Death of a 13-year-old boy from a suspected drug overdose in August 2021. Child M was groomed into criminal exploitation from early 2020. Learning includes: need to build upon flexible approaches to working with young people to understand their worlds; family-focused service responses need to be embedded across children's social care, education and the police when working with extra familial harms; manage risk via multi-agency assessments, plans and contingency; safeguarding systems should consider the context of schools in terms of safety and risk to children; parents/ carers need more information and guidance about the process of exclusions and re-integration; family cultural and language barriers to be checked and responded to by the local authority and education providers. Recommendations include: operational multi-agency groups and CSP should align strategic and operational work to disrupt criminal exploitation activities and map children at risk; partners including police, the council, and education should consider community events, to ensure work is rooted in 'lived experience'; the child exploitation screening tool should be completed at all levels of intervention when exploitation is the main risk; consider the development of a multi-disciplinary programme to proactively support pupils at risk of exclusion, when due to substance misuse and/or criminal exploitation; consider how parents/carers can co-produce policies and protocols with the local education system.
      
 Title:  In memory of Child M: a multi-agency thematic summary: extra familial harm. LSCB: Pan-Dorset Safeguarding Children Partnership Author: Sarah Holtom Date of publication: 2022  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.                                 Pan-Dorset Safeguarding Children Partnership – BCP Area   In Memory of Child M  A Multi-Agency Thematic Summary:  Extra Familial Harm  Published June 2022    Report Author Sarah Holtom MSc BA(Hons) DipSW                  CONTENTS          PAGE  1. Introduction          2       2. How the Review was undertaken      3  3. Key Learning          4  3.1 How Systems Respond to Criminal Exploitation    4   3.2 Working Together with families      8  3.3 The role of education and community provisions in keeping children     11 safe  4. Recommendations         12   5. Conclusion          13  6. Family comment on report       14            2  In Honour of Child M  Child M was a much-loved son, brother, and member of his Turkish community in Bournemouth.  His family have shared many memories of him, and he was undoubtedly cherished as the youngest member of their family.  It is impossible to put into words the loss and heartbreak they feel. Child M’s family have been left devastated.    Professionals who knew Child M describe him as a friendly and kind-hearted boy, who would always be available to those who needed him.  Child M would talk openly of his love for his family and how important they were to him.  Child M was beginning to develop his own sense of identity and style as he began to progress through his adolescent years. It is said that he liked “to look cool” and was thinking of different hair styles and his image as a young Turkish male living in the Bournemouth. In navigating these teenage times, professionals saw Child M’s need to build his confidence along with the vulnerabilities that may arise as young people find a way through times of peer pressure and influence, often experienced in school settings and the local community.  Child M’s early years were spent in London.  His family re-located to Bournemouth, and the family have a retail business in the local area.  Child M attended the local primary school, two secondary schools and an alternative education provision.  The multi-agency chronology shows Child M groomed into a world of criminal exploitation from early 2020 and reports centred upon him selling drugs at school and to adults in the local community, often via social media.  Child M said he felt frightened for his own safety, and his range of behaviours indicated this.  At times he shared he would need to carry a knife to feel safe.  Towards the end of this life, Child M was openly sorry about how he had been pulled into this world. This shows a naïve understanding of how he had been coerced and controlled by those who chose to exploit him and how vulnerable he had been.  Child M aspired for his future and had many dreams.   Child M was 13 years old when he died of a suspected overdose of the drug Ecstasy.  His untimely death has sent shock waves through his family, local community, friends, and the professionals that knew him.  Our thoughts have been with them all throughout this Review process.  The intention has been to sit alongside to hear their reflections and give them a voice into Child M’s life.  The analysis and recommendations in this report are in honour of Child M and a commitment has been given to affect safeguarding practice and system development, where needed, to support those multi-agency professionals who work tirelessly each day with children who may be at risk of similar experiences of criminal exploitation.  1. Introduction  This Learning Review is concerned with the harms to children in those contexts beyond the home through the lens of a family, community, and single and multi-agency perspective.  Extra familial harm is described as harm that occurs to children outside of their family system, often during the adolescent years because at this age their social networks widen1.  These extra-familiar contexts can pose a new set of complex issues for systems to respond to and the focus of this Report is criminal exploitation.  Other forms of this harm include child sexual exploitation, peer-on-peer abuse, gang affiliation, serious youth violence, trafficking and modern-day slavery, anti-social behaviours by and affecting peers, radicalisation, and violent extremism.     1 Extra Familial Risks and Harm, The Innovate Project   3  The Report is the culmination of multi-agency work commissioned by BCP Community Safety Partnership (BCP CSP) and BCP Area Safeguarding Children Committee (the Partnership).  It was agreed by the BCP Area Child Safeguarding Practice Review Group on 8th September 2021 that a thematic local Learning Review consider practice and system learning, which includes good practice, along with recommendations for change where required. This approach was notified to the National Child Safeguarding Practice Review Panel2.      The Learning Review pays particular attention to the Turkish community.  Bournemouth, Christchurch, and Poole have a combined population of 396,989; 17.2% are aged 0-15 years and 11.6% of the population identify as black or minority ethnic, with 6.1% with a main language not English.3  Child M’s family members are part of the local Alevi Community of around 600 families who attend the Centre.  This culture and identity are important to their family, and they describe themselves as not practising in the religion.    Given the traumatic nature of what happened, the specific details of Child M’s story are not reported in detail in this written report. This information is held in various formats by the BCP CSP and the Partnership and forms the basis for this analysis, with key learning and recommendations.  The Review does not address the question directly of whether Child M’s death could have been predicted or prevented.  It focuses on how agencies might respond differently or try different approaches when working with extra familial harms to reduce the risk of this happening to other children in the future.   In reaching the thematic summary with recommendations for change the Review worked with Child M’s family, the local community, including schools and a range of professionals from across agencies.  The BCP CSP and the Partnership would like to sincerely thank Child M’s family, local community and professionals involved for sharing their thoughts so openly and honestly at a very difficult time.  Their reflections have proven invaluable to practice and system learning.    This report has been translated into Turkish for the benefit of Child M’s family and community members.   2. How the Review was undertaken  The period under review started from May 2017, when aged 9 Child M made comment at primary school about the Manchester Bombing4, and concludes with Child M’s very sad death in August 2021.            2 The National Panel refers to the Child Safeguarding Practice Review Panel which works with the Department for Education.  It is an independent panel commissioning reviews of serious child safeguarding cases. 3 Area profile for Bournemouth, Christchurch, and Poole, maping.dorsetcouncil.gov.uk 2020 4 On 22/5/2017 an Islamist extremist suicide bomber detonated a homemade bomb as people were leaving the Manchester Arena.  23 people died, including the attacker, and 1,017 were injured, some of them children Manchester    4  The Reviews lines of enquiry were:            The methodology for the Review was split into three workstreams, with a lead appointed to work with the Review Group and Independent Reviewer and author of the Report. The approach was collaborative and ensured participation of Child M’s family, the local community, schools, and multi-agency professionals.  The voice of those who knew Child M was actively listened to via various communication means, such as individual and group discussions in the community and on-line surveys.  The workstreams included Child M’s family and the Alevi Turkish community; Child M’s peers, including schools and multi-agency professionals who worked with Child M.  The content of this report is a joint production of all professionals, individuals and agencies involved with Child M and his family, drawn together by an Independent Author from outside the local area.    3. Key Learning Points  This section considers three thematic areas with key learning points when working with extra familial harms to children in the places and spaces they occupy.  The key learning is drawn from the three workstreams.  Set out below is a summary of this work.  3.1 How Systems Respond to Criminal Exploitation    Largely driven through the work of Professor Carlene Firmin5, there is growing recognition that individualised and family-focused approaches to working with the range of extra-familial risks  of county lines6, sexual exploitation and peer on peer violence faced by many children and young people in the UK are, in isolation, not sufficient.     As the contextual safeguarding approach helpfully considers, risk should be addressed at two levels.  A contextual “lens” adopted by practitioners when working with adolescent children which focuses upon understanding who the child ‘hangs out with’ and the spaces and places they spend time in within the community is required.  Attention is directed towards helping them find safer ways of engaging in relationships and inhabiting their growing social worlds.  There are examples of this approach being adopted with Child M at a ‘child in need’ level of intervention, albeit unknowingly, by the social worker who went regularly to the places which Child M frequented to understand how he  5 Professor Carlene Firmin MBE is a British social researcher specialising in extra familial harm.  She is Professor of sociology at Durham University 6 County lines is a form of criminal activity in which drug dealers in major cities establish networks for the supply and sale of drugs to users in towns and rural areas, using other people (often children) to carry, store and sell the drugs • Understanding the extra-familial1 risks and harms experienced by Child M and other young people in the local community  • When risk of harm is beyond the family, how this is identified, assessed, and responded to by individual agencies and when working together with families  • The role that education and community safety provisions play in keep children safe and how risk is understood and managed in the context of this setting   Key Learning: Safer Communities work is needed at a Strategic and Operational Level    5  presented in the local community and to determine what work was needed in response to his identified vulnerabilities.  When at a ’child protection’ level of intervention, Child M was not supported by the Complex Safeguarding Service, as he was not assessed at the level of highest risk or involvement in exploitation.  There were two management supervision directions on his record to refer his case to the Complex Safeguarding Service, but this did not happen.  This was a practice oversight and, in hindsight, engagement with this Service might have mapped out through a contextual approach, the community risks more clearly in the spaces and places he frequented.    The second level focuses upon the safety of communities for all those children (and adults) who use the spaces such as local parks, shopping centres, local shops, and schools.  Rather than just centring on changing or strengthening the behaviour of an individual child, or adopting parenting strategies to support the family, this community safety approach would attempt to ensure safer contexts where young people spend their time and, means they can remain in their local areas as opposed to being relocated.  As well as a policing role the Police and Crime Commissioner (PCC) is also responsible for tackling crime and the causes of it to ensure safer communities. Effective partnership working at a strategic level is essential and, one of the ways this is undertaken is through district Community Safety Partnerships (CSPs). CSPs consist of five “responsible authorities” (police, local authority, fire and rescue authority, probation, and clinical commissioning groups) and by working together they have a duty to assess local community safety issues and draw up a partnership plan setting out strategic priorities.   In the BCP area CSP there are Exploitation themed multi-agency groups at Strategic, Tactical and Network Partner level which are described as moderately effective, but they are slow in pace with often a “start again” focus to the strategic work.  Some key roles in these groups have been recently vacant/subject to change, and this is likely impacting on the drive to move systems work forward.   At the time there appears to have been a limited coordinated, operational and strategic approach to the management of risk and harm to children when outside of the home, despite a strategy and toolkit being in place https://pdscp.co.uk/working-with-children/child-exploitation/bcp-child-exploitation-toolkit/  Effective strategies and progress of work are required to ensure safer communities which keep a relentless focus on disrupting perpetrators and networks.  This Review finds the wider community responses via the BCP CSP to ensuring safer areas were not joined up in the approach needed i.e., in Child M’s community, with a significant gap in understanding and mapping local area hotspots, with adults causing harm and individual or groups of children being exploited.   This resulted in children at risk of criminal exploitation being responded to in a fragmented way by services as data was not known about local areas and action plans effectively put in place by the BCP CSP.  The impact of drug use and experimentation by adolescent children had a heart-breaking outcome for Child M and his family and other children in the local area.  There has been reporting by the regional and local media of this and similar cases: https://www.devonlive.com/news/devon-news/luke-campbell-tapson-died-after-1839845 https://www.bournemouthecho.co.uk/news/19843088.police-update-lauren-hawkins-inquest/ At the time of Child M’s death, the local community came together to raise their concerns:     6  https://www.bournemouthecho.co.uk/news/19535202.mums-emotional-tribute-13-year-old-son-Child M-altun/ https://www.bournemouthecho.co.uk/news/19544559.hundreds-bournemouth-protest-death-Child M-altun/ A community safety partnership strategic response to drug supply and demand needs to be considered in the local area.    The Review methodology focused upon asking parents, carers, and community groups from three local schools their views via an on-line survey and a community event.  This approach yielded a high percentage completion rate in a short timescale.  It indicates groups and individuals wish to be involved and is a good example of working together to ensure a community-based approach and is highlighted as good practice by the BCP CSP and the Partnership.        The summary from the 267 Parents/Carers who completed the on-line survey shows:       Community knowledge amongst parents/carers was in its infancy at the time of the survey about the risks to their neighbourhoods of criminal exploitation and county lines activity and it is clear more information is needed and wanted.  Following the reduction of youth clubs, services, and workers due to austerity, the need to create safe spaces within communities for children was highlighted.                Key Learning: Ensure there are continued community-based opportunities and approaches to work together with the local area and ensure safer places to live     65% were aware of county lines related issues 19% were not aware 8% were not sure 8% need more information    7  Parents, carers, and community leads suggested the numerous improvements:   Most popular improvement suggestions:  1. Enhanced police and community officers’ presence, particularly in specific areas, parks, and open space areas  2. More information, advice, and guidance for children/young people via schools, outside of school and specific workshops/information for parents/carers at an early help level on spotting the signs of criminal exploitation and how to seek help  3. Increase in youth workers, youth centres, activities to engage young people. Provide more mentoring and advice from those who have been involved and managed to get out Young People Responses:    1. How worried are you about each of the following?  Travelling to and from school 68% Being approached to sell drugs 54% Being pressurised to join gangs 56% Crime against other people 48% Being bullied 46%  2. Top 3 worries selected: Becoming a victim of crime 107 responses  Being bullied 72 responses Local gangs in your area 69 responses Crime against other people 66 responses   3. Choose 3 things to make you feel safer – options chosen More CCTV  116 responses More police officers in uniform 108 responses Fewer drug dealers 91   More things for young people to do together 81 (youth centres/workers 70   responses)   4. How concerned are you about drug-dealing in the area you live? Never notice 97 responses Rarely notice drug dealing 34 responses Some drug dealing 45 responses Open drug dealing 18 responses  5. Where do you feel most safe?   63% of responders feel very safe/safe during the day in home area 38% of responders feel very safe/safe during the evening in home area 91% of responders feel safest at home, 2% at a friend’s home  6.  55% of responders know how to report non-urgent crime or anti-social    behaviour     8  Young people in Years 9/10 were offered the opportunity to share their views via an on-line survey available at the three local secondary schools.  There were 210 responses, and a summary of their voices is in the box at the bottom of page 7.  The safety themes identified by the young people including travelling to and from school, bullying, gang affiliation and county lines activity will need to be aligned and addressed via a joint approach to action planning from the BCP CSP Strategic Group and Partner Agency Operational Groups.  This will undoubtedly also benefit from further opportunities for young people to share their lived experiences as work progresses to understand whether it is feeling any safer for young people because of this joined up approach. 3.2 Working Together with Children & Families Those professionals working with children and young people were unanimous in their views that child criminal exploitation necessitated new ways of working with families as current national safeguarding practice frameworks are mainly focused on intra familial harm to children.  Child M’s parents called for system change. This included the adoption of a rights-based approach so that their and their children’s voices are heard, increased training for teachers and other professionals, access to youth workers, and flexible, whole family support. The emotional and psychological impact of exploitation requires specialised support for children and parents/carers. Where this support is aimed at children, consideration is needed regarding what help and support children feel comfortable accessing.     The building of social connections and relationships with peers is a key part of development during adolescence and Child M was beginning to explore who he was as a young person. He was described by his family as a very kind and gentle boy and at times they wanted him to remain as the “baby” of their family. Considerable efforts were made by Child M’s social worker towards the end of his life to understand his world; the family see this as ‘good work’ with their son. Many examples of direct work approaches were seen by Child M’s social worker to broker family relationships when supported at a child in need7 stage.  This was seen as good practice by the Review Panel and helpful by Child M’s parents as it enabled Child M to have a voice, whilst supporting his parents to enable him to progress through his adolescent development. Child M’s vulnerabilities were known by Children’s Social Care services and work was identified at the end of his life to address his susceptibility to be drawn into situations and to explore his over-friendly nature.  At times the culture against ‘snitching’, debt bondage and fear of violent repercussions to themselves and their families renders children reluctant to engage with services.   However, this was not true for Child M as a good relationship was built with him by his last social worker. Persistent work with Child M by his social worker and his family support led to the case  7 A Child in Need is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled, Working Together 2018, HMO: Gov: UK  Key Learning: Build upon the development of flexible approaches to working with young people to understand their worlds   9  stepping down to Child in Need and ultimately Early Help levels. Solutions when engagement is less forthcoming need to be even more creative and persistent.          There was a flexible social work approach, which was responsive and relationship-based with Child M and his family.  This often-meant spending time with him in local parks and visiting patterns which were very regular and often out of hours, with text messaging in between.  Open conversations about county lines risks were regularly held and at the end of Child M’s life it is likely that risk had significantly reduced, and his situation was being stepped down to early help levels.  The main issues identified were of Child M’s confidence levels when in the community and future school plans.  Child M was of course still developing as a young person, where experimentation is likely.  Drug use was not raised as a known risk through many open and honest conversations.  This has been reflected upon in terms of ensuring critical thinking and a professionally curious stance to practice. There is an ongoing police investigation to ascertain the circumstances that led to Child M’s death and any link to exploitation.   Professionals who are supported to adopt flexible approaches in building relationships to include children and focus upon understanding their worlds, keep practice rooted in the reality of their lives.   The need for more local detached, out of hours working with young people at risk of criminal exploitation is highlighted by this good practice as it is not the norm, and the worker went above and beyond contracted hours. The benefits of a guardianship approach which is built upon trust, mutual respect, hope for change and collaboration can be seen and needs further development within adolescent integrated systems, when delivering new ways of working with young people.    This Review highlights the need to work collaboratively with parents and siblings to ensure the right support to help families and manage the risks together.  Child M’s older sister and parents have been at the forefront of this Review and wish to continue to offer their insights in further systems thinking, to other families and via community planned events. It is important to have effective systems in place to respond, help or protect children who are being criminally exploited, alongside effective support systems in place to guide families who are grappling with the complexities of criminal exploitation and the push and pull factors that may exist for their children. The work of SPACE8  and the National Parents as Partners (NPIES) forums are helpful to consider when developing more effective systems, strategies and solutions when working with families in tackling criminal exploitation.     8 SPACE is a specialist self-funded organisation founded in 2018 in response to the prevalence of County Lines driven child criminal exploitation.  It works to improve the response to children and their families by campaigning, raising awareness and providing training to statutory responders and communities Key Learning: Family-focused service responses need to be embedded across children’s social care, education and the police when working with extra familial harms     10    Good practice was seen from the Child Protection Conference Team in the use of formal escalation at a child protection level when social work practice fell short of expected standards.  There is learning for children’s social care in ensuring:  • The BCP child exploitation screening tool is completed in a timely manner for all children who are assessed at risk of extra-familial harms. • Social work teams ensure assessments are completed in a timely manner, shared with parents and professionals five working days prior to a child protection conference. • Management oversight and supervision ensures compliance of practice standards. • Interpreters are considered with family consultation and booked in advance of attendance at meetings. • Receiving social work teams attend Initial Child Protection Conferences to ensure a good handover of work • Multi-agency practitioners need to ensure that Child Protection Plans link to identified risk with actions, with a referral to the specialist Complex Safeguarding Team being considered when criminal exploitation is identified.  • Risk was identified and responded to at the appropriate levels of need and stepped back down when risk was seen to be reduced9.  The warning indicators to Child M’s safety and well-being were shared between the statutory agencies, risk assessed by individual agencies and a child protection plan was established within assessment and plan frameworks when at a level of significant harm10.   However, care is needed to ensure children at risk of criminal exploitation are referred to specialist teams by all professionals, working together so to further understand and respond to the risk factors and predictability of extra familial harms. This was not considered at the Initial Child Protection Conference or Review Conference.  Professionals’ comments made about high thresholds for referral into this specialist service need careful thought by Children’s Social Care.  • Work at a statutory level needs to have a robust link with and common approach to multi-disciplinary services providing Early Help intervention   This Review has found some evidence to suggest that the assessments undertaken, and plans put in place focused predominantly on Child M’s behaviours, were single agency and silo-ed in approach and did not look beyond this to the contextual risks with sufficient multi-agency coordination. The reason for the lack of a coordinated approach is likely to rest in the Council not having a systems approach to responding to criminal exploitation.  A coordinated and systems wide response to criminal exploitation, backed up by clear policy and procedures would clearly have helped professionals map out risk to Child M and his peers when at school and in the local community and ensure targeted disruption activities. Care needs to be taken to understand the context of extra-familial harms and consider unconscious bias towards marginalised sectors in a community when assessing risk of radicalisation with young people and their families.  Understanding the significance of a child’s identity within their community networks when assessing levels of risk is important to check for unconscious bias.  Child M’s parents hold the view that the Manchester tragedies and Child M’s comments about these when  9  https://pdscp.co.uk/wp-content/uploads/2021/07/Pan-Dorset-Continuum-of-Need-Guidance-Sept-2020-V2.pdf 10 Working Together 2018, assets. publishing.service.gov.uk, HMO: London Key Learning:  Manage risk via multi-agency assessments, plans and contingency in a timely manner    11  aged 9 years old, were blown out of proportion.  The Review concurs with this view and has been curious regarding the weight this was given when assessing risk and forming a professional view when extra-familial risk and harms were considered some years later. Professional curiosity and brave conversations are required to challenge assumptions and unconscious bias openly regarding all cultures and identities to ensure incorrect hypotheses are not drawn concerning risks. 3.3 The role of the education system    Given his adolescent age and likely due to the fear of the world he was being pulled in to, Child M showed a range of behaviours which were at times challenging, especially when in and around school settings.  The typical responses seen to Child M’s higher-level behaviours were to exclude him or manage a move to a different provision and this is a typical response seen in many behavioural policies in schools across the UK as it was likely deemed, they could not keep him or other children safe.    Child M had attended three secondary school providers by the age of 13 which would indicate that a behavioural approach was governing his access to learning. Safeguarding and support in Child M’s schools where children’s behaviours were often seen within a lens of perpetrator as opposed to being an exploited child may have resulted in a lack of considering alternative ways to support him within a school setting.  It does require a more nuanced approach from education systems in the definition of child as a victim and perpetrator, and a change in mindset where parents often or other professionals supporting the family may be best placed to identify when a child is being groomed and exploited.   The education system plays a vital role in keeping children safe. Educational establishments are a source of safety and may also include spaces and places in and outside the school grounds where there are likely and actual risks.  The survey results from young people regarding how safe they feel supports this view.  Child M’s family also have many questions about how and why he became drawn into a world of drug dealing and anti-social activities, often when or around school.   Professionals shared views on the need for focused work to understand the context of some school settings in terms of risk to individual and groups of children who may be easily influenced and groomed into a world of extra-familial harms.  This would be helpful alongside considering alternative strategies to managed moves or exclusions to support children with challenging behaviours to remain within their own school setting.   Education responses and action plans are required to minimise the risks and to keep future children safe.    The relationship between a Council’s admissions processes and Academy Schools is complicated. Since 2014 Academies are their own admissions authority except where variations have been Key Learning:  Safeguarding systems should not focus solely on a child’s behaviour in school.  The context of school spaces and places need to be considered in terms of safety and likely/actual risk to children. Key Learning: Parents/Carers need more information and guidance about the process of managed moves, exclusions, and re-integration.  Family cultural and language barriers need to be checked and responded to by the local authority and education providers    12  written into their funding agreement to support fair access11. If an Academy School refuses to accept a child, the Council are not able to direct them to do so. The matter can be referred to the ESFA12 and the Secretary of State can make direction.  Managed moves are agreed between individual schools. In BCP area headteachers have not been able to agree a single process that they are all willing to adopt.  There is local authority guidance, but there is no obligation for schools to adhere to this.  When children are excluded, statutory process applies13. The statutory processes and procedures as referenced (13) sit alongside the local provisions available when children’s behaviours are seen as difficult to those tasked with educating them. (There is currently a local consultation and review of the In Year Fair Access Panel in BCP Council). The length of time taken for the transfer between mainstream and specialist educational establishments following exclusion or re-integration was considered.  Child M’s parents feel very strongly about the length of time that Child M was out of education and think their voice or choice about provision of suitable educational settings for their son were not heard. They said they felt “compelled” to send Child M to a school they did not feel was the right place for him.  Child M also talked openly about feeling scared at this alternative provision and how the other children’s behaviours made him feel unsafe. In summary this Review finds educations provisions: • focused too heavily on Child M’s behaviours as opposed to understanding what was happening to him to likely cause the behaviours.  Strategies to support and manage behaviours were limited. • did not give enough weight to checking Child M’s parents understood education processes and ensuring their voice was heard about alternative school options. • too variable in keeping Child M safe and minimising risks. 4. Recommendations   This Review highlights a need for a range of effective approaches and interventions when working with children who are or likely to be criminally exploited.  There are recommendations based upon the three areas of key learning.  Criminal Exploitation  1. The BCP CSP Chair should work to ensure that the draft written action plan is in place and includes actions to strategically address criminal exploitation / serious youth violence and drug use in the local areas.  This plan should detail specific measurable outcomes to know whether communities are safer. The action plan should detail work with the planned violence reduction unit longer-term and the BCP Youth Strategy.  2. The BCP Community Safety Partnership, in collaboration with the wider range of local agencies, should enhance current quarterly data collection/intelligence processes to gather information about community hot spots, including local schools / serious youth violence /  11 The Fair Access Protocols ensure that all schools in an area take a fair and balanced approach when admitting vulnerable children, including those whose behaviour is seen as challenging 12 The ESFA is the Education Skills Funding Agency and is a single Government agency accountable for funding education and skills for children, young people, and adults. 13https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/921405/20170831_Exclusion_Stat_guidance_Web_version.pdf   13  county lines activity in and around the surrounding areas.  This should be shared with a senior operational multi-agency group (children’s social care, health, police, and education).  This data would inform the BCP CSP Strategic Action Plan (Action 1).  The operational multi-agency group and BCP CSP should join up their approaches to align strategic and operational work to disrupt criminal exploitation activities and map individual or groups of children at risk  3. BCP partners (Police, BCP, Education etc.) should consider facilitating further community events in the next six months to listen to the local community, (families and young people) to ensure work is rooted in reality and ‘lived experience' and check whether communities feel safer.  Working Together  4. The Child Exploitation (CE) Screening Tool should be completed at all levels of intervention from early help and statutory levels of assessment when exploitation is the main risk and should form the basis of multi-agency decision-making with the family on whether a referral to the Complex Safeguarding Service is needed.  A multi-agency audit of 20-40 children at risk of CE should be completed, led by the Partnership’s QA Group to check individual children are accessing the right service at the right time according to need and achieving the desired outcome.  The scoping of the audit should consider any barriers to completing the CE Screening tool.   5. The CSP and the Partnership should facilitate a revised training/learning offer on criminal exploitation to be provided, which should include the key learning from this thematic review and ensures the voices of the community and families are represented along with the effective use of the CE Screening Tool.     Education Systems  6. The Director of Education in BCP should consider the education issues outlined in this report and provide an update by June 2022 to the actions already detailed in the WSOA (link). These actions should address the issues around the fair access protocol and how children transition from one school to another. This work should also consider how all parents are informed and supported to understand their choices.      7. The Director of Education should consider the development of a multi-disciplinary programme to proactively support pupils at risk of exclusion, particularly where due to substance misuse and/or criminal exploitation. An update should be provided by June 2022.  It should also be considered how parents/carers can co-produce policies and protocols going forward.      5. Conclusion It is highly complex work to ensure systems and practices are based upon the values of being rights-based with children whilst also ensuring their safety, as undoubtedly tension exists between the two.  This thematic summary of Child M’s last years of life shows how there is a need for a range of approaches and interventions across services when working with children vulnerable to criminal exploitation. This includes preventative, educational work at the child and family level, system change to help and support children and families exploited or at risk of exploitation and   14  community measures aimed at the provision of safe places and spaces both in local areas and school settings.  At the heart of all these approaches sits the need to listen to and involve children and their families and to work in a way which is respectful, strengths based, and hopeful, whilst also being rooted in reality.   At the child level, consideration is needed regarding school inclusion and exclusion practices and how to hold children when their range of behaviours are seen as difficult or risky. At the family level, the challenges of parenting adolescents and the impact of exploitation on parents and siblings should be supported. At the system level, there needs to be change so that child and family and community voices continue to be heard and included in decision making. This requires an adapted, flexible system able to work with extra familial risk and harms to adolescents.  In addition, consideration is needed about the creation and maintenance of safe spaces and places for children in the wider community via a commitment to joined-up work from the BCP Community Safety Partnership. More attention is needed nationally regarding the way the county lines models present and adapt within local contexts and especially in the context of COVID-19, so that this data and information can be used to develop appropriate prevention and safeguarding strategies.  The Review has started this journey of much needed improvements in the join up of local systems and there is much community and professional appetite for the work to continue.   In honour of Child M and in listening and involving his family and local community, the Partnership and BCP area CSP are now committed to drive forward the recommendations outlined in this Report.  By doing so the aim is for young people in the local area to enjoy a safe community, where their hopes and dreams for the future can be achieved.  This is the legacy and promise to Child M and his family. 6. Family Comment Child M’s mother met with interim Director of Safeguarding Children and Early Help at the BCP Civic Centre on behalf of the Review panel to provide feedback on the Report which had been finalised and translated into Turkish for the family.  As would be expected this was an emotional meeting.  M’s mother wanted to pass on the thanks from his family for the Review and the Summary document which the family felt to be considerate and caring, a celebration of their much-loved son’s life, with a strong child focus.  The family felt that the Review had completely achieved what it had set out to do and what the family had expected.          M’s family fully agree with the contents of the report, accept the findings of the Review, and welcome the recommendations made in the Learning Summary. The family particularly wanted to thank the Alevi community who attended the focus group meeting with agency representatives in December 2021 and the young people in local schools (and their parents/carers) for their feedback on safeguarding risks within their community and many suggestions for addressing these.     M’s sister also wants to carry forward the legacy of her brother’s life by working closely with the youth branch of their local Alevi community group to share her experiences and the learning from her brother’s tragic death with other young people from the community to make a difference to their lives.          The family accepts and understands why the Report does not refer to the detail of the incident, as the case continues to be a live police investigation. The family support publication of an anonymised Thematic Review Report and summary referred to as Child M.      