contribute but an initial conversation was cut short for technical reasons and the young man has not responded to further messages.   Birth father Birth mother Step-father  C84 Half-brother Half-sister Brother                                                                                CAE                                                       3                                       2 SERVICE DELIVERY 2015: First report of adverse childhood experiences 2.1.1 GP records of early and middle childhood reveal nothing of significance and C84 was known only to ‘universal’ services. In early 2015, a then rising 10 year old C84 informed his teacher that he knew where to get Crack Cocaine and Heroin and that step-father was a dealer. This information was appropriately passed to Children’s Social Care. The referral prompted involvement of the ‘Early Help Service’ and later, allocation of a family support worker FSW1 from the Family Intervention Team ‘FIT’ (a team within the Targeted Help Service). It has been confirmed that Police were not informed. Insofar as the case was considered by members of the local ‘Early Help Panel’ on in mid-February, there was clearly a systemic opportunity for C84’s ‘voice’ to have been heard more clearly. Records indicate that what the school described as a ‘Child in Need’ (CIN) meeting was convened in April and that the FIT, having arranged counselling for C84, closed the case. 2016: ‘Domestic abuse incident 1’ & assault of another pupil 2.1.2 In early July, records refer to ‘domestic abuse incident 1’ when C84 (aged 11) had called the Police. He and his siblings had been present during an argument between mother and partner. When officers attended, no offences were disclosed and the partner left the home. The ViST1 notification was graded ‘low’. Having moved up to his Secondary School in September C84 (11.5) and for the 2nd time, assaulted another pupil who was rendered unconscious and hospitalised. An acknowledged fear of reprisals by C84’s family resulted in no further action being taken by the attending officer and no ViST was completed. That response masked the seriousness of what his conduct meant to C84. The incidents, set in the context of what was known or suspected again required completion of a ViST and a decisive and collaborative (Police / Social Care) approach. Even if the victim did not wish to offer evidence toward prosecution agencies needed to address the implications for C84, siblings and probable future victims. As a result of the assault, about which C84 reportedly showed no insight or remorse, he was permanently excluded and assessed with respect to a suitable alternative school.  2017: More domestic abuse incidents, child protection responses, further violence by C84 & exclusion from school 2.1.3 By early February C84 was back in mainstream education at a local college. During his next 2 terms there, there were several confirmed incidents of spontaneous aggression and/or violence toward pupils. This would eventually prompt involvement of Pastoral Care as well as external sources of support. In May 2017, C84’s mother disclosed to  Police that she had been the victim of domestic abuse for 4 years from an ‘ex-partner’. She disclosed daily assaults witnessed by the children and being petrified of him.     1 ViST = a screening tool intended to identify and risk-assess the ‘vulnerable’.                                                                               CAE                                                       4                                       2.1.4 Mother further alleged he had threatened to kill her and the family and was claiming to have access to firearms.  She specifically alleged a physical assault witnessed by the children, on a date in early May. The ‘ex-partner’ was arrested and interviewed. For lack of evidence, the matter was not proceeded with. The children were not spoken to as part of the investigation. A ViST was graded ‘medium’ and a subsequent DASH assessment evaluated the risk as ‘medium’ and referred to the Multi-agency Risk Assessment Committee (MARAC). Children’s Social Care records indicate that a subsequent investigation led to an Initial Child Protection Conference (ICPC). Torbay South Devon NHS Foundation Trust though, has no record of any multi-agency response e.g. neither a strategy meeting or a multi-agency safeguarding hub (MASH) referral. Later in May, a verbal argument at C84’s home occurred between mother and her ‘ex-partner’ who had apparently been told ‘not to see the children for a week’ and had been living in his car. 3 of the 4 children were present. No offences were disclosed.  2.1.5 An initial ‘child protection conference’ (ICPC) was convened in mid-June and chaired by CP1. It resulted in a decision that all the children were to be made subject of child protection plans under the category of ‘emotional abuse’. Having been excluded from school for a further episode of violence, C84 (12) was spotted attempting to steal from shops. Attending police officers returned him home to his mother who felt that his conduct was worsening. No formal action was taken. Social worker SW1 was alerted. Soon after his return from time-limited exclusion, C84 again instigated a violent assault on a pupil, used obscene and abusive language toward some teaching staff and was excluded for a further 5 days. Health Trust records (none were located by Children’s Social Care) confirm that the 1st formal ‘core group meeting’ was convened at the end of June. School nurse SN2, health visitor HV1 and SW1 were present though it is  unclear whether either parent was. SW1 agreed to explore support for C84 from the Youth Offending Team (YOT).  2.1.6 Though police officers attended and searched C84, a report in early August that he possessed and was waving a penknife around, was not confirmed. Days later, when C84 (12) was accompanied by others and refusing to leave a shop from which they were banned, Police arrested him. He was later de-arrested and no further action taken. The conclusion of a review child protection conference (RCPC) in September at which mother and step-father were present, was to continue with the child protection plan. There was evidence of reduced substance misuse, the parents had though, not been living under the same roof, mother had not been offered a place on the ‘Freedom’ domestic abuse programme and the quality of contact time with the children depended wholly on step-father’s account (for unstated reasons, it was no longer being supervised). School records relating to the Autumn term evidence ongoing defiant and aggressive behaviours and following an incident on in November when C84 (rising 13) initiated an attack on a pupil, he received a time-limited exclusion. Following further aggressive conduct at school, C84 was permanently excluded and subsequently placed on roll at a local Academy.                                                                                  CAE                                                       5                                       2018: Further violence, review of child protection plans, links to     drug dealing & theft  2.1.7 In January 2018 C84 assaulted a male fellow pupil causing minor injuries. Police attended and the incident was recorded as a crime, though no further action was taken. The victim’s parents were reluctant (possibly fearful) to support a formal response. A RCPC was held in April and included mother and step-father. Records reveal an interesting contrast between the clear descriptions offered by C84’s younger brother - ongoing drug misuse, ‘5 months since he had seen the allocated social worker’ SW3 etc and the congratulatory tone adopted toward the parents who were now (they said) reconciled. A decision was made to remove C84 and siblings from protection plan status and not even to consider them as ‘children in need’2.  Intrinsic contradictions are apparent e.g. mother had not undertaken the recommended ‘Freedom’ course. Children’s Social Care regrettably failed to involve or inform partner agencies with respect to its ill-informed decision. Though no details have been provided, the level of engagement shown by C84 with a local alternative education provider is reported to have deteriorated, coinciding with a stabbing for which he was a suspect. During Spring and Summer C84 was also suspected of involvement in a number of incidents of anti-social behaviour. 2.1.8 Children’s Social Care records refer to C84 sharing images of drug wraps and an associated narrative about knife and drug crime on ‘Snapchat’. He was tentatively linked to a named local gang. This intelligence was not shared with Police. In mid-October, C84 was one of a group of teenagers who assaulted a 15-year-old boy trying to steal his phone. C84 was subsequently eliminated from the investigation.  2019: Attempted murder investigation; ongoing protection responses; drugs raid & disclosures by C84; ongoing & enhanced protection planning; further violent incidents 2.1.9 In mid-January 2019, Police attended a man reportedly stabbed and seriously injured by 4 hooded attackers. C84 was later identified as a suspect in the robbery. Following investigation, the main suspect was charged but the Crown Prosecution Service (CPS) did not authorise charging the others including C84. From this point, it was clear that C84 had the capacity to be involved in planned violence including use of a knife. In response to C84’s involvement, a well-attended strategy meeting considered the possibility of offering to voluntarily accommodate C84 under s.20 Children Act with an ‘out of area’ placement. That idea was not captured in the records of the ICPC that followed at which mother was reported as minimising the incident. C84 was reported to be engaging well with the YOT worker (YOT1). Agreed actions were to initiate ‘Keep Safe’ work with all the children and a possible referral to Community CAMHS for C84 based upon possible Attention Deficit Hyperactivity Disorder (ADHD) or Post Traumatic Stress Disorder (PTSD). No such referral was made then or later.    2 Under s.17 Children Act 1989 a child is ‘in need’ if s/he is unlikely to achieve or maintain, or have the opportunity to do so, a reasonable standard of health or development without provision of services by a local authority, or if her/his health or development is likely to be significantly impaired or further impaired  without such services, or s/he is ‘disabled’.                                                                               CAE                                                       6                                       2.1.10 In March 2019. a ‘Drugs Raid’ was completed at C84’s home. A significant quantity of controlled drugs was found and his step-father arrested. In response to the above incident and mother’s unwillingness to engage in any prosecution (thus leaving her children exposed to the ongoing consequences) a 5th strategy meeting chaired was (according to Health records – Children’s Social Care has no record) convened. The agreed conclusion was that the family would be discussed at MARAC, Children's Social Care would seek legal advice and the school nurse would a complete a lone working assessment about home visits. the case was also scheduled for discussion at a Legal Planning / Legal Gateway Meeting3 in May though no records confirm that it took place. 2.1.11 Children’s Social Care has a record of C84 in April, reporting to YOT1 (with whom he had developed and would retain an excellent working relationship) that: • He and the younger siblings were ‘terrified’ of step-father   • C84 had witnessed his mother being pinned to the floor and hit so hard that ‘bits of her face flew off’  • He had thought that his mother was dead on one occasion because his step-father had ‘stabbed her with a fork in her leg’ and held her down until she ‘blacked out’  • The step-father doesn’t allow his mother to have other people in her life and has threatened to kill her • Mother experienced a significant beating after she had told her partner to ‘be quiet’ when he started shouting whilst the family were having a meal in a pub  • C84 said that in the past when his step-father has been unable to come to the house he has ‘smashed his way in through the door’ and ‘smashed windows’ to get in. 2.1.12 C84 said that the smaller children were locked into their rooms to keep them safe but that he stayed present to protect his mum. He referred to a previous occasion when step-father had pointed a gun through the window. This was a clear and credible account which explained a great deal of the anxiety and aggression apparent in C84’s daily behaviours. The previously agreed MARAC referral had not been progressed. In late April, in response to the account by C84 (in particular a plan to kill his step-father whom mother had by then re-admitted to their home), a 6th strategy meeting was arranged. Police records (no Children’s Social Care record found) refer to C84 suffering night terrors, sleep paralysis and a disturbing calmness when talking about and carrying out violence. He thought about and planned in detail, how to kill his step-father.  Safeguarding measures were put in place with a ‘marker’ on their home to alert call takers to domestic abuse and the ‘Domestic Abuse Unit’ was made aware of the concerns. Agreement was reached for a single agency s.47 assessment and that the case be presented to the agency’s ‘Legal Panel’ in early May 2019. A subsequent failure to follow through on the legal route was a major missed opportunity.    3 Legal Gateway Panel = chaired by Head of Service with legal representation, it considers legal threshold for pre-proceedings (Public Law Outline PLO) or issuing of notice of Care Proceedings                                                                               CAE                                                       7                                       2.1.13 Information not apparent in the chronology provided, was that, following consultation with an unnamed Independent reviewing officer (IRO) in late April, the case had been determined by an unnamed manager, to be transferred into the ‘Innovations team’4. That team was to be tasked with getting the case to the Legal Panel within 14 days. A ‘Risk Assessment’ and ‘Danger Statement’ were also to be completed. No evidence has been found that the tasks were completed.  It has also proved impossible to find any evidence of management oversight, supervision or of progressing what had been defined as urgent. 2.1.14 Toward the end of April, C84 with others was apprehended ‘hot-wiring’ a car. After a review of the case, no further action was taken. At a RCPC in June (with SW5, HV2 and mother and step-father). It was noted that the children were continuing to make disclosures and that the parents had been found to have drugs at home. No work had taken place with parents or children and no home visits or core group meetings completed. The failure to execute agreed plans should have triggered escalation to management. No minutes have been traced.  2.1.15 About a week later, C84 was involved in an altercation on a bus. The victim was not traced and (aside from a verbal warning and confiscation of alcohol found during a body search) no further action was possible. A ViST graded ‘green’ was submitted. In early July 2019 a local Academy initially agreed to try to manage C84’s education whilst an assessment for an Education, Health and Care Plan (EHCP) was being undertaken. It later reversed its offer citing new (unspecified) information shared via the SEN process and by Children’s Social Care. Police records dated 10.07.19 refer to an earlier undated ‘complex strategy meeting’ and discussions about the links between C84 and others known to be involved in crime. A description of how C84 had contemplated killing his step-father was shared. Further material was apparently supplied and reflected within Children’s Social Care, concerns of the risk posed by the stepfather and of criminal and possible sexual exploitation. The conclusion of subsequent research by Police was that no additional action by that agency was required and that Care Proceedings might offer the most appropriate way forward. 2.1.16 Children’s Social Care records refer to a positive relationship between C84 and worker YOT1. Reference was made to ongoing domestic abuse and the reputation of the step-father. The latter was not supposed to visit but had been seen at the house. An obvious need to expedite legal action appeared to have been recognised.  In mid-August a complex strategy meeting noted that C84 might be at risk of criminal and possible sexual exploitation e.g. missing children stayed at his address and one informant described his bedroom as having 3 single beds in it. C84 had been seen (by whom is unknown), to be aggressive towards his mother who was thought to fear him. SW6 was allocated the case. Given chronic exposure to domestic abuse, it is unsurprising C84 had assumed the role previously occupied by step-father.    4 This team (of independent social workers) is reported to have been a response to what had been recognised as an urgent need to more effectively respond to identified risks.                                                                               CAE                                                       8                                       2.1.17 There were further examples over the Summer of unprovoked violence and fire-raising by C84. For lack of sufficient evidence (sometimes a result of fear) no formal action followed. An early example of such a situation was when C84 (15) seriously injured (possibly by means of a knuckleduster or similar weapon) the face of an 18 year old victim. A refusal by the victim and his girlfriend to offer evidence blocked the possibility of a successful prosecution. So as to avoid overnight detention in custody, C84 was de-arrested; though the seriousness of the assault in the context of known history could have justified overnight detention in custody. A further strategy meeting in August heard from YOT 1 that C84 spoke constantly about violence and was still reporting step-father’s presence at home. It remains unclear why step-father’s presence was not confirmed and legal steps taken to prevent it and/or initiate alternative care arrangements. In the light of the local College’s understandable refusal to offer C84 a place, the local authority Special Educational Needs (SEN) caseworker requested that C84 stay on roll at his Academy until an appropriate education package was finalised.C84 returned to his previous part-time timetable in September 2019. 2.1.18 In early September, Police were alerted to a large-scale fight involving a female stamping on another’s head and involvement of numerous other youths including C84. A lengthy investigation culminated in a file being submitted to the Crown Prosecution Service who authorised charges of ‘Affray’ for several individuals including C84. He appeared at court and pleaded guilty (he later received a 12 month Referral Order and was ordered to pay compensation). 2.1.19 Health records of a discussion in September offer an insightful and worrying summary of how disturbed and dangerous C84’s lifestyle was. The threshold for s.47 enquiries was agreed to have been met and tasks allocated accordingly. Records refer again to C84’s previously disclosed difficulties sleeping and his nocturnal enuresis. Agencies were asked to complete chronologies to support legal planning. Such potentially useful chronologies were not developed. 2.1.20 At subsequent ‘core groups,’ YOT1 offered some useful challenge to stepfather’s claim to offer a positive influence. The record also refers again to C84s suspected and untreated post-traumatic stress disorder (PTSD), night-terrors, ‘frozen moments’ and difficulty sleeping. Stepfather’s known record as a domestic abuser and essentially unchanged relationship and behaviour pattern, inevitably meant that his impact on C84 and siblings was continuing to shape their development and conduct. YOT1 obtained C84’s agreement to be seen by a CAMHS worker embedded within the YOT. Unfortunately, what appeared to be a promising relationship ended when this individual left his position. In mid-October, C84 was stop-checked by police officers, searched and a bag containing 200 Valium found. He was arrested on suspicion of possession with intent to supply a controlled drug and released under. The CPS subsequently decided to charge C84 and that month C84 was again implicated, though with insufficient evidence to prove involvement in activity associated with drugs and theft.                                                                                  CAE                                                       9                                       2.1.21 In late October 2019 Health records (none were found by Children’ Social Care) of a further CPC indicate that direct work should be undertaken with the children to help them to address their trauma and build resilience and self-esteem. In mid-November 2019 in unspecified circumstances, C84 attempted to choke a passenger on a bus. For unexplained reasons, though initially arrested, he was subsequently de-arrested and no further action followed. C84’s Academy concluded in November that the impact of him being ‘on roll’ was incompatible with the efficient education of other children and was unable to support being named as the appropriate school in the Education Health and Care Plan (EHCP). The Plan identified his primary area of need as ‘social and emotional mental health, with high risk behaviours linked to avoidant attachment style, with a high level of anxiety and alongside a lack of a father figure and distress due to bereavement’. It concluded he did not have the skills to understand and regulate his emotions. His symptoms of trauma – sleeplessness, panic attacks night time enuresis and heightened threat response were also cited. From this point onward, C84 was awarded by the local authority SEN team the status of ‘Educated Other Than At School’ (EOTAS). In consequence, the prospects for a young man acknowledged to be intelligent and able were significantly further diminished. 2.1.22 Further multi-agency meetings at this time acknowledged increasing concerns about criminality. Police charged C84 with possession of an offensive weapon (a knuckleduster) – a decision supported by the YOT. A ‘risk management meeting’ was convened to address the risk implied toward staff by the apparent return of C84’s step-father to the family home (contrary to the expectations of the child protection plan). Appropriate precautions were made for professionals having contact – though the impact on C84 and siblings remained unchanged. 2020: Potential Care Proceedings; further domestic abuse; knife-related arrests 2.1.23 On a date in February 2020, the case was finally presented to Torbay’s Legal Gateway Panel. The conclusion drawn was that the Public Law Outline (PLO) process should be implemented. During Spring term (by then with Covid 19 restrictions in place) attempts to engage C84 in remote learning were failing. C84 witnessed a further episode of domestic abuse in mid-March when his mother sought Police assistance in response to her ex-partner trying to kick down the front door whilst threatening to stab her with a knife. 2.1.24 In late March an unidentified manager (records include no reference to her role) chaired a ‘PLO Outline Meeting’ attended by a team manager, SW10 and C84’s mother and birth father. The local authority and mother were legally represented and father (who reported receiving minimal notice) agreed to proceed without representation. Stepfather was not present. The meeting discussed a previously written ‘PLO Report’. The record noted and congratulated mother for ‘agreeing’ to enrol in the ‘Freedom Programme’ (a need for which had been identified nearly 3 years earlier). Though mother declared her relationship with step-father to be over, she did not deny his more than occasional presence. It was acknowledged by the social worker that the issue of stepfather’s presence had been insufficiently defined in previous protection plans. In fact, the ongoing failure to insist on ‘no visits’                                                                               CAE                                                       10                                     rendered the precautions set up by Police of limited value and left each child (with no means of knowing if/when step-father would appear or how he and mother might behave) with high levels of insoluble anxiety. A ‘Schedule of Expectations’ was signed by mother, father of C84 and younger siblings (but significantly, not by C84’s step-father when later invited to do so), set out an expectation that the latter would not remain in the house and that all parties would cease from use of illegal substances and use of violence.  2.1.25 A further potentially positive output from the above meeting was the commissioning of an independent social worker to complete within 12 weeks of starting, an assessment of mother’s capacity to provide safe and sufficient parenting. Research conducted during the course of this CSPR has reported that there was a ‘Legal Gateway Review’ in early  April (no record kept by Children’s Social Care), that a parenting assessment of mother was being progressed and that the PLO process was to be followed. No records have been provided with respect to the results of such an independent report or the output of a scheduled ‘review PLO meeting’ scheduled for later that month.  2.1.26 A new SW11 was allocated in March 2020. Toward the end of April, C84 and an associate were arrested and investigated for suspected ‘malicious communication offences’ but were later released with no further action. Records maintained by YOT1 refer to other (sometimes named) individuals staying at C84’s home. Presumably a reflection of the PLO process and need to involve relevant individuals, a face to face meeting (in a public place with suitable back-up) was held with step-father. He claimed to have become a positive influence on C84. He also referred to C84’s mother being the dealer and owner of the drugs found in the family home. This allegation was or became known to Police though no explicit response to it has been found.  2.1.27 In mid-May, a RCPC concluded that C84 and sibs should remain subject to protection plans. C84’s plan was to be re-written and a single assessment updated to ensure a coherent record of history and family functioning. This was be shared with the core group. A further conference was planned for November 2020. Though there was little apparent linkage with the legal planning, it appears that a decision was made to step down from the PLO and work with the family under the existing plan. Records indicate that (aside from stepfather’s reported absence) little had changed i.e. the decision to abort the PLO process ignored agencies’ experiences and was optimistic. Later in May 2020, C84 and siblings were present at home which was searched by Police following a stabbing nearby in which their mother was suspected to have been involved. Concerns about the neglected and unhygienic state of the home and vulnerability of the younger children and dogs present, were identified by officers. The children were noted to be neither surprised or upset by a large number of officers descending on them in the middle of the night to search the home.  A 12th strategy meeting concluded that all children required s.47 enquiries and child sexual exploitation (CSE) assessment toolkit should be utilised for C84.                                                                                 CAE                                                       11                                     2.1.28 In mid-June 2020 Police found C84 in possession of large kitchen-type knife and he was arrested for ‘possession of a bladed article in a public place’. He was charged and bailed to appear before the Youth Court. No bail conditions were imposed and C84 was subsequently sentenced in October 2020 to a Youth Rehabilitation Order (YRO) with a Supervisory Requirement. Days after his arrest, Police received a report of a large group of people beating up another male who suffered a knife wound to his left shoulder and right thigh. C84’s was located and found to have blood stains on his clothing. He and an associate were interviewed on suspicion of wounding and released under what remains an ongoing investigation. If C84 had been released ‘on bail’, he could have had conditions imposed which might have potentially provided some reduction of risk of further offences; the recorded rationale for ‘return under investigation’ (RUI) was that C84 did not know the victim or his whereabouts but this omitted consideration of the fact that C84 was already on Court –imposed bail for possession of a knife. 2.1.29 At a subsequent virtual strategy meeting the agreed result was again that s.47 enquiries were be carried out for all children. The possibility of mother moving out of area was raised. C84’s developmental exposure to repeated trauma and disinhibited use of spontaneous and instrumental use of violence would remain without regard to where he might live. In mid-August 2020 2 males wearing baseball bats and a 3rd male with a knife, stabbed a victim in the upper left leg. C84 was a suspect and after a failed attempt to locate him, mother advised that he son was willing to hand himself in. C84 and others were arrested and bailed to allow the investigation to continue. It is a matter of speculation whether the imposition of ‘conditional bail’ after the incident in June would have in any way constrained C84’s habitual use of violence. 2.1.30 In late August a final (within the scope of this CSPR) strategy meeting was convened and co-ordinated responses agreed for C84 and siblings. A further change of social worker occurred and SW12 was allocated. The author was supplied with a ‘Missing & Exploitation Triage Record’ complied in November 2020 i.e. beyond the period of review. During the review period, reports of C84 as missing and offered a ‘return to home interview’ were limited to 3 occasions all within September 2020.  According to his own explanation (offered on one of those 3 occasions to the worker from the commissioned Service Provider), his unauthorised absence reflected a simple choice to spend time with unidentified friends and in so doing, breach the terms of his court-imposed bail.   ………………………………………………………………………………..                                                                               CAE                                                       12                                     3 FINDINGS & RECOMMENDATIONS 3.1 RESPONSES TO DEFINED LINES OF ENQUIRY C84’S BACKGROUND, EXPERIENCES & SAFEGUARDING PRACTICE Initial Insights into C84’s Lived Experience 3.1.1 C84 (aged 10) sharing with a trusted teacher a clear account of parental substance misuse and of his step-father being a drug dealer, offered a clear and coherent snapshot of just one ‘adverse’ element of his lived experience. Because this referral was not at the time shared with Police, its implications for day to day experiences and how growing up in such an environment was impacting, remained unexplored. The well-intentioned provision of school-based counselling (any benefits of which remain unknown), implied that the problem was C84’s to resolve. Though a year elapsed before the next recorded crisis, it is significant that it was C84 (11) who called the Police when mother and step-father’s arguing had frightened him and younger siblings. His growing sense of responsibility for protecting (and later still, controlling) them became more apparent as he entered teenage years.   3.1.2 The incident when C84’s attack on a fellow pupil was sufficiently serious to required hospital admission should have been recognised as an opportunity to better understand his unregulated emotions and what was triggering and shaping his aggression. The family of the victim feared the reaction of C84’s family and the decision by Police to take no further action closed off the potential for a more informed joint or multi-agency approach. Having resumed a mainstream school in 2017, C84 continued to display aggressive behaviours. Further opportunities arose in May to gain some insight into the nature of the domestic abuse incidents that mother reported and their impact on C84 and his siblings. Initial Child Protection Efforts 3.1.3 Whilst the decision in late May 2017 to make C84 subject of a child protection plan was entirely justified, the content of the plan formulated was weak and poorly implemented. Core groups often remained unrecorded (in particular by Children’s Social Care) and allocated tasks uncompleted. Records indicate several more episodes of violence and in early 2018 a further and regrettable example of the incident leading to no further action by Police because of anxiety in the victim’s family, of retaliation. The decision at the RCPC in April 2018 that C84 no longer required to be subject of a protection plan, nor even merit ‘child in need’ status was ill-informed. Critical elements of the previously agreed plan remained undone. The decision may have been influenced by the presence of step-father and the parents’ misleading assertion that they were  ‘reconciled’. Neither the school or its linked nurse were involved in or informed of the results of this RCPC.                                                                                  CAE                                                       13                                     3.1.4 Throughout the rest of 2018 and early 2019, C84 was involved in several more serious criminal incidents (including an attempted murder) though never prosecuted. Whilst not captured in the formal Children’s Social Care records of the RCPC in late January 2019, other agencies’ records reflect discussion about the use of s.20 accommodation and placement out the area. The value of this conference was diminished by the absence of an educational representative or school nurse. On this occasion, the potential value of a referral to CAMHS was identified. This useful thought would recur but was never followed through. Whether C84 would have been considered eligible is a matter of speculation. What is very clear is that many of his behaviours and criminal conduct were a function of ongoing trauma. Recognition of the Need for & Failure to Progress Legal Proceedings 3.1.5 The strategy meeting held in response to the drugs raid of March 2019 helpfully recognised that mother was not able to prioritise her children over her partner and determined that the case should be brought to MARAC and to ‘Legal Planning’. A month or so later C84 offered as clear a statement as one could wish for about the impact of the step-father’s re-admission on the family. In addition to some helpful actions by Police (domestic abuse marker on the home address, and alerting its Domestic Abuse Unit), the result of those discussions was that Children’s Social Care would complete a single agency assessment and present the case to the Legal Panel in May. At this point in time, there was a dramatic (and still not wholly understood) systemic failure within Children’s Social Care, the details of which are provided above in paragraph 2.1.3. 3.1.6 The RCPC convened in mid-June 2019 may have been fully cognisant of the above de-railment of legal planning but did recognise and record that there has been a significant failure with respect to implementing the protection plan agreed back in February. Regrettably, the chairperson did not escalate the issue and the opportunity to initiate decisive legal action was greatly delayed. There was further debate over the Summer about C84 contemplating that he might kill his step-father and Care Proceedings were yet again seen as an option. It was at this stage that the obvious risks of criminal exploitation and (less obvious) risks of sexual exploitation were recognised. Also emerging was evidence of ‘child on parent abuse’ (COPA). Without regard to his fear and resentment of his step-father, C84 had experienced many years of his influence and demonstrations of how to assert control over a physically more vulnerable person. Records offer further examples of C84’s sometimes spontaneous and sometimes instrumental use of violence. Insofar as he and his family were by then well known, it is reasonable to pose the question of whether such events were becoming normalised and diminished e.g. the decision by custody officer not to detain C84 overnight following a serious and unprovoked assault of a young man.                                                                                 CAE                                                       14                                     3.1.7 Further strategy discussions in September usefully included school,  Police and Social Care and captured how disturbed and dangerous C84’s lifestyle had become. His acknowledged anxiety-related symptoms were again shared though prompted no specific response. The failure to complete agency chronologies that could assist legal planning measures was just the latest example of unreliability and lack of consistency of planning. At the core groups held in Autumn 2019, YOT1 (the only professional with whom C84 seems to have had a good and ongoing working relationship) offered a welcome challenge to step-father and seemed to be more attuned than most to the need for C84 to receive some treatment for his oft-reported emotional difficulties. Mother and C84 have confirmed the respect in which they hold YOT1. 3.1.8 In the unprovoked attack on a bus passenger in November, C84’s initial arrest was, for unknown reasons, reversed and no further action taken. This again raises the question of ‘normalising’ the unacceptable as a means of coping with seemingly impossible challenges. Whilst C84’s violent behaviours continued, the strategy meetings and review conferences of Autumn 2019 reflected little or no change of circumstance or risk. By then, C84 was of EOTAS status. His completed EHCP encapsulated symptoms and difficulties in regulating emotions, but did not include any recommendations for referrals. Insofar as C84 is widely acknowledged to be an intelligent and capable young person, it is regrettable that his trauma-related conduct was unable to be contained by individual (or preferably combined) efforts of those responsible for special education provision and safeguarding planning. 3.1.9 Finally, in February 2020, while C84 was still on bail for possession of an offensive weapon, his case was presented to the Legal Gateway Panel and the PLO process initiated. A ‘Schedule of Expectations’ was formulated days after another incident of domestic abuse in which mother reported being threatened with a knife. Step-father refused to sign the document and at a pre-arranged meeting in a safe place, claimed to now represent a positive influence on C84. He also alleged that C84’s mother was a drug dealer. By the time of the next RCPC in May 2020, no confirmation of core group meetings has been located and (aside from step-father’s departure) little had changed. Whether in any way connected with step-father’s allegation is unknown, but in the first of the 3 stabbings that triggered this CPSR, mother was suspected to have been involved. Police officers’ observations of C84’s home indicated squalor and physical neglect. The conditions might have reflected a recent deterioration or a more chronic situation that had not been observed, evaluated and/or recorded by the latest social worker. Recognition of Physical & Emotional Health Needs 3.1.10 Perhaps diverted by the more obvious needs associated with his family environment and/or the several different school nurses involved, the need to complete routine immunisations remained undone throughout the period under review. Of greater significance, is that in spite of C84’s consistent acknowledgement of what were significant anxiety-driven symptoms, the much-discussed CAMHS referral was never progressed.                                                                                 CAE                                                       15                                     Information Sharing / Recognition of Exploitation 3.1.11 Case closure in April 2018 by Children’s Social Care had not been shared with partners and the circulation of CPC minutes was unreliable. Many core group meetings appear to have no formal or agreed output record. Insofar as can be discerned from often incomplete and some missing records, there were no examples of withholding relevant information from any other agency. Though rather speculative, it may be that the involvement of the YOT (helpful though YOT1 herself  clearly was) diminished the attention paid by Children’s Social Care to the origins of C84’s anxieties and aggression i.e. criminal behaviours could be left to YOT and Police. It seems very clear that they were largely rooted in the fear and violence generated and sustained by the parental relationship. Whilst there was some recognition of the risks of criminal exploitation, records provided have little to say, beyond speculation, about ‘County Lines’ dealing. The risk of sexual exploitation cited on a couple of occasions refer (justifiably) to the risks to various ‘runaways’ who were afforded shelter in C84’s home. ACKNOWLEDGMENT OF GOOD PRACTICE 3.1.12 Amongst a worryingly high proportion of poor practice and management, there are some positives: • Setting aside the overall systemic failure to provide school-based education, individuals in mainstream schools and providers of alternative education were very committed to meeting the educational and wider needs of a bright young pupil in spite of numerous examples of C84 posing a risk to other pupils • YOT1 developed and maintained an excellent working relationship with C84 and his parents and was commendably willing to challenge some of their misleading assertions; she alone, sought to progress the idea of CAMHS involvement and her value to the family is acknowledged by mother and son  SUPERVISION & OVERSIGHT 3.1.13 The CSPR has not been provided with any detail of how individual practitioners were supported or challenged by their managers. The report above makes it clear that the child protection process which should have provided a source of more objective oversight failed. The reasons for that may lie (in addition to a good deal of disguised parental compliance) in the extraordinary turnover of allocated social workers and/or an apparently widespread reluctance to challenge C84’s family. Further opportunities for a more objective or strategic perspective on the operational efforts e.g. by involvement of MARAC, escalation of the muddle within Children’s Social Care in Summer 2019 and earlier consultation with the Legal Gateway were entirely missed.                                                                                    CAE                                                       16                                     RESPONSES TO OFFENDING BEHAVIOURS 3.1.14 From C84’s first criminal assault at the age of 11 through to the end of the review period in September 2020, the frequency and often severity of violence is striking, as is an apparent reluctance to pursue criminalisation or prosecution. Aside from several more minor or unsubstantiated incidents, a collation of the most significant events are: • Aged 11, rendering a fellow pupil unconscious – no further Police action and no ViST • Aged 12, shoplifting and a violent assault on a pupil at his new school – Police not informed • Rising 13, a 3rd serious assault of fellow pupil – excluded Police took no further action and no ViST was completed • Rising 14, involvement in a violent robbery when 3 accomplices were charged with attempted murder – CPS did not authorise charges  • Just over 14, an altercation on a bus – no further action • Aged 14.5 and probably by means of a ‘knuckleduster’, attacking and seriously injuring a young adult – a fear of reprisals prevented evidence gathering and C84 was released from custody • Aged 14.5 committing ‘Affray’ – for which he was prosecuted and received a Referral Order • Aged 14.75, attempting to strangle a passenger on a bus –later ‘de-arrested’ and no further Police action • Rising 15, C84 was arrested for possession of an offensive weapon – with YOT support, prosecution followed 3.1.15 Although it appears that the much delayed presentation to the Legal Gateway was intended to focus on welfare-related issues, the alternative criteria of s.31(1) Children Act 1989 could have been adduced as convincing grounds for seeking a Care Order viz:…..’a court may only make a Care Order or Supervision Order if it is satisfied (a) that the child concerned is suffering, or is likely to suffer, significant harm; and (b) that the harm, or likelihood of harm, is attributable to (i) the care given to the child, or likely to be given to her/him if the Order were not made, not being what it would be reasonable to expect a parent to give to her/him; or (ii) the child being beyond parental control. 3.1.16 To the list of his most serious assaults should be added what YOT1 had established and shared across the network viz: that C84 had acknowledged to her, his constant preoccupation with violence and a fear that he might be beyond helping. It remains uncertain why some responses seem to be less than rigorous. The possibilities that emerge and might usefully be debated range from a belief that a much ‘disadvantaged’ C84 should be afforded more chances, a hope that he would not re-offend through to his family representing sufficient threat i.e. that minimal responses might be for the ‘greater good’  or safeguard ‘community harmony'. It might also be that the dramatic nature of C84’s conduct distracted professional attention from his very substantial emotional needs.                                                                                 CAE                                                       17                                     OVERALL EFFECTIVENESS ? 3.1.17 In spite of the considerable efforts in each involved agency, a multi-agency consensus as to need / risk and required action was never achieved. This may partly have reflected discontinuity arising from constant turnover of social workers and, linked to that, inadequate record keeping.  The historical management infrastructure of Children’s Social Care was clearly weak. Insofar as that agency was of central importance in planning for C84’s safeguarding, the following limitations constrained what partner agencies could achieve: • Maintenance and timely circulating records of key meetings such as strategy meetings, core groups and conference records  • Progressing a referral to MARAC in 2019  • Progressing a referral to CAMHS • In early Summer 2019, losing sight of the case and its urgent central objective of Legal Planning RESPONSES TO ‘MISSING’ EPISODES  3.1.18 Within the records supplied, the relatively few episodes of C84 being reported ‘missing’ all occurred in September 2020 and were a function of imposed bail conditions. Each return home, was accompanied by an invitation to explain and discuss his breach of bail conditions. In most instances, C84 declined to do so and it is not obvious what additional or alternative action could have been taken.  3.2 CONCLUSIONS / SUMMARY OF MISSED OPPORTUNITIES  3.2.1 Transcending agency-related responses to the given lines of enquiry the major ‘missed opportunities’ i.e. where a different response from one or more agency might have had a positive strategic impact were in chronological order: • Acceptance by Police of ‘no further action’ following 11 year old C84’s serious assault on a pupil in 2016 • The conclusion at the RCPC in April 2018 that C84 no longer required a protection plan and circumstances did not satisfy s.17 Children Act 1989 ‘child in need’ criteria • A failure to follow up the recognition at the ICPC of February 2019 (or thereafter) that a Child and Adolescent Mental Health Service (CAMHS) referral was required • A failure to access the Legal Gateway Panel in 2019 • No escalation of the recognition in June 2019 that no work had been undertaken to implement the earlier agreed plan • Unjustifiably aborting the Public Law Outline (PLO) in 2020                                                                                 CAE                                                       18                                     3.3 RECOMMENDATIONS TORBAY SAFEGUARDING CHILDREN PARTNERSHIP 3.3.1 The Partnership should compare the findings of this CSPR with findings emerging from other comparable cases, identify commonalities and develop priorities for the local Partnership, including in particular: • The (untested in this case) capacity in the local network to recognise and address identified need for therapeutic trauma-related responses via CAMHS CHILDREN’S SOCIAL CARE 3.3.2 The Head of Service should take all necessary steps so as to be able to offer the Safeguarding Partnership an assurance that: • Uncompleted tasks such as home visits to those subject of a child protection plan are detected and recorded at review conferences    • Those responsible for chairing functions such as child protection conferences have the knowledge and professional confidence to escalate serious service delivery failures of the sort observed in this case DEVON & CORNWALL POLICE 3.3.3 The Police Service should review and refresh its expectations of Police- imposed conditional bail in cases where there is an extensive history of violence.   ‘C84’ Publication Version 29.07.21 