Spans the period from March 2018 when concerns relating to physical abuse by Child D's father and indicators of sexual abuse were raised until August 2020, when Child D's brother admitted sexually abusing his sister. Learning themes include: signs and indicators of child sexual abuse, especially the possibility of sibling perpetrated sexual abuse; cultural considerations; language barriers; the role of family members within a household; and no recourse to public funds. Recommendations for the Partnership include: seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded; make information available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse; all agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings; consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats; seek assurance that existing tools such as genograms are utilised for the purpose of considering a family's composition and the roles that all family members play within a unit especially male family members; and make information available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds.
      
 Title:  Child safeguarding practice review ‘Child D’. LSCB: Cambridgeshire and Peterborough Safeguarding Children Partnership Board Author: Cambridgeshire and Peterborough Safeguarding Children Partnership Board 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.                                 1     Cambridgeshire and Peterborough Safeguarding Children’s Partnership Board  Child Safeguarding Practice Review ‘Child D’ 2022                   2  Contents 1. Introduction .................................................................................................................................... 4 2. Methodology ................................................................................................................................... 4 3. Chronologies ................................................................................................................................... 5 4. Scope of the review......................................................................................................................... 5 5. Contact with family members ......................................................................................................... 5 6. Summary of Agency Involvement ................................................................................................... 6 Events of 2018..................................................................................................................................... 6 Significant event .............................................................................................................................. 9 Events of 2019................................................................................................................................... 10 Events of 2020................................................................................................................................... 13 7. Analysis.......................................................................................................................................... 17 1) How were risk and protective factors identified, assessed, and managed within the family? 17 Initial identification of risk ............................................................................................................ 17 Assessment of risk ......................................................................................................................... 18 Identifying other indicators of abuse: ........................................................................................... 19 No recourse to public funds .......................................................................................................... 19 Summary: identification, assessment and management of risk: .................................................. 20 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children? .................................................................................................................... 21 Examples of good communication and inter-agency working: .................................................... 21 Areas for improvement: ................................................................................................................ 22 3) How well did agencies identify and respond to signs of child sexual abuse?........................... 22 Medical examinations ................................................................................................................... 22 Indicators of child sexual abuse: ................................................................................................... 23 Assessment of indicators of child sexual abuse: ........................................................................... 23 Barriers to disclosure: ................................................................................................................... 24 4) How was the voice of the child recognised and responded to within the case? ..................... 24 GP: ................................................................................................................................................. 24 Addenbrookes Hospital: ................................................................................................................ 25 Barriers to communication ........................................................................................................... 25 The child’s lived experience: ......................................................................................................... 25 Evidence of Child D’s voice: .......................................................................................................... 26 Family members: ........................................................................................................................... 26 5) Was Covid a factor in safeguarding and supporting Child D and did it have an impact on how agencies communicated and shared information? .......................................................................... 27       3  School non-attendance as a risk factor: ........................................................................................ 27 Presentation at A&E: ..................................................................................................................... 28 Inter-agency communication: ....................................................................................................... 28 6) Were there language or cultural barriers to the family accessing services and support? ....... 29 7) Can you identify any areas that you consider to be good practice? ........................................ 30 8. Summary ....................................................................................................................................... 31 9. Key areas of learning: .................................................................................................................... 32 Signs and indicators of child sexual abuse ........................................................................................ 32 Cultural considerations: .................................................................................................................... 32 Language barriers ............................................................................................................................. 32 The role of family members within a household .............................................................................. 33 No recourse to public funds .............................................................................................................. 33 10. Recommendations .......................................................................................................................... 33 Signs and indicators of child sexual abuse ........................................................................................ 33 Cultural considerations ..................................................................................................................... 33 Language barriers: ............................................................................................................................ 33 The role of family members within a household .............................................................................. 34 No recourse to public funds .............................................................................................................. 34          4  1. Introduction  This report has been edited for publication to protect the identities of those involved.  As a result personal information, beyond basic details, has not been included. Child D, her mother and two, now adult, siblings lived in a two-bedroom flat in the local area and had no recourse to public funds, the impact of which was significant financial pressure on Child D’s mother to support the family with her income. The family experienced overcrowding in their property which was located in an expensive part of the county, as well as social isolation.  They frequently spent time in Europe with family members, including Child D’s father.   Child D was assessed for additional learning needs and had an Education, Health and Care Plan. Child D’s mother may also have had additional needs.  She was referred for assessment but was not felt to have met the threshold. This case was referred to the Child Safeguarding Practice Review (CSPR) subgroup for consideration of a rapid review by Cambridgeshire Constabulary in August 2020. The circumstances of the case were: Child D’s older brother provided details to the Police that he had been sexually abusing his sister, Child D. He was arrested and later sentenced to a custodial sentence for the abuse, having admitted numerous serious sexual and other assaults against her. There had been recurring and ongoing concerns with regards to the safeguarding and welfare of Child D since the family moved to Cambridgeshire. There had been previous concerns related to possible sexual harm and a medical examination was undertaken in April 2018 but no findings were noted.  There were concerns relating to neglect, physical abuse perpetrated predominantly by her father and emotional harm, as well as consideration of Child D’s additional vulnerabilities due to cognitive and learning needs and the impact of English being a second language.  Child D was made the subject of a Child Protection Plan in March 2018.  2. Methodology  Following the CSPR referral a rapid review was undertaken. The case was discussed at a CSPR Subgroup meeting in September 2020 and it was agreed that the case met the criteria for a local CSPR. Relevant agencies were required to complete a “key events” chronology, which once completed, were combined into a single composite chronology.  The chronology was used as the basis for a virtual multi-agency information gathering event with the chronology authors from the relevant agencies. Those present at this meeting were asked to consider the information within their own agency’s chronology and to participate in an in-depth case discussion regarding the safeguarding issues surrounding Child D in the timeframe of the review, which is outlined below. The aim of this discussion was to extract learning and good practice relating to Child D in order that practice might be improved across the safeguarding children workforce.   A multi-agency practitioner information gathering event was also held which took place virtually and included those practitioners who had worked with Child D and her family both       5  during and after the timescale of the review. The aim of this meeting was to explore and understand the context of practice within the timescale of the review as well as considering questions posed within the terms of reference from the practitioners' perspectives. These processes have been the vehicle used for the review process alongside discussion and evaluation of this report for accuracy.  As such the analysis included within the report has been either provided by or confirmed with this multi-agency group of author’s and practitioners. 3. Chronologies The following agencies were required to complete a chronology on an agreed template: Cambridgeshire Constabulary  Cambridgeshire Children’s Social Care  Cambridge University Hospitals NHS Foundation Trust: Addenbrookes Hospital Cambridgeshire Education Safeguarding Service  SEND (Special Educational Needs and Disabilities) Service 0-25 Cambridgeshire Community Services  NHS Cambridgeshire and Peterborough Integrated Care Board Sexual Assault Referral Centre (The Elms: Mountain Healthcare) 4. Scope of the review  This review aims to consider those events specifically related to safeguarding within the time period from:  1st March 2018, the date that a strategy discussion was held as a result of concerns relating to physical abuse by Child D’s father and indicators of sexual abuse. An accumulation of concerns which had been shared with Children’s Social Care by Child D’s school were considered and a decision made for a section 47 inquiry to be carried out. To August 2020, when Child D’s brother made the disclosure of abuse.  5. Contact with family members  As with all child safeguarding practice reviews, it is important to gain the views of the families of the subjects of these reviews.  Attempts have been made to communicate with Child D’s mother via letter and text message using translation services.  Whilst some of these attempts were responded to, the majority have been unsuccessful.  Attempts to speak with Child D have not been made directly as it was felt by those having supported her most recently, that this would not be in her best interests.       6   As a result, neither Child D’s nor her mother's voice have been directly captured as part of this report and it is recognised that this is missing. Multi-agency records and practitioner feedback has been used to give some indication of their lived experiences through the timeframe of the review, as well as the inclusion of Child D’s voice via the Investigating Officer, who led the criminal case against her brother.  Consideration has been given to making contact with Child D’s brother as part of this review, but it was felt that without Child D’s or her mother’s view this would not offer a balanced perspective.  It has been agreed however, that the appropriate family members will be notified in writing of the completion of this report should they wish to obtain a copy. 6. Summary of Agency Involvement  Events of 2018  According to Police and Children’s Social Care records, a strategy discussion was held on 1st March 2018 following Child D making a disclosure at school of physical abuse by her father. Records of the meeting show that an accumulation of concerns were considered which had been recorded by school and an after-school club, as well as concerns which had been raised in November 2017 by school resulting in a Strategy Discussion between Police and Children’s Social Care at that time, where it was agreed that a single agency section 47 enquiry should be undertaken by Children’s Social Care and an Initial Child Protection Conference should be held. It is not clear why an immediate medical examination was not considered at this point. On 8th March 2018, Child D attended her GP with her mother. The GP conducted a physical examination and found no visible injuries. The GP shared details of this visit with Children’s Social Care and the Police on the following day. A discussion was held in the multi-agency safeguarding hub (MASH) on receipt of this information on 9th March 2018 as to whether a child protection medical examination should be offered to Child D. The Social Worker spoke with the GP on 12th March and it was agreed that Child D should be seen by her own GP again the following day as she was still experiencing pain, representing another missed opportunity to refer Child D for a medical examination.  It is unclear to what extent the GP was involved in the discussions on 9th March. On 12th March 2018 Child D told school staff that she was still in pain. The school staff informed the allocated Social Worker who spoke with Child D’s mother on 14th March and advised Child D’s mother to take Child D back to the GP. It does not appear that the potential indicators of sexual abuse, as indicated by the symptoms Child D described, were recognised as such.   On 20th March 2018 Children’s Social Care record that Child D had not been taken to the GP by her mother despite her agreeing to do so.  On the same date Child D was assessed by an Educational Psychologist in recognition of her additional needs.  The outcome of this assessment was an Education Health and Care plan which is detailed later in the report.  Child D reported again to school staff on 23rd March 2018 that she was still experiencing pain. School records evidence that this was communicated to the Social Worker and then discussed       7  at the Initial Child Protection Conference held on 28th March 2018. The Designated Safeguarding Lead from Child D’s school and a School Nurse were present.  According to the records from Child D’s school, both of these practitioners noted a number of indicators of child sexual abuse. A number of other vulnerabilities were discussed at this meeting including additional educational needs, language barriers not just for Child D but also for her mother, domestic abuse, overcrowded housing and unexplained injuries. It was agreed, according to school records, by all professionals, that Child D would be supported under a Child Protection Plan for physical abuse as this appeared to be the most significant risk at that time. Records from Children’s Social Care suggest that indicators of sexual abuse were recognised within the plan and a child protection medical was requested to take place to explore this possibility.  This was requested the following day and arranged for 5th April 2018. Child D’s sister was 17 years old and it was decided that she should be supported under a Child in Need Plan as it was perceived that the risk of physical abuse to Child D’s sister was not as high as she was not displaying the same indicators of abuse.  As Child D is the subject of this review, the circumstances surrounding her have been the focus of this report, however it is acknowledged that Child D’s sister may have been vulnerable or subjected to abuse in her childhood also.   During a home visit by the allocated Social Worker on 4th April 2018, a bruise to Child D was disclosed. The Emergency Duty Team was notified, which suggests the visit took place outside of office hours. No other action is recorded but the medical examination at the Sexual Assault Referral Centre (SARC) was due to take place the following day. Child D attended the SARC on 5th April 2018. Bruising was noted to various areas of Child D’s body but there were no abnormal genital findings noted. Sexually transmitted infection screening was refused by Child D’s mother.  Later the same day, Child D’s Social Worker contacted her GP to request an appointment as Child D was still experiencing pain and required assessment for treatment, as suggested by the Doctor who conducted the examination at the SARC.  On 6th April 2018 the Social Worker requested a strategy discussion with Police which took place in the MASH relating to the unexplained bruising to Child D observed on 4th April.  It was agreed that Child D should have a child protection medical, but this appears to have been unnecessary given the analysis provided within the medical report produced by the Forensic Medical Examiner at the SARC.   On 10th April 2018 Child D attended the GP with her mother. The appointment had been made with a female GP, the Social Worker attended, and a telephone translation service was used. An examination and tests were undertaken but no evidence of a cause for her symptoms could be found. Child D’s own words are well recorded in the records for this appointment but it is not clear whether the GP was made aware of Child D’s learning needs. Children’s Social Care records for 16th April 2018 include a discussion between the Social Worker and Child Protection Chair regarding the bruising noted on 4th April. Agreement was then sought from a Senior Manager for a Legal Planning Meeting, to determine whether the threshold for initiating care proceedings had been reached. This decision was based on the concerns that had been raised at the Initial Child Protection Conference, and particularly the bruising that had been observed on 4th April. This was agreed by the manager but there is no evidence within Children’s Social Care records that any further action took place. This is a significant missed opportunity to explore professional’s concerns further and impress upon Child D’s mother the level of risk that was perceived.  On 3rd May 2018, an Education, Health and Care Plan assessment was agreed.        8  A Review Child Protection Conference was held on 5th June 2018, and it was agreed that Child D should remain on a child protection plan under the category of physical harm. Analysis provided within the chronology submitted by Children’s Social Care suggests that those in attendance at the meeting remained mindful of the possibility of Child D having experienced child sexual abuse, but it is clear from the records that the focus of professional's concerns was on the risk of physical abuse to Child D from her father and the contact that she had with him. The previous consideration of seeking legal advice due to the level of concern does not appear to be referenced at this meeting, nor is it clear whether any previous interventions of support had been achieved.  There is no suggestion in the records that any lack of progress was challenged by those present.  On 14th June 2018 there is a record within the school chronology of inappropriate behaviour by Child D at school which was recorded to be shared at the next Core Group meeting. On both 19th and 26th June, the school raised concerns with Children’s Social Care regarding a lack of supervision being experienced by Child D at home and then on 2nd July, the school again contact Children’s Social Care with concerns of inappropriate behaviour being displayed by Child D at school. It is not clear what action, if any, as a result of these concerns was taken. The next Core Group meeting was held on 25th September 2018, but these issues do not appear to have been raised and as such a further opportunity to explore Child D’s behaviour and to revisit the potential indicators of child sexual abuse, was missed. Child D attended the GP again with her mother and older sister on 10th July 2018. The GP advised plenty of fluids and a cautious diet. There was no interpreter available for this appointment, so the GP wrote advice on a note for Child D and her mother to take home.  Again, on 13th July 2018, school records note concerns relating to a lack of supervision of Child D at home, after Child D reported to school staff that she had been left alone in the flat by her brother. This was a missed opportunity for the Core Group members to consider what role Child D’s brother might play in caring for, or at least supervising, Child D in her mother’s absence.   On 27th July 2018, the records for Children’s Social Care note that advice was received from the Educational Psychology service relating to Child D’s communication needs. On 15th October 2018, the Special Educational Needs and Disabilities Assessment Team records show that an Education, Health and Care Plan (EHCP) was issued in recognition of Child D’s significant additional learning needs1.  On 22nd October 2018, during case supervision the allocated Social Worker suggested that Child D could be stepped down from a child protection plan to support under child in need processes. Child D had expressed to the Social Worker that she was happy at home, felt ok about her brother and had not been left alone with her father during the holidays. The Social Worker felt that this was an indication that the risk of harm had reduced. Education records for 12th November 2018 show that bruising was noted to Child D on this date which did not match the explanation she gave for the injury. The allocated Social Worker was informed by the school but there is no corresponding information in Children’s Social Care records, demonstrating another gap in the recording in relation to this child. Equally there is no record that the school had chased Children’s Social Care on this occasion to determine what action they had taken.  1 This time span between the assessment and final ECHP plan is in line with Government guidance: https://www.gov.uk/children-with-special-educational-needs/extra-SEN-help        9  Child D attended her GP again with her mother and brother on 15th November 2018. The GP advised gastroenteritis.  Significant event  There are multiple entries in the combined chronology for the 19th of November 2018 from Police, Education and Children’s Social Care. Injuries are noted on Child D while she was in school but the staff member was unclear as to how the marks might have been caused. Child D could not provide an explanation for the injuries. There is insufficient detail within any of the agency records to be able to determine whether questions were being asked of Child D in a way that was commensurate with her learning difficulties. First aid was provided in school and the allocated Social Worker was informed. A strategy meeting was then held between the Police and Children’s Social Care and a single agency section 47 enquiry by Children’s Social Care and a child protection medical were agreed. An appointment was made with the GP later the same day because it was judged that immediate treatment for the injuries may be required.  An opportunity was missed here to find out whether Child D could have had an immediate child protection medical with a Paediatrician, negating the need for her to be seen twice.  Child D attended the GP appointment with her mother and the allocated Social Worker. Child D was unable to provide a clear explanation for the injuries. GP records are very detailed and include notes of Child D’s behaviour and the communication between Child D and her mother, in their first language. The GP undertook an examination of Child D’s injuries and her mother suggested, via a telephone translation service that the injuries were self-inflicted, although Child D herself denied this. The practice nurse dressed the injuries and provided spare dressings, but Child D declined further examination and requested a female doctor.  Following the appointment, the GP sought advice from colleagues and arranged an appointment at Accident and Emergency with a Paediatric Registrar at Addenbrookes Hospital. Child D’s mother agreed to attend with Child D along with the Social Worker. Information within the combined chronology suggests that Child D and her mother did not attend this appointment as they were contacted by Addenbrookes to advise them to attend Hinchingbrooke Hospital on the following day instead.  It appears that they did so and Child D was examined but that the details of this examination were not shared with the GP or Children’s Social Care.  Had an immediate child protection medical been arranged, Child D and her mother would have only been required to attend one appointment and information sharing following that appointment might have been improved. Cambridgeshire Community Services records for the Community Paediatric service show that Child D was seen by a Consultant Community Paediatrician relating to the injuries on 20th November 2018.  The Paediatrician noted that Child D’s injuries were likely to have been a combination of accidental and non-accidental injuries as well as possible self-inflected injuries. Child D‘s own explanation had been inconsistent. All injuries were photographed, and the Paediatrician also noted concerns of neglect. It is not clear from the combined chronology whether the details of this appointment were shared with other agencies or whether any action was taken.   The following day, 21st November 2018, Child D made a comment to school staff which was then verbally shared with the allocated Social Worker but does not appear to have been recorded within Child D’s records.  This comment should have triggered curiosity as to Child D’s relationship with her brother, and again the role he played in her care. On 22nd November 2018 there is a record of communication between the Social Worker and school relating to the injuries noted on 19th November to Child D and information that Child D       10  had said she was being bullied at school. It is around this time that a referral was made by the school to a Play Therapist from Cambridgeshire Women’s Aid. This referral was possible because Child D and her mother had previously resided in a women’s refuge.  A Review Child Protection Conference was held on 28th November 2018 and all those present agreed that Child D should remain on a child protection plan for neglect. The concerns at this time were that Child D was not sufficiently supervised at home, her mother had not supported her to gain medical treatment and that Child D’s emotional wellbeing was suffering.  The risk of physical harm was perceived to have reduced, despite the Paediatrician’s conclusion on 20th November that Child D may have been displaying non-accidental injuries. There does not appear to be consideration of any ongoing risk of sexual abuse. Child D attended the GP on 10th December 2018 but it was not noted who had attended with Child D. The following day, 11th December, the GP attempted to gain an update from the accident and emergency appointment arranged on 19th November, a demonstration of the GP’s level of concern. It was concluded that Child D had not been taken to the appointment.  A number of missed opportunities can be noted throughout 2018, to explore Child D’s lived experience and the structure of her family.  Additionally, during this period there were missed opportunities to arrange the SARC medical before this took place on 5th April and a further missed opportunity for acute health intervention via a child protection medical for the injuries in November 2018.  Assessment of her education, health and care needs concluded that she had significant learning needs but there is no clear evidence of how practitioners working with her factored these needs into the contact they had with Child D.  A lack of clarity in the records relating to health involvement via Core Groups and Child Protection Conferences, as well as inconsistent information sharing with the GP can also be found in this period. Events of 2019  On 1st January 2019 is it noted in the Children’s Social Care records that statutory visits were not being carried out according to procedures in this case because the home environment had not been observed and an understanding of Child D’s current home situation and potential risks could not be gained. This had resulted from Child D’s wish to see the Child Practitioner at school rather than in her home because of the limited space within the property. Whilst it was correct that Child D’s wishes were taken account of, home visits should have been carried out in addition to seeing Child D in school. On 4th January 2019, a School Nurse from Cambridgeshire Community Services reviewed the relevant records having received a copy of the minutes of the review child protection conference on 28th November 2018.  At this point in time the School Nurse was an information only member of the Core Group, which could be considered as a missed opportunity for consistent health oversight of this case given the level of acute health involvement. However, this must be balanced with the pressures to this service at the time. The School Nurse then contacted the allocated Social Worker asking to be invited to the next Core Group meeting and to suggest that a health assessment be carried out, based on the concerns relating to self-harm and emotional health contained within the child protection plan.  The GP contacted the allocated Social Worker on 14th January 2019 and was informed that Child D and her mother had been asked to attend Hinchingbrooke hospital on 20th November in place of the appointment arranged by the GP at Addenbrookes. The Social Worker had taken Child D and her mother to this appointment, but the GP was unable to gain details of the       11  appointment from the hospital despite making a number of attempts to contact them.  It is unfortunate that the GP did not escalate this as the information may have added to the picture of Child D’s lived experience for the GP. Concerns were raised by the school on 6th February 2019 when Child D made a comment relating to her father’s behaviour towards her mother. This was shared with the Designated Safeguarding Lead in school but does not appear in Children’s Social Care records. Child D began working with the Play Therapist in school in February 2019.  A health assessment was completed in school by a School Nurse with Child D on 7th March 2019. Child D’s mother was not present for the assessment. Child D described that she would have liked her own bedroom and did not believe that she could read or write as wll as her peers.  Child D’s voice is described in the records as being captured throughout the assessment and the School Nurse used a variety of methods to engage Child D and gain her views.  On 14th March 2019 there is evidence in the combined chronology of communication between Cambridgeshire Community Services and Children’s Social Care which confirmed that Child D’s older sister, her older sister’s husband and their baby, Child D’s niece were living at the same address as Child D, her mother and her brother. The baby, Child D’s niece, was later subject to an Early Help Assessment to consider her own needs and that of her parents. Child D attended the GP with her mother on 25th March 2019 for an emergency appointment. Observations and an examination of Child D were both normal. The GP booked an appointment for the following day with a female GP and an interpreter. Given the previous information both shared with the GP and observed through appointments with Child D, there was a missed opportunity here to pick up on a further possible indicator of child sexual abuse. Child D and her mother returned to the GP the following day, 26th March 2019. There is very good recording by the GP for this appointment, including observations of a respectful, comforting and supportive response from Child D’s mother towards her. Direct questions were asked by the GP of Child D relating to the potential causes for the symptoms she was experiencing but there is insufficient detail to determine whether these questions were appropriate to Child D’s level of understanding. Both Child D and her mother denied any concerns, but Child D was not seen alone.  On 2nd April 2019, Child D made some concerning comments to a music therapist she had been seeing at school. This information is recorded in the school records as having been shared with the Social Worker. Unfortunately, despite several attempts to contact the company offering this service, no further information has been obtained. Child D was seen in her home on 17th April 2019 by a Health Visitor who was attending to see Child D’s sister and her sister’s baby. The Health Visitor noted Child D’s appearance and recorded that she had not seen any new bruises or injuries, a good demonstration of following the ‘Think Family’ approach. On 30th April 2019, according to the school records, Child D made further comments to the music therapist in school. This was communicated to the allocated Social Worker.  A review of Child D’s Education, Health and Care Plan was undertaken on 22nd May 2019. At that time, Child D’s school was exploring a specialist placement for Child D with increased funding. It is also mentioned that the housing needs of the family were being assessed and that Child D would remain open to Children’s Social Care whilst this was ongoing.        12  A review Child Protection Conference was planned for 23rd May 2019, but the meeting was adjourned due to a lack of information provided by the new Social Worker to allow for consideration of both progress against and the impact of the child protection plan at the conference, despite the fact that the Social Worker was suggesting that Child D could be supported under a child in need plan rather than a child protection plan. It was also noted that the conference could not go ahead without an interpreter for Child D’s mother having been arranged. On 24th May 2019 Child D told the Play Therapist working with her at school of an unusual punishment used by her mother towards her. The allocated Social Worker was informed and Education records also suggest that a discussion with mum took place. When this event was explored with school staff, they spoke of mum’s shock and disbelief that Child D had made this disclosure.   The review Child Protection Conference which had been due to take place on 23rd May, was held on 29th May 2019. Children’s Social Care records state that a representative from Child D’s school and the allocated Social Worker attended this meeting and it was agreed that Child D could be supported under a child in need plan. It was discussed that no further injuries had been reported and Child D’s mother had sought appropriate medical treatment for her when it had been necessary. Child D was not in contact with her father which it was felt reduced the risk of physical harm. Some areas of support remained but it was agreed by both agency representatives that these could be addressed within a child in need plan.  The School Nurse had been unable to attend due to the meeting having been rearranged but had sent a report for the meeting. The report however had not included an opinion as to whether Child D should remain on a child protection plan or step down to a child in need plan and without this information, it cannot be evidenced that this meeting represented multi-agency decision making. The GP should have been invited to this meeting given the involvement she had had with Child D. Again, on 30th May 2019, the Conference Chair raised concerns to Children’s Social Care managers. These concerns were relating to the ‘quality of reporting and a lack of multi-agency oversight.’ There is no further detail relating to these concerns nor a recorded response.  Child D attended the GP on 6th June 2019 with her mother. A telephone translation service was used. Child D described injuries which were itchy. She gave multiple explanations and the GP completed an examination and discussed concerns with Child D’s mother that the injuries were unexplained. The GP completed a referral to Children's Social Care and informed Child D’s mother of this. Comprehensive recording was completed again by the GP, which included observations of ‘good attachment and rapport between daughter and mum.’  The referral completed by the GP is recorded on Child D’s record held by Children’s Social Care but there is no record of a response.  On 27th June 2019 a referral was made to the Community Paediatric Service for a review of the Education Health and Care Plan in place for Child D as it was felt that the plan in place was not adequate to meet her needs in school. A review was undertaken, and the result was that no additional medical diagnosis could be found, but genetic testing for Child D would be offered.   The following day, 28th June 2019, Child D attended the GP with her mother: this was the fourth attendance for related complaints in the time scale of this review. There is good recording of behavioural observations within the GP’s records, and it was advised that Child D might have been suffering from growing pains. No other concerns were noted. It appears       13  from the records that Child D was seen by the same GP as on at least some of the previous occasions, who would therefore have been aware of Child D’s history. Child D’s case was reallocated by Children’s Social Care on 29th August 2019 to a Child Practitioner who spoke Child D’s and her mother’s own language in order to improve communication with Child D’s mother, who was unable to speak English. Until this point interpreters had been used for interactions with the family by Children’s Social Care. The practitioner made visits to Child D at school, as well as at home where it was noted that Child D was sharing a room with her mother. Contacts with Child D and her mother increased, according to the combined chronology, following this change of practitioner to complete the work within the child in need plan.  A child in need meeting was held on 31st October 2019 and concerns were raised that Child D’s mother might be the victim of domestic abuse.  She was offered support from Cambridgeshire Women’s Aid as well as support to obtain legal advice in relation to custody of Child D. Given the previous perceived risk of physical abuse to Child D from her father, there should have been consideration of this risk based on her mother’s injury. On 19th November 2019, Child D attended the GP with her mother for a respiratory related complaint. No concerns were noted from the examination but a follow up appointment was made to allow Child D and her mother to monitor her symptoms at home. Child D and her mother returned to the GP on 3rd December 2019. Monitoring of Child’s symptoms had been completed at home and the GP noted that the results were normal. Child D became upset but could not explain why. Despite offers from the GP, she did not wish to be seen alone or with her older sister. A further appointment was offered. On 13th December 2019, Child D was seen in school with an injury.  First aid was provided in school, but it was felt that the injury required medical attention, so Child D’s mother was contacted and asked to take Child D to see the GP. Children’s Social Care were also informed and contacted Child D’s mother to reiterate the need for her to take Child D to the GP. Child D and her mother were seen by the GP later the same day. Child D gave an account of how she had sustained the injury, but her mother had given the school an alternative explanation. The GP noted that communication with Child D’s mother had been difficult due to a lack of interpreter. The wound was dressed by a nurse and Child D gave the same account to the nurse as she had given to the GP. The concerns communicated by the school at the practitioner's information gathering event were that Child D had been without supervision, which they believed would have presented a risk of harm to her, given her level of cognitive functioning.  A strategy discussion at this point may have helped to gain a better understanding of this potential risk.  It appears that this injury and the potential lack of supervision which might have resulted in the injury were give insufficient weight in the context of the identified risks to Child D. Events of 2020 Child D told a member of staff at school on 7th January 2020 that her father had been at the family home. Child D’s mother was spoken to but did not agree that Child D’s father was staying with them. It is recorded by the school that Children’s Social Care had been due to close the case, but it remained open based on this information.   On 8th January 2020 Child D’s father attended one of Children’s Social Care’s offices and informed staff that he was not being permitted contact with Child D by Child D’s mother, but that Child D had been in contact with him. When the Child Practitioner saw Child D, she said       14  that she wanted to live with her father because she would not have to share a bedroom. Children’s Social Care planned to assess Child D’s father for his suitability to have contact with her at Child D’s request.  Child D attended the GP with her mother on 14th January 2020 for a review following the last appointment. Child D reported breathlessness to the GP, but as Child D was acting as the interpreter for her mother, the GP recorded that it was difficult to gain Child D’s mother’s perspective. The GP asked about Child D’s previous presentation with an injury. There is again good recording by the GP of Child D’s own words and behaviour, particularly when the GP explained that Child D’s physical symptoms may be anxiety related. Child D became upset at this suggestion and despite offers of support by the GP, Child D left the appointment upset. On 17th January 2020, the GP contacted the Child Practitioner to discuss Child D’s injury, sustained in December 2019. It is unclear from the records what the delay had been in making this contact. The GP explained that her concerns related to the inconsistent explanations for the injury. The Child Practitioner informed the GP of the family's current situation in relation to Child D’s father and the impact that contact with him had had on the whole family, as well as the suggestion of Child D attending a specialist educational placement, which had been distressing for Child D. The GP and Child Practitioner agreed to share information to support the family. A child in need meeting was held on 12th February 2020, attended by the school and SENDCo (Special Educational Needs and Disabilities Co-ordinator). It was agreed at this meeting that the case could be closed with no step down to early help as the tasks within the child in need plan had been completed. However it does not appear, again, that this meeting was quorate.  The GP was not invited and could perhaps have added to the picture of Child D’s lived experience having only seen Child D a month earlier. On 23rd March 2020, the UK went into a nationwide ‘lockdown’ of restrictions to activities and travel because of the Covid-19 pandemic. These restrictions included the closure of schools to all pupils with a number of exceptions. These exceptions included children open to Children’s Social Care and those with an Education, Health and Care Plan. On 25th March 2020 school records show that due to Child D’s Education, Health and Care Plan, she was eligible to continue attending school. However, Child D’s mother expressed that she wanted Child D to remain at home due to fears for Child D’s health. Weekly telephone calls were made to Child D’s mother during the period of school closure but only three of these calls were successful and Child D was spoken to once. School records suggest that Child D expressed that she would have liked to have returned to school but despite repeated offers of a school place, this was declined.  The statutory annual review of Child D’s Education, Health and Care Plan took place on 16th June 2020. This was a virtual meeting which neither Child D nor her mother attended. Child D was due to start her secondary education in September 2020 and a specialist placement was agreed based on her level of additional needs.  On 7th July 2020, a home visit to Child D’s address was undertaken by staff members from Child D’s school due to the infrequent contact that had been achieved and a lack of online learning being completed by Child D. It is unclear how Child D was being expected to complete the online learning nor whether she would have been eligible for a school funded laptop in order to access this. Child D was asleep when staff arrived at the address. Her brother woke her for what is described as a ‘short conversation’ and it was not recorded who else was present at the address.       15  Significant event Child D and her mother attended the accident and emergency department of Addenbrookes hospital on 3rd August 2020. During an examination, a mark was noted on Child D’s arm, a potential indicator of an assault. Nursing staff recorded a number of concerns relating to Child’s presentation and behaviour. Child D was also referred to the ear nose and throat clinic. Multiple bruises and other marks on Child D’s body were all noted in detail. A referral to Children’s Social Care was completed, samples taken for testing and antibiotics prescribed as well as the ear, nose, and throat appointment. Child D and her mother were in the accident and emergency department for several hours on this date. There is no suggestion in the records that Child D was seen alone. There was a missed opportunity for a Strategy Meeting here which would have allowed for immediate consideration of the potential risks, as well as involvement from the Police to determine whether the mark should be further investigated. One safeguarding strategy would have been to admit Child D to a ward within the hospital but given the context of the COVID-19 pandemic this may not have been possible or deemed to be an appropriate course of action on balance. Children’s Social Care records show that an initial referral was received from Addenbrookes on 3rd August. Child D was reopened to the original team for a duty visit, a Social Worker was tasked with seeing Child D within five days and completing a child and family assessment in line with section 17 processes2. Additional information was received by Children’s Social Care from Addenbrookes on 6th August 2020 relating to Child D’s attendance on 3rd August. Her presentation whilst in the hospital was described as ‘concerning’. The following day, 7th August 2020, a home visit was undertaken by a Social Worker to Child D’s home. Child D, her mother, and brother were present. Child D was not seen alone. She stated that she did not remember the mark observed in hospital four days earlier and her mother and brother described Child D as a child who bruised easily. No safeguarding concerns were raised as a result of this visit and a note was recorded for the case to be picked up on the following Monday: 10th August 2020. There is no further activity recorded on the case file until 17th August.  Significant event  On 17th August 2020 Child D’s older brother approached Police. Using a telephone translation service, he confessed to sexually abusing his younger sister, Child D. He was arrested and interviewed and following multiple contacts with Child D in relation to the information provided by her brother, an achieving best evidence (ABE) interview3 was conducted by Police Officers in the presence of an intermediary.   2 The Children Act 1989 Section 17 of the Act places a general duty on all local authorities to 'safeguard and promote the welfare of children within their area who are in need. ' Basically, a 'child in need' is a child who needs additional support from the local authority to meet their potential. https://www.scie.org.uk/publications/introductionto/childrenssocialcare/legalandpolicycontexts.asp#:~:text=The%20Children%20Act%201989&text=Section%2017%20of%20the%20Act,authority%20to%20meet%20their%20potential. 3 Achieving Best Evidence in Criminal Proceedings Guidance on interviewing victims and witnesses, and guidance on using special measures March 2011       16  Children’s Social Care records from the same date show a referral from the Police in relation to the above incident, which was recorded as a critical incident. A multi-agency Strategy Discussion was held, a joint section 47 enquiry was agreed and a medical assessment for Child D at the Sexual Assault Referral Centre (SARC) was planned. Records from the following agencies also include details of this meeting: Cambridgeshire Community Services, The Elms Sexual Assault Referral Centre (SARC) and Addenbrookes hospital. The Strategy Discussion included consideration of Child D’s one year old niece.  An examination was booked at the SARC for 20th August 2020 and discussion also included consideration of Child D’s learning difficulties, historic domestic abuse concerns, the recent attendance at Addenbrookes hospital and physical abuse concerns. Child D did, later, make disclosures corroborating the information her brother had provided.     https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf        17   7. Analysis  This section of the report aims to answer the following questions as posed within the Terms of Reference: 1) How were risk and protective factors identified, assessed, and managed within the family? 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children? 3) How well did agencies identify and respond to signs of child sexual abuse? 4) How was the voice of the child recognised and responded to within the case? 5) Was Covid a factor in safeguarding and supporting Child D and did it have an impact on how agencies communicated and shared information? 6) Were there language or cultural barriers to the family accessing services and support? 7) Can you identify any areas that you consider to be good practice?  1) How were risk and protective factors identified, assessed, and managed within the family?  Initial identification of risk The risk of sexual abuse to Child D was first identified on 22nd November 2017 when Children’s Social Care contacted Police to request a Strategy Meeting to discuss concerns from her school relating to possible indicators of abuse towards Child D. Attempts are recorded to have been made to contact Child D’s mother, but these were not successful. Additionally, there were previous concerns of physical abuse and emotional abuse, as well as concerns of inappropriate behaviour. The Strategy meeting involved Police and Children’s Social Care.  There does not appear to have been a representative from health present.  The outcome was for a single agency section 47 enquiry to be completed but no further detail has been explored as this event fell outside of the timescale of the review. There is evidence within agency records that these factors were discussed again on 1st March 2018 when a further Strategy Discussion was held. As a result of these discussions, it was agreed that an Initial Child Protection Conference should be convened. It is not clear why Child D had not been subject to a Child Protection Plan in the interim period.  There was no evidence that protective factors were identified or discussed within this meeting. In addition, very few protective factors were identified by those agencies who had been involved in working with the family which suggests a lack of consideration of any strengths relating to Child D and her family or what was going well for them.  A medical examination at the Sexual Assault Referral Centre (SARC) was arranged for 5th April 2018 which Child D attended with her mother. There is no indication within records of why the examination was not arranged until after the Initial Child Protection Conference. The examination was discussed in detail at the author’s multi agency information sharing session and it was agreed that it was unusual for a child to request to be seen alone, as Child D did.       18  It appears that that staff were concerned of the impact on Child D of agreeing for her to be examined without her mother present to support her, although a Crisis Worker would have been present. Child D did agree to have her mother present when this was explained to her. The result of the examination was that no abnormal genital findings were noted. The medical report produced by the Forensic Medical Examiner highlighted the possible indicators of sexual abuse in detail, as well as including: ‘A high proportion of children who have been sexually abused do not have genital or anal injuries at examination.’ The outcome of this examination appears to be significant in terms of the way the risks to Child D were perceived going forwards as the focus of multi-agency intervention shifted from possible sexual abuse to physical abuse. Learning point: Practitioners should feel confident to explore and fully record each of the presenting risk factors or indicators of abuse for a child or family and consider each of these indicators individually and as a collective when assessing risk and planning interventions.  There was agreement from the multi-agency group that working with families where there are suspicions of sexual abuse but an absence of either disclosures or physical evidence, presents significant challenges and that this was particularly true for working with Child D and her family where there did not appear to be an obvious perpetrator.  The concerns for Child D resulted in the Child Protection Chair and Social Worker discussing the case on 16th April 2018 and making the decision to seek agreement for a Legal Planning Meeting. However, records suggest that this meeting was not convened which was a missed opportunity for escalation of concerns at an early stage in supporting the family. There is no indication of why this meeting did not take place. Equally there is no evidence that the CP Chair escalated the fact that this action had not been progressed. Since the timescale of this review Children’s Social Care have added safeguards to practice which include a ‘Legal Tracker’ which facilitates the monitoring of such discussions and aims to decrease the likelihood of the circumstances observed in this case reoccurring. Learning Point: Practitioners must feel able to escalate a lack of progress or action against agreed outcomes within their own agency. They should be aware of relevant single agency procedures for raising such concerns. It appears that there was some early identification of possible sexual abuse, and certainly the risk of physical abuse was recognised and documented.  However, the early recognition of sexual abuse was quickly overshadowed by the perceived indicators of physical abuse. Assessment of risk  When the period following the examination at the SARC was discussed, it was agreed that whilst the risk of sexual abuse to Child D was recognised and discussed, it was not considered by those involved who might have been perpetrating this abuse. Professionals believed that Child D had ‘difficult’ relationships with both her brother and father: she was described as fearful of her father, but it was suggested that the idea of Child D’s brother posing a risk of sexual abuse was ‘almost unthinkable’ and as a result the risk he might have posed does not appear to have been considered.   It was unclear at this time what role the brother played in the family, specifically how much time he spent with Child D and what their relationship was like. At the point at which it became clear that Child D’s brother was living with the family, this is something that should have been explored with Child D and her family members to allow professionals to gain a better understanding of the family’s situation and their relationships with one another. This might have supported a more thorough assessment of the potential risk to Child D. Research by the       19  Centre of Expertise on Child Sexual Abuse suggests that sibling perpetrated sexual abuse is likely to be ‘the most common form of intra-familial sexual abuse’ but that there is a ‘comparative lack of disclosure’ of this type of sexual abuse.4 Learning point: It is therefore an area of learning for agencies across the children’s workforce to be alert to the possibility of sibling perpetrated sexual abuse when working with families where child sexual abuse indicators have been identified but there is a lack of clarity relating to the possible perpetrator of abuse.  This observation is also applicable to the risk of physical abuse as it appears from early on that Child D’s father was the perceived perpetrator following Child D’s disclosures and none of the other family members including her brother were considered, suggesting the possibility of confirmation bias and a lack of professional curiosity as to an alternative hypothesis. Identifying other indicators of abuse: Following Child D’s presentation at the GP on 19th November 2018 there are concerns recorded in the chronology that the injuries observed by school staff, and then the GP, might be self-inflicted, as well as Child D telling school staff that she was being bullied. Again, whilst there is recognition of the risks in relation to Child D’s mental health, it is unclear what support was offered to her, beyond monitoring her well-being in school, at this stage. It does not appear that the possibility that Child D was self-harming was responded to appropriately, nor is there evidence of any consideration of why she might have been doing so. There is evidence of consideration of risk from the chronology on 6th February 2019. Child D mentioned to a member of staff within school that she was not allowed to see her father because he was abusive towards her mother. Whilst this information was to be shared at the next Core Group meeting, there does not appear to be recognition of the impact of Child D’s experience of the domestic abuse between her parents or the lack of contact she was having with her father. Rather, the focus of support is on the mitigation of risk.  In March 2019 there is mention in the chronology of Child D’s older sister’s partner living at the family address. The family were already living in overcrowded conditions and the impact that another adult moving in might have had on the family dynamics and the pressure on each person created by a lack of physical space and privacy does not appear to have been considered at this stage. There is mention later in the chronology of support relating to housing being offered.   Child D was no longer subject to a Child Protection Plan on 29th May 2019 and was then being offered support under the child in need (section 17) framework. This appears to be in contradiction to the information shared on 24th May 2019 relating to Child D’s disclosure of physical punishment by her mother. School staff spoke of Child D’s mother’s shock and surprise when this event was discussed with her and it was felt at the time that this disclosure from Child D did not suggest a risk of harm to Child D from her mother but there was a lack of professional curiosity as to the reasons that Child D might have made such a disclosure and whether or not someone else could have perpetrated the punishment. No recourse to public funds:  4 ‘Sibling sexual abuse: a knowledge and practice overview’ Yates and Allardyce 2021 https://www.csacentre.org.uk/csa-centre-prodv2/assets/File/Sibling%20sexual%20abuse%20report%20-%20for%20publication.pdf        20  On 13th July 2018, there were concerns raised by Child D’s school pertaining to a lack of supervision by Child D’s mother at home due to mother’s working patterns. This would have been an opportunity to explore with Child D’s mother and the older siblings, what safeguards were in place for Child D when her mother was working, and Child D was not in school. Child D’s mother had no recourse to public funds and her lack of spoken English would likely have limited the employment options available to her. It is unclear to what extent Child D’s father offered any financial support, as he lived predominantly in Europe. As a result, Child D’s mother worked long hours to financially support her family which meant that she was away from the family home and Child D was left with her older sister and/or brother for much of the time that she was not in school.  The school spoke of the fact that Child D’s mother had reduced her working hours in order to better support Child D in response the school’s and Children's Social Care’s concerns for her, but that this had a financial impact upon the family. It seems that whilst the risk to Child D of possible harm from neglect was considered on reflection of the case, there is no evidence in the records that a more holistic assessment was undertaken in 2018-2020 which considered the impact of financial pressures on the family. School staff also talked of the support they had sought to offer to Child D in the form of free school meals but that this had been unavailable to her because of the family’s lack of recourse to public funds.  It was discussed at this meeting the challenge of this financial constraint on the family and the pressure it would have placed upon them. Additionally, Child D’s brother was thought to be sending some of the money that he earnt to his family members in his home country to support them, reducing the amount of money he was able to use to support his family in the UK. Whilst this area was discussed by the authors and practitioners involved in this review, there was no such consideration in the records of what this might have meant for the family at the time. Since 2020, a No Recourse to Public Funds Policy and Procedure have been in place within Children’s Social Care to support any such families and is available online for all social care practitioners. Learning point: Practitioners should have the necessary knowledge to consider the impact of financial pressure, poverty and specifically no recourse to public funds upon a parent, carer or family’s situation and their ability to act protectively. Summary: identification, assessment and management of risk: It has been difficult to make an accurate assessment of how the risk of harm to Child D in this timeframe was addressed and managed. The risks of neglect, physical, emotional and sexual abuse do appear to have been recognised at points throughout the timeframe, but it is the author’s opinion that, whilst the indicators of sexual abuse were explored when concerns for Child D were first presented, around November 2017, when there was not any corroborating evidence, the focus of support being offered to the family appeared to shift to possible physical abuse.   It was suggested within the author’s learning event that a consideration of possible sexual abuse remained throughout the time that Child D was supported on a child protection plan and that Child D was asked questions relating to this possibility on multiple occasions.  However, analysis provided by Children’s Social Care as part of the chronology suggests that there might not have been a complete understanding of the risk of harm to Child D due to a lack of home visits being completed.  Whilst she was being seen in school at her own request, due to the overcrowding in her home environment, this meant that Child D’s mother was not as involved       21  as she should have been. Additionally, the relationship between Child D, her mother and her other family members could not be accurately observed and assessed, and it was unknown to what extent Child D’s mother was protective.  Generally, the perception of the practitioners who had supported the family was that Child D’s mother’s understanding of the involvement of Children’s Social Care and the risks they were working to reduce was not clear. This may have been due in part to the fact that Child D’s mother did not speak or understand English or may have been reflective of cultural differences between the UK and her country of origin, or a combination of these factors.  It is recognised within this analysis that the changes of practitioners and managers within Children's Social Care that Child D and her family experienced, were likely to have contributed to an incomplete picture of Child D’s experiences and may have compounded her vulnerability. Within the health sector, the GP had begun to build a picture of Child D’s needs and there is evidence of communication with Children’s Social Care but the GP received unclear messages from Child D and her mother, hindering the understanding of Child D’s situation and any risks to her. The school do appear to have recognised Child D’s needs and vulnerabilities and there is evidence of school staff seeking additional therapeutic support for Child D on multiple occasions. It is the author’s opinion that more reflective recording which sought to gain a clearer understanding of the level of risk to Child D would have been helpful. As recent research by the Centre of Expertise for Child Sexual Abuse states: professionals ‘need to understand CSA and the signs and indicators which signal that it may be occurring. In order to record that concern, they need the confidence to name it as such, and to address it.’5 This point is detailed further in this report. 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children?  Examples of good communication and inter-agency working: It is clear from the chronology and from both of the information gathering events held that the main agencies supporting Child D and her family during the time period of the review were Children’s Social Care and Child D’s school. Whilst health and therapeutic services were involved, this was usually for a time limited period. Those practitioners involved in this review agreed that inter-agency working was good in the later part of the time frame when the Child Practitioner had supported the family. Communication, particularly between the school and Children’s Social Care was also described as good. Core Groups and child in need meetings were run well and those involved were able to input their concerns. There is evidence of good information sharing and communication between the GP and Children’s Social Care.  The school sought appropriate additional therapeutic support for Child D when her needs suggested this might be helpful.  It was not always possible to secure support because of referral criteria or waiting times, but this did not result from a lack of effort on the school’s part. There were two periods of time when additional support was secured, and the information provided suggests that Child D responded well to the support and the activities she was offered and that communication between these support agencies and the school was good.   5 THE SCALE AND NATURE OF CHILD SEXUAL ABUSE: REVIEW OF EVIDENCE Kairika Karsna and Professor Liz Kelly (2021) https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/        22  Areas for improvement: There are some examples of difficulties in communication earlier on in the timeframe.  Child D was seen by the GP and a Paediatric Doctor in relation to injuries to her body but there appears from the chronology to be some confusion in relation to which hospital Child D attended for additional examination of these marks.  This resulted in the photos taken at the hospital of these injuries, not being shared with the GP. This was unfortunate as the GP went on to see Child D for a number of appointments in the following months and this additional information may have allowed the GP to explore the potential causes of these injuries further and gain a clearer understanding of Child D’s lived experience. There was then a further delay as the GP experienced difficulty in speaking with the Social Worker at the time about these injuries.  When this did happen, it is unclear from the chronology how this issue was perceived and what possible support was considered for Child D, given that there was a suggestion that the lesions may have been self-inflicted – although Child D herself denied this – and she would have been only 10 years old at the time.  Based on the information within the chronology, the decision made on 29th May 2019 to ‘step down’ Child D from a Child Protection Plan to support under section 17 child in need processes appears to have been made at a meeting that was not quorate. Records indicate only the Social Worker and school were present at the Review Child Protection Conference, although Child D was receiving support from a Play Therapist at the time, as well as having seen her GP on a number of occasions. Child D had made a disclosure to the Play Therapist on 24th May 2019 regarding a physical punishment by her mother. Given the previous concerns relating to physical abuse, it is difficult to understand why this disclosure was not given more weight: although records do suggest it was discussed at the conference. The strategy discussion held on 19th November 2018 in relation to injuries to Child D should have triggered a greater multi-agency response. Whilst Children’s Social Care took the lead as a section 47 enquiry was already underway, Police records show that no further information was shared with them in relation to the matter, nor was it chased by them. It was unclear at that point how the injuries had been caused and, in the author’s view, there should have been greater consideration given as to how and when these injuries might have occurred, as well as who might have inflicted them. The child protection medical which Child D attended at the time suggested that the injuries were a mixture of accidental, non-accidental and self-inflicted.  There does not appear from the records to have been sufficient curiosity in relation to these injuries and whilst there is some consideration of Child D’s emotional wellbeing, there does not appear to have been a response to these directly.  A review strategy discussion may have helped to pull information together from the child protection medical and facilitated a discussion between those involved about what action could be taken in response.    3) How well did agencies identify and respond to signs of child sexual abuse?  Medical examinations: School staff spoke of ‘red flags’ and indicators of possible abuse. It is clear from the records and discussion held as part of this review, that the risk of child sexual abuse, as well as other forms of abuse were well recognised at an early stage and were recorded as such.        23  It was agreed at this meeting and the author’s meeting that there is limited awareness of the fact that forensic evidence of sexual abuse from medical examinations of children is extremely uncommon and should not be taken as evidence of the absence of abuse. ‘The consensus in published research6 is that, for children of all ages who have experienced sexual abuse of any kind at any time, an anogenital examination will commonly find no signs of injury.’7 In Child D’s case, there appear to have been a number of indicators of abuse which should have been given greater consideration, including behavioural manifestations and medical indicators.  Learning point: to increase awareness of practitioners of the possible outcomes from a medical examination at the SARC and the context and likelihood of these potential outcomes. This information should then be used to inform the risk assessments in place for a child or family.  Additionally, knowledge and understanding relating to child protection medical examinations and medical examinations undertaken at the SARC, including the differences between the two, should be increased amongst practitioners. Indicators of child sexual abuse: It was universally agreed that the current child protection processes place too great a reliance on a child or young person to make a verbal disclosure of abuse.  This is a recognised systemic issue; the 2020 Joint Targeted Area Inspection Report into Child Sexual Abuse in the Family Environment states: ‘Professionals rely too heavily on children to verbally disclose.’8 It is also recognised that: “This is a heavy, and frankly unrealistic responsibility. Children cannot and should not be the only witnesses to the harm they experience; it is the responsibility of the adults around the child to respond to help-seeking behaviour and to safeguard them”i as stated by the Centre of Expertise for Child Sexual Abuse. Verbal disclosure was likely to have been an even less realistic expectation for a child with Child D’s additional needs, without considering the extent of the grooming behaviour she had been subjected to. Practitioners spoke of Child D’s interest in menstruation and particularly the idea of starting her periods herself. A discussion was held that explored the potential cultural aspects of these topics and it was agreed that this was not an area that had been fully understood or appreciated at the time by those working with the family. This area will be explored further later in this report, but it is mentioned here as it was believed by some of the group that in hindsight there may have been cultural influences on Child D’s behaviour particularly in relation to relationships, sex, boys and men which may have prevented a full understanding of the indicators of child sexual abuse. Assessment of indicators of child sexual abuse: There is no evidence within agencies records that practitioners completed a sexual abuse assessment tool. The Brook Traffic Light tool which was in place at the time but has since been replaced by a local child sexual behaviour assessment tool9, may have been useful. The  6 Sapp and Vandeven, 2005; Mollen et al, 2012; RCPCH, 2015  7 The role and scope of medical examinations when there are concerns about child sexual abuse A scoping review fDr Michelle Cutland (2019) https://www.csacentre.org.uk/documents/the-role-and-scope-of-medical-examinations-when-there-are-concerns-about-child-sexual-abuse-a-scoping-review/  8 https://www.gov.uk/government/publications/the-multi-agency-response-to-child-sexual-abuse-in-the-family-environment/multi-agency-response-to-child-sexual-abuse-in-the-family-environment-joint-targeted-area-inspections-jtais  9 Cambridgeshire & Peterborough Safeguarding Children Partnership Board Child Sexual Behaviour Assessment Tool https://safeguardingcambspeterborough.org.uk/wp-content/uploads/2021/10/Child-Sexual-Behaviour-Assessment-Tool.pdf        24  tool may have provided an understanding of Child D’s behaviour in the context of what would be normal behaviour for someone of her age, as well as checking against the expected behaviours of a younger child given that Child D was functioning at a younger age.  There is evidence in the chronology and from the information gathering events that Child D’s behaviour was noted by school and other professionals to be an indicator of concern, particularly the behaviour and language she displayed. The complexity of her chronological age, her level of understanding and the cultural considerations should have been examined alongside information relating to normal developmental behaviour relating to sex and relationships in order to plan interventions that aimed to reduce her vulnerability to grooming and abuse. Barriers to disclosure: Whilst there is evidence of recognition of the indicators of child sexual abuse at least early on, there does not appear to have been consideration given to what the barriers to disclosure might have been for Child D at the time. It was discussed by practitioners that it is recognised now that Child D was subjected to grooming behaviour by her brother from a young age but there appears to be no consideration of the possibility that Child D had been subjected to grooming in 2018. There could have been greater professional curiosity displayed in relation to the timing of when Child D’s behaviour changed, in order to build a picture to support the hypothesis of child sexual abuse. Questions such as ‘who does Child D spend time with and when?’ ‘When does Child D’s behaviour change and specifically when do the indicators of concern present? Do changes in her behaviour correlate with specific events such as when her father visits the family or when mum is at work or when she is in a safe environment?’ might have assisted in understanding the level and nature of risk to Child D. One of the barriers identified by practitioners in responding to Child D’s vulnerability to child sexual abuse were the difficulties experienced in communicating with Child D’s mother. This was partly related to the difference in language spoken by Child D’s mother and the professionals involved. But there were also difficulties in supporting Child D’s mother to understand the risks to Child D and her role in protecting her child from abuse. It was suggested that these challenges as well as regular absences of the family on trips out of the country may have meant that possible disguised compliance was not recognised and so went unchallenged. Additionally, it was felt by professionals that, whilst the risks of child sexual abuse were recognised early on, and Child D was spoken to on multiple occasions about what might be going on for her, it became inappropriate to continue with a repeated line of questioning. What should have appeared in the records of all agencies however was the continued hypothesis that Child D may have experienced child sexual abuse and that there may be an ongoing risk of that abuse based on the behaviour she had displayed and the other potential indicators that had been noted. Learning point: practitioners need to feel confident in not only identifying indicators of possible child sexual abuse but working with those indicators and their own concerns, particularly in the absence of a disclosure or medical evidence, to carry the hypothesis of sexual abuse throughout the work they complete with a child or family. 4) How was the voice of the child recognised and responded to within the case? GP:  There is excellent recording of Child D’s own words and observations of her behaviour within the GP records for the time scale of the review. This is significant as Child D and usually her mother, presented to the GP an inordinate number of times within this period for a number of       25  different complaints. There is also evidence of direct questions posed by the GP to Child D relating to child sexual abuse and her responses are well recorded. On the occasion that Child D requested to see a female doctor, this was responded to, and the GP escalated their concerns by referring Child D to be examined by a Paediatric Registrar.  Addenbrookes Hospital: On the occasion of the 3rd of August 2020 when Child D and her mother attended the emergency department of Addenbrooke's Hospital, it was established early on that something was concerning about Child D’s presentation and behaviour. Child D underwent a medical examination and a psychosocial assessment in response to this and Child D’s own words, as well as detailed descriptions of her presentation are recorded. Whilst Child D was asked direct questions relating to her presenting injuries, it is not clear if her behaviour was challenged with her, suggesting another missed opportunity for professional curiosity. There was also recognition that photographs had not been taken of the marks on Child D's body and this learning has been taken forward by the hospital. Barriers to communication: It is clear that Child D's voice, as well as her behaviour are noted early on in the time frame of the review. But as previously outlined, in the absence of a verbal disclosure of abuse by Child D the behavioural indicators appear to have been given less weight. Practitioners were clear however, that Child D was directly questioned by those working with her and provided with multiple opportunities to make disclosures of child sexual abuse. Indeed, she was perceived to have formed relationships with professionals and made verbal disclosures of physical abuse. Without Child D’s own perspective however, it is not possible to correlate whether she felt she had such opportunities. The complicating factor of Child D’s learning needs must also be considered. Although the relevant assessment information from the Education, Health and Care Plan can be seen from the records to have been shared, it is not clear to what extent this information was understood by each agency and therefore whether Child D was asked age-appropriate questions that she could be expected to understand. The child’s lived experience: It is noted by Children’s Social Care on reflection on this case that direct work with the family on ecomaps, genograms and the family story might have been useful in gaining an understanding of the family, as well as providing an avenue for Child D to give her perspective on those relationships and their impacts on her. There are recorded concerns relating to family relationships between Child D's mother and father, between Child D's older brother and sister, and Child D’s relationships with her siblings so it would have been a useful exercise to complete such tools with each member of the family and compile all the information to better understand their perspectives. The role of Child D’s brother particularly was not well understood, and he was agreed to have been largely ‘invisible’ by practitioners when they were working with the family in 2018 and 2019. This is a suggestion that resonates with both local and national child safeguarding practice reviews where the presence and role of particularly male figures linked to the family have gone unexplored. Discussion with those practitioners involved with this case as part of this review did include consideration of the lived experiences, both past and present of all of the family members within the household, particularly the impact of any abuse or trauma they may have experienced, but it was not clear that this had happened earlier.        26  Learning point: exploring the role of each family member within a household from the perspectives of each member is important in gaining an understanding of the dynamics and any potential risk within the family unit. Evidence of Child D’s voice: Other examples of where Child D’s voice was sought and captured were the assessment conducted by a school nurse on the 7th of March 2019. Records include drawings by Child D and her own words as well as observations of her completing various activities. The school had a particularly good understanding of not only Child D’s learning needs but the impact of those additional needs on her academic ability and social skills. Child D’s voice was well documented in school records as well as changes in her behaviour or any inappropriate behaviour that she displayed. There was one occasion on the 6th of February 2019 when Child D talked about her father in school. There could have been further exploration with Child D on this occasion about the context of what she said and the reasons why she had brought up that particular subject, but the impression gained from the records was that her school knew Child D well. Whilst the detail occurred outside of the time scale of this review, it is important to recognise within this report that during the information gathering event for practitioners, detail was shared relating to the police investigation and the efforts made by the relevant officers in engaging Child D and obtaining her perspective. This included significant rapport building and multiple home visits. It became apparent during the investigation that Child D was a victim of significant grooming by her brother, and this is highlighted here because of the impact that this will likely have had on Child D and her feelings of safety and confidence to speak with professionals about the abuse she suffered. Certainly, the views she expressed during the investigation and afterwards suggested that a verbal disclosure from her would have been extremely unlikely. There was also discussion relating to Child D’s perception of the relationship between herself and her brother which she expressed to the investigating officer and how what she had said and felt might be uncomfortable or unsettling for practitioners to consider or discuss, which was taken as a learning point from this case.  Learning point: all practitioners should have support and opportunities to discuss any element of a case that is uncomfortable for them or ‘unthinkable.’ They should be supported to record their suspicions or feelings related to a case in an appropriate way that informs ongoing risk assessment. Both of these discussions highlighted the significant barriers to disclosure in place for Child D and why continuing consideration of her behaviours and general presentation were so important. Family members: What is missing from the records and to an extent from the information gathering event for practitioners, is Child D’s mother’s voice. Practitioners were able to describe her reaction to her son’s admission of abusing Child D and her feelings towards him in the immediate period following. There is also some evidence of assessment of her ability to be protective towards Child D but it is not until the Child Practitioner became involved in supporting the family that there is any evidence of Child D’s mother expressing her perspective. It is regrettable that attempts to make contact with Child D’s mother for the purpose of this review have been unsuccessful.        27  5) Was Covid a factor in safeguarding and supporting Child D and did it have an impact on how agencies communicated and shared information?  At the point that the COVID-19 pandemic began to have a significant impact on everyday life in the UK, Child D was not being supported by any agencies beyond her school. Support from Children’s Social Care had ended when the case was closed on the 17th of February 2020, five weeks before the country experienced the first and most stringent lockdown on the 25th of March 2020. Shops, restaurants, leisure facilities and schools were all closed. Only essential services continued and only those working in those essential services who could not work at home were permitted to travel to work.  School non-attendance as a risk factor:  Schools were able to offer a small number of places for children to continue attending but these places were only available to children in specific categories. One of these categories was children who had an education health and care plan (EHCP), of which Child D was one. This meant that Child D was eligible to continue attending school, and a place at her school was offered to her. Child D’s mother turned down this offer, stating her concerns for Child D’s health and Child D remained at home. The school representatives stated that it had been suspected that Child D herself had also not wanted to attend school at least initially, due to feelings of anxiety in relation to COVID-19. The context of this time was that, as so little was known about the virus, and there appeared to be a substantial number of deaths across the population caused by it, there was widespread fear of contracting the virus. This was compounded by the severity of the restrictions placed upon the country.  It is the author’s opinion that there should not be judgement placed upon Child D or her mother's decision-making in relation to Child D’s attendance at school during this time for these reasons. However, the impact of this decision was that Child D was believed to be at home for large amounts of time without the supervision of her mother as she continued to work to financially support the family. Weekly contact was attempted by the school via a staff member who was able to speak the same language as Child D and her mother, but this was most often unsuccessful. Child D also experienced difficulties accessing the virtual work provided by school and as a result, there was almost no contact with the family by any professionals. On the 7th of July 2020 school staff completed a home visit to Child D as they were concerned by the lack of contact with Child D and her mother and there was no evidence that Child D was completing any online learning. Child D was seen, although only engaged in a short conversation at the door to the property, having been woken by her brother. She was offered the opportunity to return to school but again refused. It was discussed that whilst this single contact with Child D in the three and a half month period since the COVID-19 restrictions began, might seem in hindsight to be an insufficient response from the school, it was over and above the guidelines in place at the time. It is known now that Child D’s mother had to change her job as a result of the closure of so many businesses during the period of restrictions and that this meant a change to her working hours but due to the lack of communication at the time, this was not known then. Had there been a clearer picture of the level of supervision present for Child D, a safeguarding referral or a referral to early help services may have been appropriate.       28  Presentation at A&E: The next contact that any agencies had with Child D was on the 3rd of August 2020 when she presented to the emergency department at Addenbrooke's hospital. As has previously been detailed, she was examined, and concerns were noted relating to the presenting injuries and her behaviour. The Consultant then commenced a safeguarding referral to Children’s Social Care because of her concerns relating to Child D’s presentation. A number of learning points and actions for the hospital were shared at the information gathering event for practitioners, including changes to the internal safeguarding referral process and dissemination of the Child Sexual Behaviour Assessment Tool. It was recognised that it had been difficult for the Consultant to assess Child D’s behaviour with a lack of contextual awareness of her learning needs on this occasion. As Child D was not being seen by any other professionals at this time because of the COVID restrictions, this contact stands alone in the records as the most detailed assessment, and therefore an important opportunity to gain an understanding of what Child D’s situation was at that time and how she might have been feeling. It does not appear from the records that she was seen alone which represents a missed opportunity to have explored her presentation with her directly. Children’s Social Care responded to the hospital referral by completing a home visit to Child D on the 7th of August 2020. Unfortunately, Child D was again not seen alone during this visit and the explanations provided by Child D's mother and brother were taken at face value. There is no further activity on Children Social Care records relating to Child D until the 17th of August 2020 which is the end of the time scale of this review. Given that Child D, like so many children, had such little contact with professionals during the period of COVID-19 restrictions, those occasions on which she was seen by practitioners were of even greater importance and should have been maximised by offering Child D the opportunity to speak to the relevant professionals on her own and by ensuring that appropriate measures were taken to support her to communicate. Addenbrooke's Hospital would not have had the benefit of access to records detailing historical concerns and Child D’s learning needs, but Children’s Social Care would have, and this information should have prompted a thorough assessment of Child D’s situation and presentation at that time. Inter-agency communication: When the topic of COVID-19 was discussed, there were no significant concerns expressed for the impact that COVID and the associated restrictions had had on information sharing or communication in relation to this case. Whilst it was recognised that telephone communication initially was more difficult, as particularly Children Social Care practitioners were working at home, this was quickly rectified, and email communication was unaffected. Face to face meetings were replaced by virtual meetings: not a wholly new concept, although it was recognised that this would have been significantly more challenging for children and families to have adapted to. Police Officers continued to work in communities in the same way and health staff largely continued to operate in their roles, albeit amidst significant additional pressure to the healthcare system. The final consideration is that related to the use of personal protective equipment (PPE). For the interactions that practitioners had with Child D after March 2020, face masks would have been worn by professionals and would have been required by members of the public, as well as other PPE such as gloves, aprons, or visors where appropriate. The authors and practitioners groups involved in this review expressed the view that whilst face masks       29  particularly could be seen as a barrier to communication, in their collective experience most children had quickly adapted to seeing other people wear them as their use was so widespread in society. The Police Officer present suggested that the achieving best evidence (ABE) interview conducted with Child D had been more awkward than might have been the case as both Child D and the interviewing officer wore face masks but didn't feel this had been significantly detrimental. All practitioners agreed that face masks have become a part of working practice at the time this review was taking place and that their use in the context of the pandemic was entirely appropriate.  6) Were there language or cultural barriers to the family accessing services and support?  All agencies involved in supporting this family agreed that there were considerable communication problems. Child D herself was able to communicate to an extent in English, as well as her own language but she was described as fluent in neither language which, compounded with the fact that she was assessed as having been functioning significantly below her chronological age, meant that she had complex communication needs. Practitioners from Child D’s school described her as being aware of her own difficulties, particularly in comparison to her peers, and this would cause her to feel frustrated and impacted upon her self-confidence. Child D’s mother was not able to speak English, and had a very limited understanding of English and translation services should have been used each time any professional wished to communicate with her. There is little detail in the combined chronology relating to the use of translation services: the GP records are the clearest. It was universally agreed by practitioners that, for this family, the fact that all communication with mum required the use of interpreters was a significant barrier to engagement and must have been a significant challenge for Child D's mother herself. The school representatives described that it had been difficult to communicate with Child D’s mother using telephone-based interpreters and when a staff member provided some assistance, they experienced difficulty in understanding her. The possibility of Child D’s mother having learning or communication needs of her own was also discussed and it was agreed that this was a further challenge as it meant that even when translation services were used, verbally or for documents such as letters, Child D’s mother’s understanding of the information that was being translated could not be accurately determined.  All practitioners agreed that communication with the family had become easier when the Child Practitioner who could speak the same language was allocated by Children’s Social Care. Additional interpreters were used for Child Protection Conferences to explain some of the more complex language. Indeed, it was apparent that Children’s Social Care had made significant attempts to ensure that Child D and her mother were provided with information in their own language in all their interactions. However, it was agreed that this case highlighted what might be ‘lost’ in terms of communication when using interpreters. Practitioners described that some interpreters they had worked with were better than others, but largely they did not check the understanding of the person they were translating for, rather simply translating ‘yes’ or ‘no’ answers. Additionally, the terminology so extensively used by safeguarding practitioners such as ‘child       30  in need’ or ‘public law outline’ do not directly translate if similar terms are not used in the family’s own language. It was highlighted that the culture within the family’s home country is vastly different to the UK in relation to safeguarding and child protection and this would have presented an additional challenge to Child D's mother in understanding the reasons for agencies’ involvement and concerns. The learning in relation to language and communication barriers is that time and effort should be taken to explain matters in a way that is accessible and to check the understanding of the person you are speaking with. Unfortunately, it was recognised that these considerations are often incompatible with time constraints and high workloads. It was also agreed that consistency in the interpreters used can assist when families are discussing difficult or personal information. Whilst it was agreed that having a practitioner engaged with the family who could speak their own language was undoubtedly beneficial, the challenge of that practitioner being required to fill two roles was also recognised. Learning point: when there are known communication difficulties, practitioners should feel able to modify time scales such as the length of meetings to meet the needs of the families they are supporting to better ensure their understanding and engagement. Beyond Children’s Social Care, it appears that face to face translation services were not consistently used by agencies. Whilst recognising the cost of these services it was agreed that in a case such as this where there are complex communication needs, face to face translation services provide the best opportunity to share information with families, assess their understanding and promote their engagement.  Learning point: it should be the preferred default position that face to face translation services are offered to families who require these services for each face-to-face intervention for those family members.  However, it is realised that there are barriers to this and that this target may be aspirational but the barriers to facilitating this should be recorded by the appropriate professionals.   Finally, there were discussions held as part of this review relating to the cultural aspects of this case and it was agreed that practitioners had not sought to gain a better understanding of what the similarities and differences might have been between the culture of the family’s home country and the UK and how this might have impacted upon Child D, her mother and their family life. The Child Practitioner did appear to have explored this and demonstrated knowledge of Child D’s brother’s and sister’s upbringings as well as Child D's mother’s own experiences before she had moved to the UK. But there was not a clear understanding across agencies of how the families' previous cultural experiences might have affected their perception of risk, and therefore Child Ds mother's ability to be protective towards her. The result of the challenges in communication faced by both Child D and her family and those practitioners supporting them having not been fully explored is that it is not clear if the right interventions were offered to reduce the risk of harm to Child D.   7) Can you identify any areas that you consider to be good practice?  Some examples of good practice have been noted in this report: extensive use of interpreters by Children’s Social Care, recording of the indicators of child sexual abuse at the Initial Child Protection Conference and recording, specifically in relation to Child D’s voice and behaviour       31  by the GP. In addition, the GP had made follow up appointments when Child D requested a female GP and where there had been concerns for Child Ds wellbeing. Recording by the school was also particularly good, making clear the concerns for Child D. Good multi-agency working has also been noted, and attendance at Core Groups appeared to be good. Practitioners spoke of the way in which Core Groups were led in the later part of the time frame to take into account Child D’s and her mother’s communication needs. Efforts were made by practitioners from her school, health, Children’s Social Care and voluntary agencies to build relationships with Child D and recording suggests that she was open to communication with those who were supporting her. There is some evidence of single agency challenge within the chronology. On the 23rd of May 2019, the Child Protection Chair adjourned the Review Child Protection Conference and escalated her concerns relating to the lack of information being presented to a manager. Again, on the 30th of May 2019, there is recorded challenge from the Child Protection Chair following the de-escalation of support for the family from child protection to child in need, relating to the quality of recording and a lack of multi-agency oversight. There is not however, a response recorded to this escalation from a manager. On 4th January 2019 a School Nurse on reviewing Child D’s records, contacted the relevant Social Worker to request an invitation to the next Core Group meeting and offer a health assessment for Child D due to the recorded concerns of possible self-harm. This was highlighted within the chronology as good proactive practice by the School Nurse. There are multiple examples throughout the chronology of occasions when Child D’s voice and her lived experience as interpreted through both her verbal and non-verbal communications are noted.  Such examples can be found under question 4 within the Analysis section of this report.   Finally, whilst it falls out of the time scale of this review, it was agreed that the response to Child D, her brother and her other family members following the disclosures made by her brother had been swift, appropriate and involved the necessary multi-agency partners. Consideration had been given to Child D’s needs and the relevant support had been put in place for her.  8. Summary  It was agreed by those involved in this review, that this had been a complex case with a number of inter-relating risk factors such as the language barrier, Child D’s learning needs and the family’s living and financial situation. The case was also considered to have been unusual in the way that the abuse that Child D suffered came to light. Because of the information Child D’s brother shared with the Police during their investigation, significant detail was known of this abuse which offers the benefit of ‘absolute knowing’10 that the abuse had taken place in the time scale covered by this review. However, it must be acknowledged that this had not been the case in 2018/19 and all the learning highlighted within this review can be gleaned with the benefit of this information that had not been present at the time.  10 The myth of 'absolute knowing': when is the evidence enough? Anna Glinski 2019 for the Centre of Expertise on Child Sexual Abuse: https://www.csacentre.org.uk/resources/blog/the-myth-of-absolute-knowing/         32  Whilst each case will be different as each child is unique, it is hoped that the key areas of learning outlined below might support practitioners to work with cases of child sexual abuse and specifically sibling perpetrated sexual abuse. Perhaps the most profound point of learning in this case was that, had her brother not admitted to abusing Child D when he had, it might still not be known that she was suffering this abuse. For those involved in this review, this highlighted the greatest challenge of working with children and young people in relation to child sexual abuse: how to support children and their families when abuse is suspected but not known? 9. Key areas of learning:  Signs and indicators of child sexual abuse a. Practitioners should be open to the possibility of sibling perpetrated sexual abuse as the most common form of intra-familial child sexual abuse. b. Practitioners should have support and opportunities to discuss any element of a case that is uncomfortable for them or ‘unthinkable.’ They should be supported to record their suspicions or feelings related to a case in an appropriate way that informs ongoing risk assessment. c. Practitioners should be professionally curious within their roles when there are indicators of child sexual abuse but no clear perpetrator of that abuse. d. The possible reasons for non-disclosure should be considered where there are indicators of child sexual abuse and used to inform interventions with the child. e. There remains a reliance on verbal disclosure from children or the presence of medical evidence as confirmation of sexual abuse. When research suggests that either incidence is uncommon, greater consideration should be given to other potential indicators and non-verbal forms of communication. f. Similarly, practitioners should feel confident to carry a hypothesis of child sexual abuse i.e. keeping in mind that something may have happened when there is not clear evidence. g. Tools are available which might assist practitioners in understanding their own concerns in relation to child sexual abuse, including the local Child Sexual Behaviour Assessment Tool Cultural considerations: h. Cultural considerations such as attitudes towards relationships, family life, child development and abuse should be explored when this may impact upon a parent or family's ability to act protectively.  Language barriers i. It is important to take time to ensure families who have language or communication needs can engage with agencies and processes in a way that is comparable to those families who do not.  j. The preferred default position is that face to face translation services are offered to families who require these services for each face-to-face intervention for those family members. The barriers to facilitating this should be recorded by the appropriate professionals.         33   The role of family members within a household  k. The importance of a family’s composition and the roles that all family members play within a unit should be considered as part of any risk assessment. No recourse to public funds l. Practitioners should have the necessary knowledge to consider the impact of financial pressure, poverty and specifically no recourse to public funds upon a parent, carer or family’s situation and their ability to act protectively.  10. Recommendations  Signs and indicators of child sexual abuse It is recognised that since the commencement of this review, the Safeguarding Partnership in Cambridgeshire and Peterborough have undertaken significant amounts of work to monitor and improve practice relating to child sexual abuse across the children’s workforce.  As a result of this, a recommendation will not be included within this report for additional work, rather the focus should be on determining the impact of the work already undertaken.  1. Cambridgeshire and Peterborough Safeguarding Children Partnership Board should: a.  seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded  b. Consider how the impact of this work has improved practice in order to evaluate the effectiveness of this work. Cultural considerations: 2. Information should be made available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse, in order to support children and families who are impacted by cultural variances. Language barriers: 3.  a. All agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings involving the family.  Any barriers to facilitating the family’s access to services should be recorded. b. The Safeguarding Children Partnership Board should consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats.       34  The role of family members within a household  4. The importance of a family’s composition and the roles that all family members play within a unit should be considered as part of any risk assessment.  The Safeguarding Partnership Board should seek assurance that existing tools such as genograms are utilised for this purpose and that the role of male family members particularly is highlighted.   No recourse to public funds  5. Information should be made available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds.  Where this impacts upon a family, this should be recorded and considered as part of any plan for support.       i Don't wait for them to tell us: recognising and responding to signs of child sexual abuse Jane Wiffin (2019) https://www.csacentre.org.uk/resources/blog/disclosures-csa/  