Serious sexual abuse of eight children, several of whom have disabilities including one child with serious physical and learning difficulties, by members of Family S. Review covers abuse during the period August 2010 - May 2016. Criminal proceedings resulted in several adults receiving custodial sentences from four years to life imprisonment. The children had all come to the attention of statutory services over a number of years due to neglect by their carers. Evidence of indirect or incomplete disclosures, both verbal and non-verbal. A police investigation into disclosure of sexual abuse made to a foster carer in 2015 was closed within a matter of weeks with no further action. A second police investigation, triggered by information emerging out of Family Court procedures, uncovered repeated abuse of a number of children by members of Family S, a family where sexual abuse of children had become normalised over at least three generations. All of the children are white British. Issues identified include: the need to hear the voice of the child, and not the louder voice of adults; need to develop knowledge of sexual abuse in relation to disabled children and ways to provide opportunities for non-verbal children to communicate; and the impact of gender on the on the response of services. The review followed a systems-based methodology. Recommendations to the Safeguarding Board include: develop skills and knowledge in communicating with children who disclose sexual abuse; embed understanding of grooming and sexual offending in practice; and ensure a clear pathway is in place for identifying and working with complex intra familial sexual abuse.
      
 Title:  Serious case review [Children]. LSCB: Coventry Safeguarding Children Board Author: Sian Griffiths Date of publication: 2020  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.                               Coventry Safeguarding Children Board  SERIOUS CASE REVIEW  2020        Independent Author:  Sian Griffiths Date: March 2020      Serious Case Review Report for Publication March 2020  1  CONTENTS            1 Introduction: 1.1 The circumstances leading to this Serious Case Review 1.2  Methodology  Page 2 Page 3  2 Summary of the case and involvement of agencies  Page 6  3 Appraisal of Practice and Analysis:  Introduction Page 8  4 Appraisal of Practice and Analysis: Recognition of Child Sexual abuse  Page 8  5 Appraisal of Practice and Analysis:  The response Page 22  6 Concluding Comments Page 33  7  Recommendations for the Board Page 34        Serious Case Review Report for Publication March 2020  2  1.  INTRODUCTION  1.1  The circumstances that led to undertaking this Review   1.1.1 In early 2015 three children were removed from their home and placed in foster care as a result of significant neglect. Three months later one of the children disclosed that she had been sexually abused over a period of time by members of another family, some of whom were known to the children’s mother. A police investigation took place but was shortly afterwards closed with no further action. The children were subsequently made subject of Care Orders and remained in a long term foster placement.  However, in 2016 the Police investigation was reopened and at this point was identified as a major complex investigation into sexual abuse relating not only to these three children, but several others.  Within the resulting criminal proceedings, several adults were sentenced to custodial sentences from 4 years to life imprisonment for sexual offences and for child cruelty.  1.1.2 The cases of 7 of the children identified as being victims of sexual abuse during the police investigation, were referred to the Serious Case Review Sub Group of the Coventry Safeguarding Children Board in December 2016 by West Midlands Police.  A Recommendation was made in relation to these 7 that the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20151,  had been met, in that there was information that:  abuse or neglect of a child is known or suspected; and   either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.1.3 The SCR Sub Group was aware that other victims of abuse had been identified and given the ongoing Police investigation it was recognised that further victims might also be identified.  However, the decision was taken that it would not be proportionate to include all the victims within the Review.  The conclusion was reached that the experience of the 7 identified children could be expected to lead to the most learning. This conclusion was not a judgement on the seriousness of the impact on any other victims.   1.1.4  During the course of the Police investigation another child was identified and was included in the remit of the report.  This eighth child was understood to have serious physical and learning difficulties and was therefore included in the Review as this was likely to provide additional important learning. 1.1.5 The Independent Chair of Coventry Safeguarding Children Board formally made a decision to undertake a Serious Case Review on 4th April 2017. The National Panel was notified the following week, and the Independent                                                  1 Working Together: HM Govt 2015 Serious Case Review Report for Publication March 2020  3  Reviewers were also identified at that point.  The first meeting of the Review took place in June 2017. 1.1.6 Due to the complex criminal investigations and other proceedings in the summer of 2018, the Review was unable to be completed until February 2019.  As a result of concerns about the welfare of some of the children publication did not take place until the February of 2020.  1.2   Methodology   1.2.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews.  The guidance establishes the purpose as follows:  Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2015:73.)  1.2.2. The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”.  In particular, case reviews should be conducted in a way which:   recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings 2  1.2.3. The methodology for this Review was underpinned by the principles outlined in Working Together 2015, including the need to use a systems approach.  The author of this report is familiar with a systems-based methodology.  In particular, this approach recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is intended to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely.  A central purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely.                                                  2 HM Govt, Working Together (2015:74) Serious Case Review Report for Publication March 2020  4  1.2.4. Two experienced independent reviewers were commissioned to Chair and Author the Review.  The Chair, Alastair Cuthbert and the author, Sian Griffiths, are both independent of all the agencies in Coventry.   1.2.5. The Independent Reviewers worked with a Review Team consisting of Senior Managers and Safeguarding leads from the following agencies:  AGENCY  ROLE CAFCASS Service Manager Coventry City Council (Children’s Services) Strategic Lead Quality Assurance Coventry City Council (Education) Head of Student Service Coventry City Council (Legal Services) Legal Advisor NHS Coventry and Rugby and NHS Warwickshire North Clinical Commissioning Groups Head of Safeguarding / Designated Nurse & Prevent Lead  (Coventry) Nursing, Quality & Safety NSPCC Service Manager University Hospitals Coventry and Warwickshire Named Doctor for Child Protection & Chair of SCR Sub Group West Midlands Police Detective Inspector & Vice Chair of SCR Sub Group  The Safeguarding Children Board Manager was also a member of the Review team and the Board provided administrative support.  The Review Team met on 9 occasions.  Given the length of time before this Review could be completed, some substitutions and apologies were provided by members of the Review Team.  1.2.6. The Review process included the production of chronologies and succinct Agency Reports produced by the following key agencies:   Cafcass (Children and Family Court Advisory and Support Service)  Coventry City Council Children’s Services  Coventry City  Council Education   NHS Coventry and Warwickshire Partnership Trust (CWPT)  NHS Coventry and Rugby Clinical Commissioning Group (for GPs)  NSPCC  University Hospitals Coventry and Warwickshire NHS Trust  West Midlands Police  A full check was made across the voluntary and statutory sector for any agencies who might have been involved with the children concerned.  During the course of the Review further information was provided by:   Coventry Youth Offending Team  Serious Case Review Report for Publication March 2020  5  1.2.7. A range of primary documentation was made available to the Review and the Independent Author spoke with a number of professionals who were able to provide further information regarding specific policy and practice issues.   1.2.8. The Independent Lead Reviewer and members of the Review team undertook a number of meetings with individual professionals who had direct involvement with key members of the family.  A total of 14 professionals, from across the key agencies took part in individual meetings, providing a significant amount of information regarding their involvement.  The Independent Author had a range of additional conversations with other relevant professionals, including the Police Senior Investigating Officer and CRASAC (Coventry Rape and Sexual Abuse Centre).   1.2.9. Towards the end of the process, a meeting took place involving the majority of the key professionals who had been seen individually.  The purpose of this event was to check factual accuracy, but most significantly for the professionals concerned to contribute to the analysis and future learning. Given the passage of time since the events, it was not possible to meet with some of the key professionals who were no longer in employment with the various agencies.  Therefore, in order to ensure this meeting included contributions from across the safeguarding partnership a number of front line professionals who had not been directly involved with the children also attended the meeting.  1.2.10. The Independent Author and Chair also met with senior members of a Religious Organisation who were able to provide relevant contextual information including a range of documentation.  1.2.11. The timeframe under consideration for this Review was:  August 2010 – May 2016  The period identified began at the point at which it is understood some of the children first came into contact with their abusers.  The period ended when the second Police investigation was established.  1.2.12. The Review was asked to take into account any learning gained recently from previous Serious Case Reviews. The focus would be to identify further learning, or the degree to which previously identified learning had been translated into practice.  The Terms of Reference identified the following issues for particular consideration, however these were not intended to limit any other learning that might emerge:    i. It has been recognised that significant neglect played an important part in the lives of these children, increasing their vulnerabilities. However, the focus of this Review is intended to be on sexual abuse and child trafficking, so that the Coventry SCB can learn lessons about the way in which agencies respond to these particular forms of abuse.  The Serious Case Review Report for Publication March 2020  6  issue of neglect is therefore required to be a focus just in so far as it contributes to the learning regarding sexual abuse.   ii. What does this case tell us about the way in which child sexual abuse and trafficking is recognised and responded to?   iii. To what extent was the behaviour of those individuals who were involved in the abuse recognised as being an indicator of potential risk to children. Were agencies aware of possible risks and how did agencies respond to this?  iv. Where practitioners had concerns in relation to the children or the alleged perpetrators of abuse, were there barriers to intervention and if barriers existed what were these?  v. Did ethnicity, culture or religious identity play a part in the way in which agencies understood or responded to the families?  1.3.11. In order to ensure anonymity where individual children are referred to in this report, identifying details, for example age, family relationships or gender may be altered.  The perpetrators of the sexual abuse are referred to as Family S.    1.3.12. The involvement of the children and key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. In relation to the children, advice was sought from key professionals before considering making contact with them in order to ensure that any support needs or current vulnerabilities were taken into account.  4 of the children and 3 adult family members agreed to meet with the Independent Reviewers.  A further family member contributed their views in writing.  1.3.13. In order to prevent any possibility of identifying any of the children, their families, or their individual stories, their contributions have been taken into account throughout this report but are not included here in detail.  1.3.14. The Independent Reviewers would like to thank the young people and other family members who contributed to this Review.    2   SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILY  2.1. This Review has considered the experience of each of these 8 children and their involvement with the relevant agencies in considerable detail, drawing on a significant body of material.  Given the amount of professional involvement with each of the children over a 6 year period and, more significantly, the necessity to protect the children’s identity and privacy a conscious decision has been made to provide only an outline summary of the facts, rather than describing each child’s story in detail.   Serious Case Review Report for Publication March 2020  7   2.2. The children were linked by their contact with members of Family S but did not all know each other. The children and their families had all come to the attention of statutory services over a number of years prior to sexual abuse being identified, because of concerns about their welfare.  These services included the Police, Health, Education and Children’s Services.  There were repeated referrals to Children’s Services in relation to all of the children resulting over time in Strategy Meetings, Statutory Assessments, CAF and Child in Need plans and, for 7 of the children, Child Protection plans3.  2.3. A shared feature of the lives of the children was their vulnerability and their experience of neglect by their carers. Neglectful parenting over long periods was the most frequent reason for the involvement of Children’s Services.   The neglect was typically longstanding and chronic in nature.  The three children from the same family described a particularly disturbing level of neglect, leaving them routinely hungry, cold, and unsupervised.  This created a clear opportunity for members of another family to groom and sexually abuse them.  Almost all the children lived in households where there was some level of parental drug or alcohol abuse and domestic abuse.  2.4. There were also many similarities regarding the children’s vulnerabilities.  Some of the children had health needs and learning disabilities, ADHD and emotional and behaviour problems were also a feature.  Two of the children spent some, or all, of their education in specialist facilities.  Three of the children in their early teenage years were frequently missing from school, and there were concerns about inappropriate sexual activity as well as anti-social behaviour.  One of the children had previously been a victim of sexual assault by an unrelated person.  2.5. All of the children have been identified as white British.  With the exception of one child there is no information to suggest that religion or faith was a significant part of their lives.  Some members of Family S, however, were understood to be members of a Religious Organisation although they did not have positions of trust within the organisation.  2.6. Family S were known to both Police and Children’s Services, frequently as a result of the adults’ alcohol use and allegations of domestic abuse.  What has                                                  3 CAF: The CAF is a shared assessment and planning framework when it is felt that a child has additional needs, in order to identify those needs and co-ordinate services to meet the needs.  Child in Need: A Child in Need Plan, or CIN, is a multi agency plan put in place with the family under Section 17 of the Children Act when a child is in need of extra support from different agencies, but is not assessed to be at risk of significant harm.  Child Protection Plan: Statutory Multi-agency plan put in place when a child is assessed to have suffered, or be likely to suffer, Significant Harm.  Strategy Meeting/discussion: required whenever there is reasonable cause to suspect that a child is suffering, or likely to suffer significant harm.  This should include Children’s Services, the police, health and any other appropriate body.  Serious Case Review Report for Publication March 2020  8  also emerged is that Family S had been viewed for many years, both by the community and by professionals, as a family that worried people, but about whom the concerns were not specified or were unresolved.  2.7. The first police investigation into child sexual abuse following the first child’s disclosure in 2015 was closed within a matter of weeks with no further action.  The second Police investigation was triggered by information emerging out of Family Court procedures.  This second investigation uncovered repeated abuse of a number of children, including non-recent abuse of a relative of Family S, who was now an adult. The sexual abuse was, for some of the children, of the most serious kind and for one of the children began at the age of 3 years old.  3 APPRAISAL OF PRACTICE AND ANALYSIS: Introduction   3.1. This Section will appraise the key aspects of multi-agency practice that have been identified by this Review. It will consider what multi-agency learning there may be for future practice in respect of the Terms of Reference outlined by the Safeguarding Board and any other learning that might have emerged.    3.2. In particular, the Safeguarding Board was clear that the focus of the Review should be on Child Sexual Abuse.  It was evident from the beginning that neglect was a significant factor in the children’s lives.  However, because of the extensive amount of learning that had already been identified in other recent Serious Case Reviews, the prime purpose of this Review was not to analyse the neglect, but to identify the learning relating to sexual abuse.  It should also be noted that there is reference to Child Trafficking within the Terms of Reference.  Whilst this was not ultimately evidenced in the criminal proceedings, within the terms of this Review trafficking is considered likely to have been a feature.  3.3. Individual agencies have identified specific learning for their organisation in the course of this Review and this will be referenced as relevant within this Review.    3.4. This analysis consists of two overarching sections:  Recognition of Child Sexual Abuse and Responding to the Abuse.  This structure will encompass the key issues identified within the Terms of Reference as well as any additional learning.   4:      ANALYSIS: Recognition of Sexual Abuse   4.1   The Focus on Neglectful Parenting.  4.1.1. In reviewing the experience of these children across a period of 6 years, what is powerfully and most immediately apparent is the consistent picture of neglect running through their stories.  All of the children experienced neglect of varying kinds.  However, what was evident at the time, but even more so Serious Case Review Report for Publication March 2020  9  with the advantage of all the information available to the Review, was the chronic nature of the neglect of some of the children over years. These children lived without their basic physical needs being met, without safe boundaries, and without protection from harm.  4.1.2. It is important to establish that there is clear evidence of neglect being recognised and responded to in a variety of ways, by a number of the agencies who worked with the families. Neglect was clearly the prime focus for professionals. However, agencies struggled to achieve significant change in the children’s circumstances over time.  One of the issues that impacted on professionals’ ability to intervene effectively, was that the level of neglect seen across many families they worked with made it difficult to identify which children were at greatest risk.    All these families lived in an area of high socio-economic deprivation where poverty, neglect and disturbed behaviour in children was far from uncommon. There is evidence of referrals being made to Children’s Services, discussions at both single agency and multi-agency meetings as well as practical help such as meals and clean clothing being provided to children, in particular by the schools. However, the recognition of neglect appeared to have the effect of obscuring what else was taking place.  At the same time, because effective long-term responses to the neglect were not put in place at an early enough stage, the potential for making sense of what else was happening remained hidden for too long.      4.1.3. When professionals came together to contribute to this Review they spoke openly and thoughtfully about the very real difficulties of working effectively with families in which there are entrenched problems, sometimes over many years. They recognised a familiar shared sense of feeling worn down by repeated attempts to intervene or to encourage change.  This experience could mean that small changes could be too easily seen as an improvement when the reality was that in the long term the change was not significant.  There was agreement that cases should not be closed without a very clear assessment that children’s needs have actually been met to a standard that is explicitly identified as good enough. Children’s Services now have in place specific requirements regarding information to be included in the record when a case is closed, including a contingency plan should there be a further referral.  This is being monitored through routine audit activity.  What is nevertheless apparent is that when working with families presenting these sorts of challenges there is a particular need for very robust reflection, peer and management challenge, and of course clarity and support from management as to how to proceed.  If professional resilience in these situations is to be maintained, it has to be supported at an organisational level.    4.1.4. There were a small number of occasions when there was a direct focus on sexual abuse.  One of the children had previously disclosed that she had been sexually assaulted by someone unconnected with those in this Review.   She had told her parent, who in turn contacted the Police and a successful prosecution resulted.   A strategy meeting took place resulting in a Child in Need Plan.  This child was referred to the NSPCC for support which was a positive action, but the continuing focus of the CIN plan then shifted to neglectful parenting.   This was not the only occasion when an issue was Serious Case Review Report for Publication March 2020  10  identified regarding sexual behaviour or previous sexual abuse, in which the safeguarding focus reverted back to neglect.  4.1.5. The responses by agencies to the neglect and the implications will be considered further later in this section.  What is of significance here is the way in which the neglect predominated in professionals’ thinking in effect acting as a barrier to prevent them recognising abuse.  Cognitive psychology has identified a range of common errors in human thinking which are evident when dealing with complex problems.   One of those common errors is described by Kahneman4 as ‘what you see is all there is’. That is, the phenomenon of reaching conclusions based on early judgements, inadequate information and a focus on existing evidence, but without a recognition that there may be other evidence which we are not seeing.  A fundamental area for learning throughout this Review is how organisations can help to create a working environment in which professionals are able to check and challenge themselves and each other regarding the judgements they make.  4.2   Indicators of sexual abuse  4.2.1. Identifying sexual abuse in the absence of a direct, clear disclosure by a child who is being abused presents a considerable challenge to professionals.  It is estimated that only 1 in 8 children directly disclose that they are being abused.  It is also the case that if children do disclose, it is most likely to be to the non-abusing parent. Children very rarely spontaneously disclose sexual abuse to professionals and therefore identification of sexual abuse is reliant on active scrutiny by professionals, not by a child’s verbal disclosure.  Despite this, the safeguarding system is heavily reliant on disclosure for action to be taken. None of the children provided an entirely unambiguous disclosure about the sexual abuse which they were experiencing from members of Family S prior to the summer of 2015. However, there were indirect or incomplete disclosures, both verbal and non-verbal in relation to all of the children subject to this review.   4.2.2. Indirect communication: Each of the children to some degree communicated their distress through their behaviour.  There is evidence of actions been taken to respond to these behaviours, for example, organising specialist help or seeking practical support for the family. However, although it was evident that professionals were worried about the children and about specific aspects of their behaviour, there is almost no evidence that the possibility of sexual abuse was considered as an explanation.   Possible indicators of sexual abuse included:   Bed wetting and/or smearing faeces in the absence of other explanations eg: age, developmental stage, underlying medical conditions.  Young children self-harming  Incidences of extremely distressed behaviour in school.  Fire setting and anti-social behaviour                                                  4 Kahneman, D (201:85) Serious Case Review Report for Publication March 2020  11   Sexualised behaviour in school or with older teenagers or adults.  Distressed and aggressive behaviour.  Dramatic changes or deterioration of behaviour.  Missing from home  Young children physically affectionate towards unfamiliar professionals.  4.2.3. The sexual nature of some of this behaviour could have led to a consideration of sexual abuse, with issues such as the onset of bedwetting in older children widely recognised as potential indicators.  There was, at times, some quite unusual behaviour that clearly registered as of concern, but did not appear to lead to an equally clear response, sometimes only reported at a distance from the event.  Mostly these behaviours were seen and understood in the context of other problems, not least the levels of neglect and other pressures in the home such as domestic abuse, parental separation and conflict, or substance misuse.  That the information was not always passed on to other professionals meant that the ability to explore the reason for such behaviours was further limited.  4.2.4. It must also be noted that for some of the children it would have been difficult at the time for professionals to identify a pattern of behaviour that would immediately suggest sexual abuse.  However, there is little to suggest that the possibility of there being underlying causes other than neglect were considered. Neglect is not uncommonly found in conjunction with other forms of abuse and it is crucial that the naming of neglect does not have the effect of detracting from other possible abuse.    4.2.5. There is no simplistic causal relationship between neglect and sexual abuse.  However, there is “enough evidence for us to be certain that neglect and IFCSA (intrafamilial child sexual abuse) do co-occur”.5 Although the reasons for this co-occurrence are not yet fully understood, the same research suggests that it may be linked to the quality of the parent-child relationship.  Had the practitioners had this in the forefront of their minds, not least in the relationship between the siblings and their mother, including her frequent absences and the lack of any safe boundaries for them, this might have triggered the hypothesis that these children could be at risk of some other form of abuse, not only neglect.  4.2.6. Listening to the children: As well as communicating through their behaviour there were also occasions when the children made partial verbal disclosures.  Although these did not go unnoticed, they did not result in a clear enough recognition of what the children might be trying to say, or decisive enough action that could have created an opportunity for them to tell more clearly.  Even on those occasions that children did say something which might have been expected to raise concerns, this did not seem to be enough to lead to an explicit recognition about what was being expressed or the confidence to take action.                                                   5 Allnock (2016:7) Serious Case Review Report for Publication March 2020  12  4.2.7. This was apparent on a number of occasions.  One child made comments in school about sexually inappropriate comments from a sibling.  This was noted, but there is no information that it was passed on to Children’s Services at the time.  One of the children told her Social Worker that her mother required her to share a bed with an older child and also that he said rude things to her.  This did appropriately lead to a Strategy Discussion between Children’s Services and the Police and an agreement to undertake a joint home visit.  However, the mother would not allow the Social Worker to come into the house, only allowing entry to the Police.  Although the Police spoke to the children in the house and assessed the physical conditions, it is not apparent that there was a direct conversation with this child about what she had said and what help she might need.  Actions were taken to deal with the home conditions and the mother was specifically instructed that the older child should not be allowed to stay in the house.  However, what would have been expected at this point was that the child who had made the comments should have been given the opportunity to talk further, in a safe place and without a parent present.     4.2.8. It is of concern on this and other occasions that even when visits were undertaken by Social Workers, these were not always used effectively as opportunities to communicate with the children about what was happening to them and what they needed from professionals. It is the case that there were occasions, particularly after the first child made a disclosure to a foster carer, when the children were spoken to on their own and Social Workers used child friendly methods and tools.  However, this was not a consistent picture prior to this point. Too often Social Care Records identify that the children were spoken to in the home using very direct questions, to which there was little response, and which failed to enable the children to express what was happening to them.  4.2.9. On one occasion there is reference to work being done directly with the Children using tools from the Signs of Safety approach. This highlighted that the children had worries, but not what these were, and it is not evident that this led to a continuing programme of work with the children.  One home visit, which was recorded in some detail, illustrates the degree to which the professional engaged with the mother’s perspective and focussed on the practical aspects of neglect in the home rather than seeking to relate to the children and understand their sense of their lives.  The mother had said that she could not manage the children’s behaviour. The Social Worker asked the children why they behaved like this and whether they felt their mother was coping. The children did not respond. There is no evidence of a subsequent attempt to meet them alone, or to spend time with them building a relationship and understanding their perspective.  4.2.10. Attempting to engage children by using a questioning style and framing questions in terms of the children’s behaviour and its impact on their carer, would indicate to those children quite clearly what the professional was interested in. Children respond to the cues given to them by adults.  Developing the skills to communicate in a genuinely open way, so as not to close children down, can take time and practice.  Without speaking to the Serious Case Review Report for Publication March 2020  13  Social Workers concerned it is difficult to be completely clear why there is so little evidence of meaningful communication with the children.  Nevertheless, it must also be noted that this was not purely an issue for Children’s Services staff.  There is little to suggest that other professionals were significantly more able to engage with the children in a way that enabled them to speak freely. This highlights a priority area for improvement across the safeguarding partnership in order to hear the ‘voice of the child’ in a meaningful way.  4.2.11. We have learnt from research, from previous Serious Case Reviews6 and from practitioners themselves that there are some common factors that contribute to this difficulty in communicating with children. Some of these reasons undoubtedly relate to time and work pressures. Developing relationships and communicating effectively with frightened or traumatised children requires time and a consistent, well supported worker.  We know that if a child does disclose to a professional it is most likely to be someone in school with whom they have, over time, developed a relationship.  Social Workers do not usually have regular day to day contact with individual children and so relationship forming requires more conscious work.  4.2.12. During this period the Local Authority was not performing well, leading to an inadequate judgement by Ofsted in June 2014.  Caseloads for Social Work staff in Coventry were at a peak, the second highest in the country.7  At the beginning of 2015 there were 98 agency Social Workers.  Whatever the skills of individuals, over reliance on agency workers does not support the development of long term relationships with children and families. As such, the working context for Social Workers would not have provided the conditions needed to ensure this sort of work was carried out effectively.  4.2.13. There are other particular barriers to identifying and naming sexual abuse, including lack of confidence about skills and discomfort about speaking to children about sexual activity. Some practitioners we spoke to had concerns as to how they should speak to children about sexual abuse without unintentionally asking leading questions. This is something that has been recognised elsewhere as an unhelpful barrier to disclosure8. Recent research9 in relation to Social Workers’ confidence in working with child sexual abuse identifies a number of other difficulties, which are equally likely to impact on other professionals’ responses:   The rapidly changing nature of the world in which sexual abuse takes place (CSE, sexting, internet, etc) making it difficult to keep pace.  Very limited training on child sexual abuse during social work qualifying training, leaving new practitioners feeling unprepared.  Limited workplace training, which was predominantly focussed on understanding sexual abuse, rather than direct work with families.  Lack of understanding of healthy sexual development in children.                                                  6 SCR Case U:  Norfolk Safeguarding Children Board 2018 https://www.norfolklscb.org/wp-content/uploads/2017/01/NSCB-Case-U-SCR-2017-FINAL-JUL-2018.pdf 7 Coventry Children’s Services Improvement Plan 2016/17.   8 Marchant & Turner (2017:55) 9 Martin et al (2014 Serious Case Review Report for Publication March 2020  14   Lack of adequate time for reflective supervision or peer support.  4.2.14. It would be wrong to suggest that there was no positive communication with the children prior to the first child making a disclosure in summer 2015.  Clearly some professionals, not least those working within school settings, were communicating regularly with them. One child responded very positively to a NSPCC worker on two separate occasions and a Consultant Psychiatrist was also able to develop a positive relationship with one child.  However, too often at key points there was an absence of thoughtful engagement and constructive listening that might have enabled the children to express more fully what was happening to them.   4.2.15. Communicating with children requires different skills to communicating with adults and communicating about sexual abuse demands particular care and confidence, something which can take time to develop.   Fundamental is the development of a relationship with the child that enables them to trust that they will be responded to thoughtfully, and that they will be believed.  It is also important that disclosure is not seen as an event but as a process which will take place over time with a safe and trusted adult.  In particular, it requires focus not just on verbal disclosure but:   “attending in the widest sense to all of children’s communication – everything that they say and do, sounds, words and sentences, to expressions, gestures, eye gaze, play, demonstrations, behaviour and drawing.”10   4.2.16. For some professionals, particularly those working in specialist settings, these skills will be well developed, as will the knowledge base.    Communicating with children should undoubtedly be considered a core skill for those working directly with children. However, when communication proves difficult, or children’s responses seem unusual or hard to make sense of, the option of seeking advice, expertise or support from other specialist settings should be considered. Whilst there will have been professionals and agencies available at the time with the relevant expertise, there is little to suggest that the professionals involved with these children either considered seeking such help or had a clear route for doing so.  4.2.17. In October 2016 a Paediatric Sexual Assault Service (PSAS) was set up covering the West Midlands. This is delivered by Birmingham Community Health Care NHS Foundation Trust in partnership with a number of other Health Trusts and Rape Crisis Centres. The service is staffed with specialists including Paediatricians and counsellors and provides a 'one-stop' open service to anyone up to the age of 17 who has been the victim of rape, sexual violence or sexual abuse.  Whilst the core of PSAS is a full service offered directly to victims, it also offers advice and support to professionals with a Paediatrician on call 24 hours a day. This sort of high quality child focused service provides a level of support to practitioners which was not available at the time being considered in this Review.                                                   10 Merchant & Turner (2017) Serious Case Review Report for Publication March 2020  15   4.2.18. Coventry Safeguarding Children Board is also currently working on producing guidance for staff about responding to indirect disclosures, and this is to be welcomed.  However, in order to achieve effective communication with children it is crucial not only that staff development, training and guidance are available, but the context in which key frontline professionals are working with children, supports staff to put skills into practice:  “Local authorities should recognise the importance of the child’s relationship with the social worker and organise the work so that social workers can get to know children, and are not viewed as remote, but powerful figures.”11  Children’s Services are now working to a Relationship model in cases of Child Sexual Exploitation and Abuse, a key aspect of which is not to change the child’s Social Worker.    Whilst much of the information here relates to Children’s Social Workers, the principles apply for many of the services working with children.  Recommendation 1:  Coventry Safeguarding Children Board should assure itself that partners have appropriate mechanisms in place to enable staff to:  Develop skills and knowledge in communicating with children in the light of the learning arising from this review  Access good support from their organisations to enable them to put these skills into practice effectively with children.  4.2.19. Harmful sexual behaviour. There was also evidence with some of the children of concerning sexual activity, both with other children and with adults.  Two of the children were as a result identified as being vulnerable to Child Sexual Exploitation. It was also the case that when there were concerns about the behaviour of an older male child towards a younger female sibling, the focus on protecting the younger sibling seemed to exclude considering the needs and concerns of the older boy.  In each of these situations, the next step of questioning whether the identified behaviour might itself indicate a possibility of abuse was largely not taken.  4.2.20. Policy and practice guidance is available to practitioners in relation to Harmful Sexual Behaviour within Coventry, but this Review has not been able to identify how well this is understood and how it contributes to outcomes for children.  There has however been recognition by Children’s Services of the need for greater access to expertise in working with Harmful Sexual Behaviour.  A number of practitioners have recently been appointed to Advanced Social Worker Roles.  These practitioners will develop personal expertise in the area of harmful sexual behaviour and will be able to provide advice and guidance to other staff.                                                    11 OCC (2011:15) Serious Case Review Report for Publication March 2020  16    4.2.21. Children with disabilities.  Several of the children have been identified as having disabilities. Children with disabilities are at greater risk of abuse, including sexual abuse, with studies identifying that the risk of sexual abuse is three times greater for a child with a disability12. Identifying sexual abuse in children with learning difficulties can be particularly difficult and that was evidently the case here. One child’s experience in particular exemplified these difficulties.  4.2.22. This particular child attended a specialist school, had contact with a range of specialist health services and was subject to CAFs and Child in Need Plans at various times. It is now known that she was being abused by members of her extended family with the knowledge of other family members.  However, there was no information at the time that led any of the services involved with her to consider that she might be being sexually abused.    4.2.23. The child’s Headteacher evidently knew her and her family well, was in frequent touch with the health providers and was very focussed on her welfare. The family circumstances and the quality of the care she received at home were an ongoing cause of concern. The school noted particular concerns when there was a dramatic change of behaviour and, for the first time, aggression to the staff.  The child’s communication was limited and she struggled with concepts, making it difficult to understand how she might be feeling.  The school had used specific tools to attempt to help her to express her emotions, but this continued to be difficult.  4.2.24. With hindsight, the Headteacher feels that she should have questioned the changes in the child’s behaviour to a greater extent as it had indicated that she was anxious or worried about something.  What the Headteacher had not considered was the possibility of sexual abuse, although on reflection she could see the indicators. What this has highlighted for this school and for education more widely is the need to develop further their knowledge of sexual abuse in relation to disabled children and ways to provide better opportunities for non-verbal children to communicate.  The need for greater knowledge and skills in this regard for those working with children with disabilities is subject to recommendations within the Education report for this Review.   4.2.25. The experience of this child and those professionals supporting her reflects what is more widely understood about protecting children with disabilities from abuse. Some of her behaviours, such as banging her head and rocking, seemed to have been understood as a result of her disabilities.  Research clearly identifies that: “Possible indicators of abuse such as a child’s mood, behaviour, illness or injury that for a non-disabled child would give cause for concern, for disabled children can be assumed to relate to the child’s impairment with no action to explore this further”13                                                    12 Murray and Osborne (2009:47) 13Miller, David and Brown, Jon (2014)  Serious Case Review Report for Publication March 2020  17  4.2.26. Gender.  While the abuse of these children took place irrespective of gender, there remain questions for this Review about the impact of gender on the response of services.  For the older boys, there appears to be a pattern whereby sexual behaviour likely to raise concerns for a girl, is seen, even if it is concerning, as part of a spectrum of behaviour expected of a teenage boy.   Examples included:   Boy being taken by ambulance to A&E having been drinking with a female friend.  A 14 year boy ‘dating’ a ’17 year old’ girl  Young teenager staying out with friends at night, but his mother not knowing where he was.   4.2.27. When these sorts of concerns were raised about one young teenager in mid 2014 there was initially no apparent consideration that this boy might be at risk of sexual abuse or exploitation.  However, later that year a Children’s Services Team Manager clearly identified that there needed to be a full understanding of his history, including a chronology in order to focus on the outcomes of interventions for him.  This shift of approach ultimately led to this child being subject to Care Proceedings and at this point he was also recognised as being vulnerable to Child Sexual Exploitation.   4.2.28. Religion: The role of religion had also been identified as potentially significant for this Review, although the extent of that significance was initially unclear.  Members of Family S are known to have been members of a local Religious Organisation.  However, information provided to this Review by that Organisation is that the family members’ involvement in the faith was in fact peripheral. National Leaders of the Organisation met with the Independent Author and Chair.  They confirmed that two senior members of Family S, had been baptised but were in effect excluded from active involvement in 1994 for ‘serious sins’. Information provided initially to this Review also suggested that a senior member of Family S might have a position of trust in the Religious Organisation.  The National Leaders were able to confirm that this was not the case. They were also confident that no-one within their organisation had been aware of what had taken place in the family prior to the adults being charged.     4.2.29. Nevertheless, there was information, from the Police investigation and from evidence given at the criminal trial, that the family’s interpretation of their religious beliefs may have impacted on decisions not to take action to protect the children.  Two features of this case are relevant.  Firstly, evidence at the criminal trial from a female member of Family S was that she had told her husband that she had concerns about the children, but that their religion meant that it was for him as head of the family to decide what action to take.  When he did not take action, she said her faith meant that it was not for her to challenge him. Secondly, information from some of the family members suggested that disclosure would have been especially difficult given their faith.  4.2.30. The national representatives of the Religious Organisation were absolutely clear that the explanation given as to why this individual took no action was a significant misinterpretation of their faith. Their teachings, whilst including the Serious Case Review Report for Publication March 2020  18  principle that the head of the family is the father, would never absolve an individual of responsibility for protecting children from abuse, which they define as a grave sin. They were concerned that this misinterpretation had been used to justify her own, unacceptable, position. It would be unreasonable to hold this Religious Organisation responsible for the way in which individuals chose to interpret the teachings. What it does, however, is identify the importance for any faith group of being aware of the way in which their teachings can be used by those who wish to abuse, of taking active steps to guard against such interpretations and of ensuring a pro-active approach to safeguarding within their community.  4.2.31. The Chair and Author felt there were some weaknesses in the National Organisation’s approach to Safeguarding. One of these concerned the apparent limited understanding of the requirements on Faith Groups as identified in Working Together 2018.  During the meeting the discussion regarding the requirement to report concerns was overly focussed on there not being a mandatory reporting requirement within UK primary legislation.  It seems to this Review that a clearer, more explicit recognition of the responsibility of all to actively report concerns would improve the Group’s approach to safeguarding. Secondly, the senior members of the Organisation were explicit that members of the congregation should always feel able to report any concerns. They provided the Review with a copy of a new booklet which includes articles relating to these issues and would be the subject of study at meetings.  Whilst this is a positive step, what is missing is any explicit step by step processes for someone wanting to make a referral or raise a concern.  Similarly, there is no identified Safeguarding lead with professional expertise in the organisation, or explicit and clearly publicised routes for seeking independent support or advice.  4.2.32. It is important to recognise that there was no evidence that the weaknesses identified here impacted directly on these children.  However, given the seriousness of the abuse they experienced and the involvement of the National Organisation’s leaders in contributing to this Review, it is the recommendation that they be sent a copy of the Review as an opportunity for learning about the nature of child sexual abuse and how agencies, including faith agencies should work together.                 Recommendation 2:    The Coventry Children Safeguarding Board to share a copy of this Serious Case Review with the Religious Organisation’s national leaders.  4.3   The adults  4.3.1. In order to understand why it was so difficult to identify child sexual abuse it is important to examine the approach to and part played by the adults. What emerged is that the adults were able not only to control the children but that they were also often very effective at managing the professionals.  Serious Case Review Report for Publication March 2020  19  4.3.2. Understanding the adults:  All of the children’s parents themselves had their own significant personal histories, which impacted on their parenting and their response to services.  The lack of full histories or chronologies meant that there was no clear picture of the patterns of behaviour and responses taking place over time.  Issues of neglect, domestic abuse, alcohol abuse and early experience of trauma were evidently frequent features of the adults’ lives as well as the children’s lives.  There is limited evidence to show that the adults’ histories were made sense of by professionals, or how they were taken into account when considering the children’s care.  4.3.3. Adults’ voices louder than the children’s.  The presentation of all the adults, whether conscious or unconscious, contributed to keeping the professionals at a distance. Sometimes this related to the adults’ explanations of their children’s behaviour being too readily accepted. When the school became concerned about a deterioration in one child’s behaviour, including a recurrence of bedwetting, a referral was made to Children’s Services. The child’s mother said that although her son had been sexually assaulted in the past, she believed that the main reason for his behaviour was due to his poor relationship with his absent father.  It was recommended that there should be a further assessment to better understand the experience of sexual abuse in the family.  However, when the Social Worker undertook the assessment, there was no reference to sexual abuse.     4.3.4. Some of the parents were particularly effective at keeping professionals away. There is frequent reference to one parent being threatening both to staff at school and to Social Workers. She kept an aggressive dog in the home, which on one occasion was used to chase Police Officers away. Her behaviour at school was so threatening that she was banned. She told a Social Worker directly that she would not let her into the house.  Then, for several months whilst the children were on Child Protection Plans, she either did not respond to Social Workers or actively refused them entry. A report prepared by Children’s Services relating to another child concluded that the parent was: “aggressive and threatening with professionals and avoided and discouraged the children from talking to them”. This child was told by the parent to tell teachers to ‘piss off’. As a result, professionals, but particularly Social Workers “found it very difficult to engage with the children on terms other than the parent’s”.    4.3.5. The parents behaved in various ways so as to control information and access to the children. There was a pattern of professionals being assured by the adults that they were able to protect their children, despite the evidence to the contrary. Two of the parents had themselves experienced sexual abuse in the past.  The parents’ perspective on what had happened to them and how it should be dealt with – for one of them this meant sexual abuse should not be talked about – seemed to be accepted and have the effect of closing down conversations with the children.  One of the fathers was particularly frustrated at the way in which the mother’s criticisms of his behaviour or parenting appeared to prevent his subsequent legitimate concerns being heard.    Serious Case Review Report for Publication March 2020  20  4.3.6. The degree to which the adults were able to put barriers between the professionals and the children impacted significantly on them achieving an understanding of those children’s lives.  It is of concern that the parental behaviour, including active refusal to allow access to children on a Child Protection Plan, did not lead to more immediate and effective steps to protect the children. It is highly likely that the very aggressive behaviour which professionals sometimes had to deal with impacted on professionals’ response and their resilience.    4.3.7. The very real difficulty of working with families who present as threatening requires a level of persistence that is reliant on confidence in, and active support from their managers and services.  It is not easy to tell from the information available what support and help there was for some of these professionals. Practitioners also need to know that they will be supported by their services in the face of repeated refusals by families to allow access to children.  One of the lessons for practice from the Children’s Services report for this Review is that where a family refuses to allow Social Workers access to children, this should lead to some form of management or multi-agency consultation ensuring clarity as to what action will be taken.  4.3.8. The known risks:  At times it was recognised that some of the adults posed particular risks to the children, separate from parental neglect. However, there was also a pattern whereby the identification of one type of risk appeared to mask the possibility of other risks also being present.  There were concerns over some time, particularly from the school, about the care of two of the children.  Initially these were predominantly about neglect and the quality of the mother’s parenting.  A key focus later on became the extremely serious domestic abuse that the mother was experiencing, her inability to separate from the perpetrator and the consequent risks to the children. What this legitimate focus unfortunately seemed to overshadow however, were the other significant risks to the children from their extended family.  4.3.9. These children spent considerable time with two members of the extended Family S. At a Strategy Meeting in 2011 involving Police, the Children’s Services’ Disability Team and Education, information was shared that these adults both had convictions for cruelty to a child.  One adult also had a conviction for threatening to kill a Social Worker and it was recorded had been ‘medicated for psychosis in the past’.  A decision was made to close the case and a working agreement was to be put in place with the children’s mother, stating that contact with these adults must be supervised. The Children’s Services’ report notes a lack of clear management oversight at this point and that there is no actual evidence of this agreement on the children’s file.   4.3.10. During subsequent involvement with Children’s Services, even though it was identified that both children were having frequent contact with these two adults, this does not seem to have led to any risk assessment or robust monitoring of their contact.  It was the mother’s chaotic lifestyle, abusive relationship, and complicated legal proceedings involving the children’s father that dominated the focus of the intervention.  In fact, what is now known, but Serious Case Review Report for Publication March 2020  21  was not at the time, is that both children were being sexually abused within the home of the 2 adult members of Family S.  4.3.11. Grooming and control:  Perpetrators of sexual offending need to be in control in order “to groom” their victims, but also to groom those adults who might be able to protect the children. What is known now but could only have been guessed about at the time, is the power of the control that some of the adults in Family S maintained over the children and over anyone within the family who might be in a position to disclose what was taking place. It is also now clear that this was a family where sexual abuse of children had become normalised over at least three generations and that this had been kept secret within the family. The children were effectively controlled by various means from direct threats, for example to kill a pet, to manipulation of their vulnerabilities, for example one seriously neglected child told Police that at least when they were at Family S’s house they were given a sandwich.    4.3.12. The most likely person that a child will disclose to is a non-abusing parent.  What we know for these children is that they did not have access either to a safe parent or to a parent who, for whatever reason, was able to focus fully on what was really happening for the child. The child who told her mother she did not want to share a bed with another child was not listened to. The mother, who later received a custodial sentence for neglect, told the Review she had no reason to suspect what was happening and that she did not know what signs to look for. The parents of some of the children, for reasons we cannot fully understand, but which are undoubtedly linked in part to their own problems, were not able either to hear or to act on what their children were telling them in order to keep them safe.  4.3.13. In the autumn of 2015 Family Court Proceedings were taking place in relation to a parental dispute about arrangements for some of the children.  Arrangements were made for one parent to have supervised contact with their children. Initially, other family members, including three of the adults who were subsequently sentenced for offences against children, also attended contact. During the contact there were significant concerns about the adults’ sexualised behaviour with the children.  The contact with these family members was clearly recognised as not in the children’s interests and was stopped. What is not clear is if these concerns were raised with the Social Workers or whether this was explicitly recognised as behaviour common in perpetrators of abuse. Whilst the correct action was taken in stopping the contact, it is surprising that this did not lead to immediate recognition that the children concerned might have been subject to sexual abuse by extended family members, or that these adults might pose a risk to other children.                                Recommendation 3:  Coventry Safeguarding Children Board to assure itself that partner agencies have considered their professional response to, and understanding of, grooming and sexual offending as it is relevant to their safeguarding responsibilities and have taken relevant action to embed their approach in practice.  Serious Case Review Report for Publication March 2020  22  4.3.14. What is particularly striking with the benefit of hindsight is how many professionals and agencies were aware of Family S as a family of concern, but how little they were actually understood.  The Review was told by one professional that this was a family that was being talked about at least 15 years ago.  There was also information known to different agencies about allegations of sexual abuse and convictions for child cruelty which were not clearly documented or known to all the relevant agencies.  Even with the advantage of undertaking this Review, it is difficult to tell who knew this information and when it was made available to those professionals who needed to know in order to protect the children.    4.3.15. Knowing information about a family and having a reason to intervene in their lives are clearly different things.  There were long periods when Family S did not come to the attention of the authorities.  However, there were times when it would have been legitimate to undertake a full assessment, given the various concerns raised in relation to children in the family.  There is no doubt that this was a family adept at keeping services at bay as a result of which the risks they posed were never properly identified. We also now know that there was a degree to which sexual abuse was a normal part of family life and that there had been a previous allegation of child sexual abuse by an adult member of Family S.  This information, whilst not easily accessible to professionals, might have emerged had a full assessment been undertaken.  4.3.16. Summary: The combination of the barriers facing children in telling, the barriers for professionals in seeing or making sense of what was happening and the degree to which adults either consciously, or more passively prevented communication between professionals and the children cannot be underestimated and are powerfully evident in this case.     5:     APPRAISAL AND ANALYSIS: the response.  5.1   Responding to the neglect.  5.1.1. In February 2014 Coventry Children’s Services had been judged to be inadequate by Ofsted, with the response to children at risk and neglect being identified as weaknesses.  At that time the Local Authority had already recognised that there were too many children suffering long term neglect in Coventry and that this required a response.14 Neglect has therefore been a focus for Children’s Services in their subsequent Improvement Plans and also more widely for the Safeguarding Board, which had undertaken two Serious Case Reviews in which neglect was a key factor.  As a result, the Safeguarding Children Board has identified Neglect as one of its key priorities and a Neglect Strategy was published in September 2018.                                                    14 Ofsted (2014) http://reports.ofsted.gov.uk/provider/44/331   Serious Case Review Report for Publication March 2020  23  5.1.2. In this context, and given that these events were taking place during the above time period, the focus in this section is not how neglect was managed in detail at the time, but how it impacted on services’ response to sexual abuse.  Two overlapping features of the response to neglect had a particular impact on agencies capacity to identify sexual abuse:  The need for decisive action and the cycle of stepping up and stepping down cases.  5.1.3. The need for decisive action:  As already identified, there was recognition of neglect across the agencies involved with all these families.  What was missing however, was a sense of urgency or decisive plan of intervention. We know that children will only explicitly disclose intra familial sexual abuse when they are both safe and also feel safe.  An earlier more robust response to the neglect could have indicated to the children that professionals took their situation seriously, that these might be adults who could be trusted.  It might also have led to some of the children being taken into care at an earlier stage, creating that safe space which sexually abused children need. The comments made to the Reviewer by some of the children made it very clear that they felt they needed help, including being removed from their family situations, before the sexual abuse had even begun.  5.1.4. Within just three months of being placed in foster care, one of the children made a clear disclosure to her foster carer.  This reflects what is a common pattern for children who are being sexually abused, i.e, when they believe that they are in a safe environment, and when they feel that the response they get if they speak will be one of care and belief, then they will disclose.  Although it was not evident at the time, the disclosure by this child was the trigger that led to the identification of the abuse being experienced not just by herself and her siblings, but also others.   5.1.5. There are many points when the response to the neglect across the agencies shows a lack of urgency:   No direct action taken by the Police when a child found home alone e.g. arrest of adult or taking the child into Police protection.  Reliance on referral to Children’s Services.  No evidence of clear plan of action by schools regarding significant non-attendance.  Children’s Services responses to domestic abuse and alcohol abuse and its likely impact on a child within Family S.  5.1.6. Whilst individual incidents could have triggered a more considered response, neglect is significantly something which becomes apparent over time and has a cumulative impact on children bringing with it in an increased level of long term harm. What is noticeable in this Review is that despite neglect being regularly identified for all these children, there is almost no evidence that comprehensive professional assessments either for neglect, or regarding the capacity of the parents took place.  The first reference to a formal parenting assessment for at least one child who had been subject to long term abuse only came 4 months after Child Protection Plans had been put in place.      Serious Case Review Report for Publication March 2020  24  5.1.7. Cycle of stepping up and stepping down. An important link to this lack of decisive action was what is a repeated theme of children being moved in and out of services, from Child in Need, to Child Protection, to CAF and back again.  Processes that are known as ‘stepping up and stepping down’.  The journey of one of the children shows this in stark relief:   Child in Need Plan January 2011   Initial Child Protection Case Conferences October 2011 – Child in Need plan continued  Child Protection Plan July 2012 to April 2013   Child In Need Plan April 2013 to August 2013  Case Closure August 2013 – stepped down to CAF  Child in Need Plan July 2014  August 2014 stepped down to CAF  September 2014 – Child in Need Plan agreed  Child Protection Plan January 2014 - August 2015  When this child’s case moved to a different team, the new Team Manager rightly identified the lack of any proper assessment as a ‘glaring gap’.  Further that the Child in Need plan had not been effective and that his case needed to be moved into Child Protection. This child was ultimately removed from parental care in August 2015, age 15.  This Team Manager responded decisively and clearly recognised the limitations of previous interventions.   There is no doubt that this course of action should have been considered earlier given what is known about the cumulative impact of neglect on long term positive outcomes for children.  This has particular significance for older children who are more likely to have poorer long term outcomes if they come into care later in their childhood: “Once in care, adolescents are more likely than their ‘non-looked after’ peers to “go missing”, less likely to hit educational attainment targets, more likely to be involved with the criminal justice system and less likely to make a smooth transition to appropriate accommodation and employment or training as a young adult.”15 This child did not himself disclose to professionals that he had been sexually abused, but later he was identified by the Police during their second investigation as a possible victim.   5.1.8. On too many occasions, decisions to intervene by means of a CAF or Child in Need plan do not appear not to have fully taken into account how this approach would adequately meet the children’s needs or manage the risks to them. Statutory Assessments of children are undertaken by Children’s Services. Nevertheless, decisions to step up or step down children who are already part of multi-agency safeguarding processes should, wherever possible, be jointly agreed amongst all the agencies.  Clearly multi-agency recommendations to step down a child from a Child Protection plan will be                                                  15 ADCS (2013:1) Serious Case Review Report for Publication March 2020  25  significantly influenced by the views of Children’s Services.  However, there remains a shared responsibility for the resulting decisions amongst all the partners and routes by which disagreements can be resolved.     5.1.9. This case highlights some of the difficulties in ensuring effective multi-agency working, particularly in relation to differing perspectives as to the thresholds between the different levels of intervention. Shared decision making and responsibility is a fundamental aspect of the principle of safeguarding as a partnership. There were a number of occasions when agencies disagreed with decisions, but without any apparent resolution.  One example followed a Children’s Services Initial Assessment which concluded that the children could continue to be worked with by professionals within a CAF approach as they were already doing.  The multi-disciplinary team refused to accept this, but the case was closed by Children’s Services.  There is nothing to explain whether any action, for example, escalation was taken as a result.    5.1.10. Later, one of the schools recorded a significant degree of frustration in relation to what they felt was a lack of action by Children’s Services to step up the involvement with the same children.  During the period when the children were subject to a Child Protection Plan in 2014/2015 this is particularly apparent. What is of concern is that there is the significant difference in understanding as to what was agreed at a Core Group Meeting in January 2015.  Notes of the meeting taken by the School Learning Mentor records:    “all professionals feel things have got worse.  Mum’s none (sic) engagement with social care and the evident neglect of the children made the core group feel that the children would be removed….a legal planning meeting will be happening tomorrow where the new social worker will put forward this case…it is to be hoped there is enough evidence for social care to continue to proceed to remove the children”.  School staff appeared to believe that the children would be removed during a home visit the following week.  One of the schools recorded specifically phoning the Social Worker on the day to check if this had happened but being told that, at the home visit, the threshold had not been met for removal.  However, the notes of this meeting taken by Children’s Services do not record that other professionals at the meeting recommended that the children should be removed or that some form of urgent action to do so was imminent.  Whilst a joint visit with the Police is recorded as taking place, there is no reference to the possibility of immediate removal of the children.  5.1.11. The facts of what took place at this meeting are fundamentally in dispute.  What is however apparent is that there was a significant gap of understanding between the Schools and Children’s Services as to the approach that was going to be taken and the basis on which the children could be removed from their mother’s care. It is the case that the Local Authority had begun pre-proceedings under the Public Law Outline and the mother had been properly informed that the Local Authority was considering starting Care Proceedings. Given the evident frustration apparent within the school records at the absence of an urgent response to the children’s situation, it is noteworthy that Serious Case Review Report for Publication March 2020  26  no further action was taken to challenge decisions or to seek some means to resolve the differences.  It is not entirely clear why this was the case, although professional fatigue may have been a feature and information from some school staff also suggested there was a lack of awareness of how to escalate concerns.    5.1.12. Lack of escalation when there are disputes between agencies as to the best course of action for children is a common feature of Serious Case Reviews.  This was not the only time when there was an absence of escalation and more than one of the professionals involved has reflected that they should have escalated their concerns. Anecdotal evidence of escalation to Children’s Social Care Senior Managers has been provided to this Review, but it is likely that this aspect of the multi-agency practice continues to create challenges. Reference has also been made to an Education initiative to promote and support the use of the escalation policy.  However, no evidence of this has been provided.  Given that lack of escalation is a familiar and challenging issue for the multiagency partnership a Recommendation has not been made in this Review, however it is included as an issue within the learning points at the end of this report.  5.1.13. Summary:  There is little doubt that many of the weaknesses identified here in relation to responses by Children’s Services reflect the very real difficulties that the Authority was experiencing at the time.  This was fully recognised in the Ofsted report and a previous peer review which described the service as “overstretched in terms of capacity and financial resources, and the situation was unsustainable”. The Local Authority Children’s Services was re-inspected in June 2017 and was then judged by Ofsted to have improved and as no longer being inadequate.  5.1.14.  Despite the pivotal role of Children’s Services being considered in some detail here, the crucial role of other agencies in both supporting and challenging decisions across the multi-agency safeguarding partnership must not be overlooked.    5.2     Responding to the sexual abuse  5.2.1. Although services were slow to identify sexual abuse and there are examples of poor responses, there were also examples of good practice following the child’s disclosure in 2015. This included the involvement of a Social Worker who clearly believed and supported the children, and also the efforts to ensure that one of the children who required a stable residential placement, was found such a placement with a long term commitment to it being maintained. When another child was sexually abused by an unconnected adult, part of the plan was to refer her to CRASAC (Coventry Rape and Sexual Abuse Centre) for support, but she was reluctant to attend.  It was instead agreed that she would be re-referred to the NSPCC worker whom she had previously developed a good relationship with and whose role it would be to encourage her to take up the specialist support. Giving this child the opportunity to work again with someone she had previously responded to well was a positive step.   What was interesting however was that consideration was not given to the work itself Serious Case Review Report for Publication March 2020  27  being undertaken directly by the NSPCC worker, possibly in consultation with CRASAC.  The NSPCC worker was unable to persuade the child to go to CRASAC and so her involvement ended.  Given the importance of the relationship a child has with a professional when there are safeguarding concerns, there would have been a strong argument for that relationship to be prioritised over the focus on a particular organisation’s role.    5.2.2. Linking the children and identifying a pattern of abuse. With the advantage of hindsight, we can now see that members of Family S were at the centre of what was happening to these children.  We can also see that there were key points at which this might have been uncovered earlier.  Nevertheless, in reality, identifying the network of links would have been an extremely time consuming and demanding task requiring a forensic mindset and significant resources.  Establishing a clear understanding of all the links between the children and the perpetrators was ultimately only achieved with the formation of a dedicated police team, working closely with social care staff over many months.  5.2.3. As part of undertaking this Review, a full analysis of the school attendance of a particular group of children has been undertaken by the City Council and this reveals some very definite patterns of absence across two of the families.  Evidently, tracking all the absences and their potential significance across up to 5 different schools over a 6 year period, required a concerted effort as well as the particular trigger of a Serious Case Review in order to do so.  The schools were clearly concerned about the poor attendance, frequently conducting home visits on days when these children were absent and informing Children’s Services.  However, what was missing at that time was the sort of formal, planned approach to improving their school attendance that might have been expected. A formal intervention in relation to each of the individual children’s school non-attendance might have been able to identify more clearly the patterns which have now emerged.  We cannot assume that doing so would have led to a hypothesis of connected sexual abuse as the common factor, but it could have contributed more to the multi-agency understanding of what was happening.  5.2.4. There also existed some close geographical and friendship links between some of the families.  This might suggest that it would be easy to make connections between them, especially when all the families were known at times to Children’s Services.  In reality this was not so straightforward.  Two of the children’s families were particularly well known to Children’s Services. However, there was no active involvement with one family for much of the time concerned and they were known to different Social Work teams despite living in the same locality.  No organisational structure can ensure that connections between families of concern will always be identified, neither can organisational memory, though it is often helpful, always provide the knowledge that can link families together.  Information might be shared between different professionals and services that will trigger further curiosity, but this cannot be relied upon to safeguard children from complex abuse outside of their own immediate family.  What can help is good basic Serious Case Review Report for Publication March 2020  28  safeguarding practice, from recording, to assessments to good multi-agency working.  5.2.5. Identifying the links amongst the children and the adults and beginning to question what they might mean required one or more of the professionals concerned to have: a reason for concern; an inquisitive mindset; the time and resources to follow up their suspicions; and a platform where they could share these concerns with others.  The first time there was a real possibility of identifying the abuse and Family S’s role in it, appears to have been in 2014 when a series of concerns were being raised about one young teenager.  These related to this child’s sexual activity, their contact with an adult member of Family S and allegations made by a younger sibling about sexualised behaviour.   A Children’s Services Team Manager identified the need for some sort of investigation or assessment of the role of the adult concerned and subsequently a Social Worker made a referral to the Harm Reduction Panel of the Community Safety Team regarding this adult and the child concerned.  5.2.6. The role of the Harm Reduction Panel at the time was to identify concerns and risks to vulnerable people in the community. It was not intended to act as a safeguarding service and there appeared to be no clear means of linking the two parts of the system.  One of the Community Safety Team (CST) workers was given the task of looking into the links between this particular child and adult, as well as with a number of other young people from the same school where there were worries about grooming of children locally. The CST officer clearly took a proactive approach to this task and in liaison with the school identified significant information relating to sexual activity regarding this child as well as others. Some of these concerns the CST officer reported to the Police herself given that the school had not done so, but no further action was taken as this was judged to be uncorroborated third party information.    5.2.7. The CST worker described joint visits to this child and his parent with the Social Worker. She attended multi-agency meetings where she described feeding back explicit risk concerns about this child and other children.   Information about this practitioner’s involvement is very significantly reliant on her memory and there is an absence of clear records in order to conclusively support what she has told the Review.  However, her detailed recall of these events was coherent and her manager at the time was able to confirm much of what she described.   5.2.8. It appears however, that the concerns she and her manager were raising were not understood or given adequate weight by other agencies at the time.  The practitioner felt that this was due not insignificantly to her lower professional status in relation to others. That this worker, given her role, was not working within recognised safeguarding processes may itself have had an impact on the degree to which she was able to influence. Whatever part this may have played, the outcome was that these stated concerns did not lead to any further consideration as to the nature of what was taking place.  It was also the case that although there were attempts made by the practitioner and her manager to raise their concerns further, the option of formal escalation using the Safeguarding Board processes was again not considered.  Serious Case Review Report for Publication March 2020  29   5.2.9. The CST worker and her manager subsequently worked on putting together a map to illustrate the events and connections between the child, the adult member of Family S and other adults and children. This was at a later stage shared with Children’s Services.  5.2.10. Whilst the information available at the time regarding all or any of the children may well not have been enough to trigger criminal proceedings, or other statutory action, there was a build-up of evidence that should have been recognised and responded to with much greater seriousness.  Experience in recent years of managing Child Sexual Exploitation has demonstrated the importance of building a picture, of mapping people and behaviour of concern and intervening in a range of ways to protect the vulnerable. There were undoubtedly professionals who had concerns about these children individually or in relation to members of Family S.  However, until Summer 2015, there was neither enough information to make the links, or no obvious means by which to identify the network of links which can now be seen.  5.2.11. Complex intra familial sexual abuse, involving more than one perpetrator, presents particular challenges not least because of the level of control and secrecy that is a part of familial sexual abuse. However, the experience of these children points to the need to raise awareness of this type of sexual abuse and for the multi-agency partnership to reflect further on improving the means to identify it.  The level and extent of the abuse being perpetrated by members of Family S is undoubtedly at the most extreme end of the spectrum.  These events should act as a reminder that perpetrators of child sexual abuse often do not limit their abuse to one child and that where there is one victim, the possibility of others should always be considered  Recommendation 4:  The Coventry Safeguarding Board to assure itself that a clear pathway is in place for identifying and working with complex intra familial sexual abuse drawing on current developments within contextual safeguarding practice.  5.2.12. Events leading to the first full disclosure, Summer 2015.  During the early weeks of 2015 the sibling group were still on Child Protection Plans and a decision had been made to begin Care Proceedings. The mother of the siblings had been told that another child should not be spending time in the house with them, but this still continued. Further information was becoming available which could have led to the consideration of sexually harmful or sexually abusive behaviour taking place, but this did not apparently result in a more inquiring exploration as to the full nature of the family situation. The focus of the action being taken at this time was clearly on neglect.    5.2.13. What in fact triggered an urgent response was an incident when the siblings and an older child were found out by the Police late at night. This resulted in them being made subject of Police Powers of Protection followed by Children’s Services seeking and being granted Interim Care Orders for the sibling group.  Whilst this meant that these children were now protected from abuse, there were still weaknesses in the response. No Strategy Discussion appears to Serious Case Review Report for Publication March 2020  30  have taken place, neither is there evidence of a S47 Enquiry.  The joint visit by Police and Social Work a few weeks later seemed to be focussed largely on the trigger incident rather than a deeper examination of the children’s experience, previous information about sexually inappropriate behaviour or the parental care.   5.2.14. When the first child disclosed to her foster carer that she had been regularly sexually abused by two members of Family S, the management of this disclosure was of a poor quality and failed to lead to a proper investigation or any criminal charges, despite detailed and disturbing descriptions of the abuse being given by the child.  Weakness in the liaison between the Social Worker and the investigating Police Officer were evident from the outset.  The Social Worker undertook a home visit to the children, after the foster carer reported what the child had disclosed, without consultation with a manager or with the Police.  There is also evidence of some friction and miscommunication in the relationship between the Police Officer and Social Worker. Some of the initial difficulties at the point of referral took place over a Bank Holiday weekend, which may have had an impact in the short term.   Whatever the reasons for the poor beginning, this was never fully recovered.   5.2.15. The initial Police investigation was flawed in many respects: the collection of evidence; a lack of understanding of the processes and poor awareness of good practice in joint working with Children’s Services.   ABE16 interviews were of a poor quality, the required Strategy meeting was slow to be initiated, decisions were not taken quickly about contact with the children and their mother, opportunities to preserve potential forensic and other evidence were lost.  There was also a significant absence of supervisory reviews of the investigation, the first taking place 10 days after the original referral.  5.2.16. Approximately 6 weeks after the first referral the Police investigation was closed, without the case having been taken to the Crown Prosecution Service on the basis that there was a ‘lack of independent corroboration’ and ‘inconsistency in the children’s stories.’    5.2.17. The quality of this first Police investigation has been examined in great detail within the Police report provided to this Review.  It concludes that there were very significant evidential shortcomings as well as poor management and supervision of the case.  As a result, in 2015 the Police failed to bring a prosecution for a significant number of serious sexual offences against a number of adults, and also failed to identify children who continued to be abused.  Individual officers were subject to internal disciplinary proceedings as a result.   5.2.18. Whilst individual officers are clearly expected to meet professional standards and can be held accountable if they do not do so, this nevertheless still provides only a partial explanation for such a significant failure by the Police. Importantly, what has also been identified is that although the investigating officer was an experienced detective, she had little previous experience of                                                  16 ABE interviews:  Achieving Best Evidence interviews etc Serious Case Review Report for Publication March 2020  31  child sexual abuse, and her responses suggested she had a limited understanding of the nature of joint working with Children’s Services. There was inadequate oversight by senior officers, who described problems with an understaffed and under experienced team at that time. The Review was subsequently told that it could take up to a year for a new member of the team to access Specialist Child Abuse Investigation training.   5.2.19. The lack of experience and resource pressures undoubtedly provide greater context to help us understand why this investigation progressed the way it did. Nevertheless, given the very graphic details the children provided about what had happened to them, it remains difficult to understand why this case did not raise greater concern and why it was not seen as unusual or particularly complex requiring greater resources or expertise. The details of how the case was conducted, particularly the interviews with the children and the judgements about their evidence being inconsistent suggests a fundamental lack of understanding as to how children are able to recall and describe their experience of long term sexual abuse, particularly when it has been inflicted by multiple individuals.    5.2.20. Responding to young people who may be both a victim and a perpetrator of abuse:  A particularly disturbing feature of sexual abuse of this nature is that some the child victims may also begin to engage in abusive or sexually harmful behaviour because of what has happened to them, or because of direct instruction by their adult abusers. These circumstances can be extremely challenging and distressing both for the child concerned as well as for other victims.  Professionals are faced with making complex decisions including identifying services which both meet the child’s own needs while also managing their behaviour.  Availability of such services are limited, and a child’s competing risks and needs may be in direct conflict. The professionals are also required to manage their own personal responses when working with such children, which it is well recognised can also be extremely demanding.  5.2.21. For one of the children this led to particular practice difficulties including a misjudgement by a Guardian from Cafcass appointed to represent the child’s best interests during Family Court Proceedings. This had potentially serious implications for the child’s own legal rights as a result of which the Guardian was replaced in subsequent Family Court proceedings.  However, it was undoubtedly the case that the Guardian’s actions were driven by compassion for this child and a desire to ensure proper support would be provided. Cafcass have assured the Review on the basis of their wider Quality Assurance work, that there is no evidence that the mistakes made represent wider concerns either about this individual Guardian or the service provided by Cafcass more generally.   A two day workshop to consider the learning further has been put into place by Cafcass and the Guardian was clear that there had been considerable learning for her personally.   5.2.22. Nevertheless, there is learning here, not uniquely for Cafcass, but for all services working with children in this situation.  The specifics of this incident may rarely, if ever, arise again.  However, working with children who have both been sexually abused and may have abused others is a complex and at times Serious Case Review Report for Publication March 2020  32  an emotionally draining professional task. It is a task which requires good support and challenge for the professional to ensure the best outcome for the child and proper support for the professional themselves.   Recommendation 5: The Coventry Safeguarding Board to identify the appropriate work stream for developing good practice for working with children, including those in transition to adulthood, who have been identified as having both been abused and abusing others.  5.2.23. Complex police investigation initiated.  Family Court proceedings took place at the end of 2015 in relation to some of the children. As a result of the information emerging during these Proceedings and the actions of an ISVA17 who had contacted the Police directly, a review of the first investigation was triggered. The decision to review the investigation was taken by an experienced Senior Police Officer and conducted by a detective with significant experience in Child Protection.  As a result, it was quickly recognised that this was a complex case that needed to be worked as a major investigation.   5.2.24. A team consisting of 2 full time and one part time Detective Constables was established and the investigation of this case was their exclusive focus for the following 18 months.  During that time, the children were re-interviewed by detectives with the appropriate specialist skills and were supported by Registered Intermediaries18. From the children’s own comments to this Review, both the approach of the Police and the use of Registered Intermediaries were of significant importance to them. Forensic evidence was reviewed, and new lines of enquiry established.  Very significantly this investigation began to identify other victims and develop a detailed understanding of the complex relationships between victims and abusers.    5.2.25. What is unmistakably the case is that the effectiveness of this second investigation was fundamentally linked to a decision to identify skilled and experienced Child Protection detectives to lead on the case and provide a dedicated resources and time for that team.  5.2.26. Working with the children after disclosures. Following the initial disclosure by the child in 2015, a number of actions took place in addition to the criminal investigation.  One sibling group were at this point in foster care and Care Proceedings had been initiated.  There were concerns about the relationship between some of the children and in July 2015, the first Complex Strategy meeting took place regarding a larger group of children. This meeting predominantly focussed on safeguarding the children who were still living within their families.  It is not evident that the meeting considered at this point whether there were wider concerns about the nature of the abuse and whether                                                  17 ISVA:  Independent Sexual Violence Advisor:  An independent advisor working with the victims of sexual violence. 18 Registered Intermediaries (RIs) are communication specialists who assist vulnerable victims, witnesses, suspects and defendants with significant communication deficits to communicate their answers more effectively during police interview and when giving evidence at trial.  Serious Case Review Report for Publication March 2020  33  there might be other victims.  Nevertheless, there is evidence of some good direct work by the Social Worker with the children, using child friendly tools and techniques. The children’s mother specifically referred to this Social Worker as someone who the children liked and who she felt able to talk to. She described her as listening to her more like a friend and not just being critical of her. A referral was also made to CRASAC (Coventry Rape and Sexual Abuse Centre) to provide support for the children.  5.2.27. Following the decision to open the second police investigation, a dedicated social work team, consisting of 2 Social Workers and an agency manager, were identified to work full time with the Police for 12 months, in addition to the children’s allocated Social Workers.  Strategy Meetings were held with the Police and Children’s Services and the children were supported throughout both their contact with their mother, and the various meetings relating to court proceedings and investigations.  5.2.28. Some of the problems that had been apparent earlier in the history did continue, for example in relation to the quality of assessments and the timeliness of Strategy Meetings.  Nevertheless, when during this second Police investigation further victims were identified, there is evidence of good working practices, particularly in relation to action being taken by Children’s Services to protect the children and support being provided to the children by Social Work staff and by specialist services.  One child with particular needs had a consistent Social Worker for the 12 months after his experience of abuse came to light.  The Social Worker visited regularly, enabling him to build up a rapport and seeking to understand his wishes and feelings. There is also increasing evidence of good management oversight, for example including good processes to ensure handover between managers.   6   CONCLUDING COMMENTS    6.1. The purpose of a Serious Case Review is to learn from the case in order that improvements to practice can be put in place to help families in the future.  The children subject to this review experienced significant neglect within their own family settings, compounded by a level of sexual abuse, which for some was of the most extreme kind.  Whilst the abuse was ultimately identified and appropriate responses taken to secure their safety and support their future well-being, this took too long, for which all the key agencies shared some level of responsibility.  6.2. There has inevitably been significant focus in this report about the actions of the Police and Children’s Services because of the centrality of their role in these events. Both organisations have now undertaken detailed reviews of their own agency’s practice in relation to these children, identifying the future learning.  Both have recognised what is apparent within this Review: that there were significant areas of weakness alongside other practice that was of the required standard practice.  Both identified underlying problems within their organisations which contributed to the weaknesses in front line practice at this Serious Case Review Report for Publication March 2020  34  time.  Both have put in place some significant improvements which should contribute to better services for the future.  6.3. The experience of these children and of the professionals attempting to work with them has highlighted significant learning, some of which is familiar and continues to be challenging across agencies, some of which represents emerging learning.  This Review has deliberately prioritised the key areas of practice when forming the Recommendations to maximise the likelihood of improved future outcomes for children.  Clearly within a Review of this complexity covering a large group of children over such a long time period, many other issues can be identified. Experience tells us that prioritising key areas of learning for formal recommendations is the most effective approach.  6.4. In addition, the following points are included as a reminder of some of the already familiar issues that have emerged again in this Review, several of which are already subject to work arising out of previous SCR recommendations.  This Review therefore considered that whilst they do not justify a recommendation, they do merit reference and continued reinforcement within the partnership.   Awareness of processes for escalation of disputes and support for staff in escalating concerns.  The importance of the relationship a child has with a professional.  The fundamental importance of good chronologies and robust assessments  Where records are of a poor quality or absent, this has a significant impact on future decision making.  Listening to fathers and taking their concerns seriously.  For Professional resilience to be maintained it requires effective support and supervision from organisations.  This is vital when working with families who may be reluctant to engage, or where there are repeated episodes of agency involvement.  Organisations need to ensure that they create and maintain a culture which allows and encourages reflection and challenge, including the ability to ‘change your mind’.     7   RECOMMENDATIONS FOR THE BOARDS   Recommendation 1:  Coventry Safeguarding Children Board should assure itself that partners have appropriate mechanisms in place to enable staff to:  Develop skills and knowledge in communicating with children in the light of the learning on disclosure arising from this review.  Access good support from their organisations to enable them to put these skills into practice effectively with children.   Recommendation 2:  The Coventry Safeguarding Children Board to share a copy of this Review with the National Office of the Religious Group.  Serious Case Review Report for Publication March 2020  35   Recommendation 3:  Coventry Safeguarding Children Board to assure itself that partner agencies have considered their professional response to, and understanding of, grooming and sexual offending as it is relevant to their safeguarding responsibilities and have taken relevant action to embed their approach in practice.  Recommendation 4:  The Coventry Safeguarding Board to assure itself that a clear pathway is in place for identifying and working with complex intra familial sexual abuse drawing on current developments within contextual safeguarding practice.  Recommendation 5: The Coventry Safeguarding Board to identify the appropriate work stream for developing good practice for working with children, including those in transition to adulthood, who have been identified as having both been abused and abusing others.  Serious Case Review Report for Publication March 2020  36  BIBLIOGRAPHY  ADCS (2013) Position Statement. 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