Sexual assault and sexual exploitation of an adolescent girl between the ages 14-18-years-old. Child Z lived with mother and older half-brother in Local Authority 1 (LA1). Received services for anorexia. Assaulted by older boy she was in relationship with, resulting in social care assessment, which identified risks of suicidal ideation and sexual exploitation. Case closed; referral to other services. Increasing concerns about her relationships with a number of males; diagnosed with emotional dysregulation. Pregnant at nearly 16-years-old; homelessness resulted in referral to Local Authority 2 (LA2). Detained in psychiatric unit; son made subject of care proceedings. Case transferred back to LA1 on her discharge. Mental health deteriorated; further incidents of sexual assault and exploitation. Placed in mental health supported accommodation at age 18-years-old. Ethnicity or nationality not stated. Uses a hybrid model based on the Welsh Model. Findings include: resource pressures were such that they were manifest in high thresholds; medical focus was necessary but an early consideration of home situation would have been appropriate; local authority transfer requests were not founded on the best interest of the child; lack of understanding of the lived experience of Child Z. Recommendations to LA1 Local Safeguarding Children Board includes: children who themselves have children should have their own social worker and their own separate plan for the avoidance of conflicts of interest; where the child of a child is made the subject of child protection plan, there should always be formal consideration as to whether or not the child-parent should also be the subject of their own child protection plan.
      
    Serious Case Review No:  2020/C8115  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    Child Z Serious Case Review        Anthony Haley   10th January 2020       2  Table of Contents Introduction ............................................................................................................................... 4 Methodology .............................................................................................................................. 4 Abbreviations ............................................................................................................................. 6 Terms of Reference .................................................................................................................... 8 Family Participation in the Review ............................................................................................ 8 Summary of Findings.................................................................................................................. 8 Narrative of events .................................................................................................................. 10 Early Life ............................................................................................................................... 10 Age 14 ................................................................................................................................... 10 Age 15 up to the decision to assess ..................................................................................... 11 Age 15 during the assessment ............................................................................................. 13 Age 15 after case closure ..................................................................................................... 14 Age 16 up to leaving home .................................................................................................. 15 Age 16 and no permanent home ......................................................................................... 17 Age 16 in the refuge ............................................................................................................. 20 Age 17 and living in the refuge ............................................................................................ 22 Age 17 at home .................................................................................................................... 24 Age 17 in the adolescent psychiatric unit ............................................................................ 25 Age 17 and living in unregulated semi-independent accommodation ................................ 30 Age 18 ................................................................................................................................... 32 Age 18 in adult mental health supported accommodation ................................................. 33 Analysis .................................................................................................................................... 34 Age 14 ................................................................................................................................... 34 Age 15 up to the decision to assess ..................................................................................... 35 Age 15 during the assessment ............................................................................................. 39 Age 16 after case closure ..................................................................................................... 41 Age 16 to leaving home ........................................................................................................ 41 Age 16 and no permanent home ......................................................................................... 42 Age 16 and living in the refuge ............................................................................................ 45 Age 17 at home .................................................................................................................... 47 Age 17 in the adolescent psychiatric unit ............................................................................ 47 3  Age 17 and living in unregulated semi-independent accommodation ................................ 50 Age 18 and living in adult mental health supported accommodation ................................ 52 Recommendations ................................................................................................................... 53 Recommendation 1 .............................................................................................................. 53 Recommendation 2 .............................................................................................................. 53 Recommendation 3 .............................................................................................................. 53 Recommendation 4 .............................................................................................................. 53 Recommendation 5 .............................................................................................................. 53 Recommendation 6 .............................................................................................................. 53 Recommendation 7 .............................................................................................................. 53 Recommendation 8 .............................................................................................................. 53 Recommendation 9 .............................................................................................................. 54     4  Introduction This case concerns the circumstances of Child Z who, at the start of our timeline, was fourteen years old, living with her mother and older half brother in LA1, and receiving services in relation to anorexia nervosa.  At the age of 14 Child Z had been assaulted by an older boy with whom she had been forming a relationship and services involved with her raised concerns about her home circumstances.  After initial gatekeeping, CSC1 did an assessment which recognised some risks, including suicidal ideation and sexual exploitation, and closed the case with referral on to other services.  Concerns grew further about her relationships with a number of males and she was diagnosed with emotional dysregulation.  At the age of almost sixteen, Child Z became pregnant.  Her anorexia receded and, following the birth of her son and a domestic incident, she became briefly homeless while in an unsuitable relationship with a peer.  At this point her case was referred to LA2 which is an adjoining Greater Manchester local authority.  During periods both back at home and in a refuge, Child Z’s mental health deteriorated and she continued to be sexually exploited.  She was eventually detained in a psychiatric unit and diagnosed with emerging unstable personality disorder.  Her son was made the subject of care proceedings and resided with Child Z’s mother.  On discharge from the unit her case had been transferred back to LA1 and unsatisfactory arrangements were in place to support her.   After a further deterioration in Child Z’s mental health and multiple further incidents of sexual assault and exploitation, she was placed, at the age of eighteen, in mental health supported accommodation.  Her status from the age of sixteen, in the two local authorities involved with her, did not progress beyond CIN level.   This Serious Case Review (SCR) was commissioned as a result of the harm suffered by Child Z, notwithstanding extensive engagement with agencies. Methodology This SCR was commissioned by the former LA1 Safeguarding Children’s Board under Working Together 20151. As such it fits with the transitional arrangements which transferred responsibilities to the new Safeguarding Partnership arrangements which came into place in December 2018.  The review is hybrid in that it is a systems based review that has drawn on the ‘Welsh Model’2 to ensure that practice learning has informed its outcomes.  A practice learning event was held in October 2019. The involvement of practitioners at the event proved invaluable in informing the analysis and conclusions that have been arrived at in this review.  The participants were both open and insightful in their contributions.                                                       1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 2 https://www.cysur.wales/child-practice-reviews/ 5  The review has considered Child Z’s experiences with services over a lengthy period from 01/03/15  to 26/09/18  The review has also benefited from the guidance and contributions of senior representatives of partner agencies who have participated as members of the Serious Case Review  panel which has overseen this process. The SCR panel was comprised of:  Designation Agency Lead Reviewer and Author Independent Head of Safeguarding LA1 Metropolitan Borough Council Business Manager LA1 Safeguarding Children Partnership Named Nurse Safeguarding Children LA2 Foundation Trust 1 Deputy Designated Nurse  CCG Safeguarding Families Practitioner Foundation Trust 2 Investigation and Safeguarding Review Unit Police Practice Improvement Manager LA1 Metropolitan Borough Council Service Unit Manager, Looked After Children Team LA1 Metropolitan Borough Council Senior Advisor, Safeguarding in Education LA2 Metropolitan Borough Council Service Leader, Children’s Social Care LA2 Metropolitan Borough Council Named Nurse Safeguarding Children Foundation Trust 3 Team Manager, Families Together LA1 Early Help Services    6  Abbreviations A&E Accident and Emergency Department  BZ Half-brother of Child Z CAF Common Assessment Framework  CAMHS Child and Adolescent Mental Health Services (now known as Healthy Young Minds)  CIN Child In Need CMHT Community Mental Health Team  CPP Child Protection Plan CSC1 Children’s Social Care in Local Authority 1  CSC2 Children’s Social Care in Local Authority 2  CSE1  LA1 Child Sexual Exploitation Team CSE2  LA2 Complex Safeguarding Team including CSE FIW Family Intervention Worker  FN Family Nurse   FNP Family Nurse Partnership  GP General Practitioner ICPC Initial Child Protection Conference  IDVA Independent Domestic Violence Advisor IRO Independent Reviewing Officer ISVA Independent Sexual Violence Advisor  LA1 Local Authority 1  LA2 Local Authority 2  LAC  Looked After Child M1 16 year old male involved in age 14 assault  7  M2 Boyfriend age 16 and in care M3 Boyfriend and father of CZ from Liverpool M4 Boyfriend with whom Child Z leaves home M5 Boyfriend while in semi-independent accommodation M6 35 year old sex offender M7 Boyfriend while in mental health supported accommodation MARAC Multi-Agency Risk Assessment Conference MZ Mother of Child Z OOH Out Of Hours social work PTSD Post Traumatic Stress Disorder  SARC Sexual Assault Referral Centre  YPM Young Parent Midwife    8  Terms of Reference The terms of reference below were lines of enquiry used to elicit learning through the prism of Child Z’s experiences; 1 How safe and effective are the services in place for children with mental illness and those suffering from trauma? 2   How safe are transfer arrangements between the authorities and what can we learn from the factors affecting decision making in this case? 3 How can services ensure that children who have a child receive services appropriate to their needs?  4 How effective is individual and multi agency working in relation to the safe discharge of vulnerable young people from psychiatric provision in hospital? 5 How effective are specialist responses in working with sexually active, vulnerable and exploited young people under the age of 18? 6 Are the arrangements in place sufficient for vulnerable young people as they transition to adulthood? Family Participation in the Review The SCR panel would like to express thanks to Z and MZ who agreed to be interviewed and shared their views.  Their contributions were very important to the review process and their comments are integrated into the body of the report.  BZ did not respond to an invitation to take part. Summary of Findings The SCR covered a lengthy period and a large number of interactions with professionals across disciplines, local authorities and services. A lot of individual good practice was seen.  In particular there was good practice seen by the school nurses, the CSE2 social worker, the refuge, LA1 sexual health service, LA2 Out Of Hours (OOH) service, the Family Nurse and the refuge.    Where poor practice was seen in this case in CSC1, this was within the context of a system which was under great pressure at the time.  In such systems workloads are often inappropriate, inexperienced workers and managers are not suitably supported, resources are limited, thresholds are inappropriately high and poor practice is insufficiently challenged 9  by managers at all levels.  In CSC1 at the time the resource pressures were such that they were manifest in high thresholds.  Partners experienced difficulties in accessing a service and when challenge was made it was rebutted, and because formal escalation procedures were not then followed, a satisfactory and early stage resolution was not reached.  There was an element of professionals not always understanding each other’s roles and assuming that one service’s involvement negated that of another.   CAMHS being involved was seen by CSC1 to negate a role for social work.   It is acknowledged that there have been significant recent changes and this has been reflected in the most recent improved Ofsted judgement. In CSC2, where the same pressures were not evident, and there was a far greater acceptance of a responsibility to engage with Child Z and her son, there were missed opportunities to correctly apply procedures and to respond clearly to professional challenge.    There was much good medical input through both hospital services and CAMHS, a diagnosis was reached, admissions occurred as and when necessary to manage Child Z’s weight.  A range of CAMHS professionals engaged with her over a prolonged period but, while the medical focus was necessary, an early consideration of her home situation would have been appropriate.   Had a forum existed for professional consultation outside the referral process, it would have allowed practitioners the opportunity to consult across professional boundaries and explore issues raised by Child Z.   In CSC2, the focus was ultimately on CZ, and Child Z was viewed as an adult parent rather than a child parent.  Professional challenge was not dealt with appropriately. In both local authorities, transfer procedures were poorly managed and did not follow the appropriate protocol.  Had the protocol been followed, neither transfer request would have been made.  The transfer requests were not founded on the best interests of the child.  Similarly, both authorities showed poor adherence to their own CIN/TAC processes.  Managers did not use their respective local authority’s powers or exercise their responsibilities in relation to Section 20 of the Children Act 19893. Given the amount of professional contact with Child Z, there was a lack of understanding on the part of both CSCs, of her lived experience.    There was a significant contrast between the level of service available to deal with sexual exploitation in LA1 and LA2.  LA2’s service was an integrated ‘complex safeguarding’ service with clear processes working with young people up to the age of 25.  This contrasted with LA1 who were yet to develop to a complex safeguarding model.  Its CSE service was limited to work with under 18s.                                                         3 http://www.legislation.gov.uk/ukpga/1989/41/contents 10  Issues with transition to adulthood flowed from the decisions not to make Child Z a Looked After Child (LAC), and the lack of provision in mental health services from age 16 to 18.  The multi-agency plan on discharge from the psychiatric unit was insufficient to meet her needs. Narrative of events Early Life Prior to the period under review, Child Z lived with her mother (MZ) and elder half brother (BZ).  Her parents had separated when she was three years old and her father had died when she was ten years old.  It is known that she had various physical symptoms, some of which were linked to an eating disorder.  It is known that there was some domestic violence in her parents’ relationship where alcohol was a factor, and that her brother and mother experienced depression.  MZ had a poor relationship with her own mother who was significantly affected by her alcohol use.  It was later identified that Child Z suffered from Anorexia Nervosa, anxiety and panic attacks and had expressed suicidal thoughts.  Her mental health problems were identified by the time she was eleven years old, but there had been concerns about her weight when she was nine years old in primary school.   She was treated by CAMHS with CBT and had several hospital admissions to stabilise her weight.  Child Z went onto a part time timetable to reintegrate her into school but her attendance continued to be poor and she had medical treatment for a range of conditions.  A note by the hospital (located in LA1) in November 2014 referred to the possibility that family dynamics might have a part to play in Child Z's very controlled eating.  In early 2015, just before the period under consideration, Child Z disclosed to her mother that she had been sexually assaulted in October 2014 (when she was 14 years old) in her home by a 16 year old boy (M1) with whom she had been forming a relationship.  The allegation was passed on by MZ to CAMHS who then informed LA1’s Public Service Hub but the police were not informed at this time. Age 14 MZ discussed the allegation with CSC1 and said that they did not wish to take make a complaint.  Child Z was not spoken to alone.  In a conversation with CAMHS, MZ was not prepared to allow discussion of the alleged assault, giving the reason that she felt it would be detrimental to Child Z.   Two months later, in May 2015, MZ raised concerns with the police that her daughter had been approached by an adult male requesting she perform sexual acts on him for payment.  Child Z did not participate.   She returned home and informed her mother who contacted 11  the police.  A crime was recorded; however, the male was never identified.  A referral was made to CSC1 via their Public Service Hub.  Again, Child Z was not spoken to alone by CSC1. CAMHS noted that Child Z's current boyfriend at that time (M2) was in care and may have committed a sexual offence in the past.  MZ said that she was aware of Child Z’s vulnerability and that they were never left unsupervised.  She would contact CSC1 if she had any concerns. During this period hospital admissions continued for a variety of conditions, including chest pains and palpitations, and joint pain.  Concerns continued about Child Z’s weight loss as she was not following the prescribed eating plan despite regular support from a dietician.  Child Z reported self harming and feeling low but not suicidal.  Family therapy was offered but MZ was initially reluctant to take this offer up and Child Z became ambivalent about whether she wanted to be involved with CAMHS.   She recalled later that she felt that her relationship with the counsellor was not helping as she would have wished.  She felt that she spent a lot of time with the counsellor, but that the content of the appointments was not directly linked to addressing what was going on in her life.  Child Z also later recalled that, when she met with the psychiatrist, it was in a meeting of professionals and she felt unable to express her views in this setting, as she found speaking in a group intimidating. She recalled that when in school, she felt well supported by the school nursing service.  She was able to talk to the school nurse about her problems and found that very helpful.    Age 15 up to the decision to assess In early 2016 concerns were raised with CAMHS by Child Z’s GP, the school nurse and by MZ about Child Z’s low mood, self-harm and suicidal thoughts.  Child Z was taking anti-depressants but her mood had continued to deteriorate and she reported experiencing auditory hallucinations.  She disclosed to the school nurse that she was still self-harming and told her in graphic terms how she planned to take her own life.   This was reported to CAMHS and to MZ. Child Z had repeated attendances at her GP and A&E, often being admitted to hospital for physical symptoms.    The hospital contacted the LA1 Public Service Hub at the end of January 2016 after a hospital admission, raising concerns about Child Z’s suicidal ideation and self harm.  The information was treated as information sharing and no further action was taken. The CAMHS psychiatrist noted that Child Z had lost more weight and notified her GP that "The home situation is really rather stressful…..MZ has little support in her own right and is feeling the pressure of being the sole carer for….with her complex needs."  MZ was given details for self-referral to Healthy Minds.   12  Two weeks later, the school nurse passed on her concerns about a further marked deterioration in Child Z's mental health and physical well being to CAMHS.  Child Z had refused to complete the mental well being scale for fear of being sent back to hospital.  Her weight loss appeared extreme and she refused to let the school nurse monitor it.   This was not pursued as her weight was being monitored by the dietician.   At an urgent CAMHS appointment following a brief admission to hospital, Child Z reported daily suicidal thoughts and intrusive memories of the sexual assault which had occurred in late 2014, on a daily basis.  She felt like she was being watched or followed, and was hearing voices.   In 2016 Child Z was diagnosed by her consultant as having emotional dysregulation and depression with mood congruent auditory hallucinations, anxiety and PTSD4.   Child Z again spoke about her suicidal ideation to CAMHS.  She had a plan to end her life and discussed paranoid thoughts about people watching her and wanting to kill her.  Visual hallucinations were also noted.  CAMHS discussed the situation with MZ who was recorded by them as being confident that she could keep Child Z safe.  In mid April 2016 Child Z was admitted to hospital through A&E having taken an overdose of Paracetamol.   The trigger for this behaviour was reported by MZ to be an argument about Child Z sending and receiving sexually inappropriate messages with an 18 year old man.  MZ reported that she had "appropriately addressed this with her".  One day after continuing to say that she wanted to die, Child Z was discharged.   It was agreed that on discharge the Young person's outreach team would provide support at home and that MZ would increase supervision and lock sharps and medications away.   Family therapy was started and Child Z continued to be on a waiting list for CBT.   A further referral to the LA1’s Public Service Hub made by the school in late April 2016, related to Child Z continuing to express suicidal ideation; feeling helpless and reporting parental alcohol misuse at home.  An exploration by CSC1 revealed further concerns around grooming which were shared by MZ.  A referral was made to LA1’s CSE team which included a police officer.  In mid May 2016 MZ made a phone call to CAMHS as Child Z was hearing voices and expressing thoughts of wanting to jump in front of train.  CAMHS spoke to MZ and it was agreed that MZ could supervise appropriately at home.  A leaflet on coping with hearing voices was provided to support the family.   In late May 2016, Child Z ran away from home and was admitted to hospital with suicidal ideation.   The hospital referred the case to LA1’s Public Service Hub.  The initial referral referred to the risks to Child Z of unprotected sex and multiple partners in the context of her                                                       4 https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/causes/ 13  being cared for by a parent unable to ensure safety.  MZ had asked for support and Child Z had alleged that her mother was drinking alcohol to excess.  Child Z revealed a suicide pact with another child.  LA1’s Public Service Hub declined an invitation to attend a multi-disciplinary meeting as they intended to close the contact after referring to LA1’s Early Help service.  This was challenged by the hospital, as Child Z intended to run away again if sent home.  The hospital raised the issue of the need for alternative living arrangements and further support.  This challenge resulted in the case progressing to a social work assessment by CSC1.   Age 15 during the assessment A social worker visited Child Z in hospital and negotiated a return home.     Child Z told her social worker that MZ was not letting her out alone, in an attempt to try and keep her safe.  She stated that she still re-lived the trauma of the incident when she was 14 and when asked if she wanted to make a complaint to the police, she said that she was unsure.  Child Z initially spoke positively about her relationship with MZ, but then did not want to talk further about their relationship.  The next day at a CAMHS appointment, Child Z said that, although she was happy to be discharged home, she felt that she had benefited from some time away from her mother. In a conversation later with the social worker, the CAMHS practitioner advised that her mother could not cope with Child Z.  The social worker also recorded that MZ had said that Child Z was putting herself at risk online.    Child Z was receiving support and advice on contraception from the sexual health service.  During the assessment period the sexual health service became concerned about a new relationship.  They informed CAMHS that Child Z was in contact over the internet, with a new boyfriend (M3) aged 16 from Liverpool, and was planning to meet him the following week.  Her mother was aware of this and would accompany her.  A referral was made to the CSE1 team.  As he was a peer, they determined that the case did not meet their threshold and the referral was declined.    Throughout this period, Child Z suffered a number of unexplained collapses and was admitted to hospital several times.   After investigations, a physical cause of the collapses could not be found and the results of tests were thought to point to a ‘functional cause’.  A functional cause can be a psychological response to stress5.    CAMHS work continued and in an initial summary, the CBT practitioner, who was then working with Child Z, recorded that she was using sex as a way to try and make others like her.  She wanted to have a child in order to have someone to love.                                                       5 https://jnnp.bmj.com/content/76/3/307 14  In the period up to her GCSE exams Child Z’s attendance continued to be poor but she did use the school’s support during the study leave period in June 2016.  She formally left school after her exams.  Child Z moved quickly on to a relationship with another young person (M4), also age 15, who lived with his parents in LA2.  It later became apparent that M4 had his own serious mental health problems.  M4’s father contacted the police in July 2016, stating that Child Z and M4 were in an underage sexual relationship. This was recorded as a crime but it was deemed not to be in the public interest to prosecute, as this was seen as an age appropriate relationship.   When Child Z was spoken to regarding this, she informed the police about the sexual assault by M1 (age 16) that had occurred in 2014.  A crime was also recorded in relation to this matter, and M1 was arrested.  He was not charged after the prosecution file was reviewed by CPS.  The social work assessment had been completed in mid July 2016.  The social worker identified Child Z’s vulnerabilities as being her having unprotected sex with teenage boys and speaking to older males through social media.  The assessment concluded that there was no role for CSC1 as Child Z was involved with mental health services and the threshold for LA1’s CSE Team had not been met.  The sexual health YOUthink service were involved and MZ was said to be acting appropriately, ensuring Child Z attended appointments and accessed support when needed.  The manager’s decision was to close case and for the police to re-refer, if necessary, when they had completed their investigation.    Age 15 after case closure Ten days after the decision to close the case, CSC1 received an email from the sexual health service YOUthink manager which stated that Child Z was actively trying to become pregnant.  They raised concerns around her high levels of vulnerability, including that Child Z was unaware of the background of her current boyfriend (M4).  They felt that she was at risk of CSE.  The response to the YOUthink manager from CSC1 was that case was closed to CSC and that this had been communicated to her parent.   They further advised that if professionals thought that there were safeguarding concerns, they should re-refer through LA1’s Public Service Hub.  The CSC1 team manager said that, given the CSE concerns, any challenge needed to be made to the CSE1 team.   The concerns from YOUthink were quickly followed by an email from the CAMHS psychiatrist to CSC1, expressing strong disappointment regarding the closure of the case of Child Z when there were still ongoing safeguarding concerns.  The psychiatrist asked that the email should be taken as a re-referral to re-open the case.  The email laid out, in clear terms, the issues of Child Z being out of parental control and arranging to meet unknown males.  The psychiatrist explained the risks of Child Z’s behaviours and stated that these behaviours were not features of a mental illness which could be treated.   15  The YOUthink manager also re-referred their concerns that Child Z had been planning a pregnancy. The email response from CSC1 to the psychiatrist stated that there was no safeguarding role for CSC and that the concerns had all been discussed with the CSE1 team and the police.  It stated that all referrals needed to be made via LA1’s Public Service Hub.    Age 16 up to leaving home A few days after her 16th birthday, Child Z attended YOUthink with M3 and MZ.  She had had a positive pregnancy test.  Child Z introduced M3, now age 17, as the father.   The professional concerns raised by the YOUthink led LA1’s Public Service Hub to refer to Early Help with recommendations for family support direct work around the Barnardo’s project 'Real love rocks6' and CSE prevention.   In mid September, MZ contacted the YOUthink sexual health service to tell them that M3 had finished with Child Z and that he was requesting a DNA test.  The service had closed Child Z’s case when she became pregnant, but retained a good relationship with her.   In late September the case was received by LA1’s Early Help practice manager for allocation to a Family Intervention Worker (FIW). The practice manager outlined the actions to be undertaken by the FIW.  Although there were actions set out, the recommendations in the referral were not outlined in the allocation.    There was then a delay, and the first contact was made with the family by the FIW in October.  The FIW explained that a Common Assessment Framework (CAF) meeting would be arranged to ensure that there was clarity of support and actions.   The FIW would undertake the CAF, even though it was understood that a CAF was already in place and led by CAMHS.   In early November, the FIW contacted the allocated Young Parent Midwife (YPM) who raised concerns regarding the new relationship that Child Z had started with M4.  At this point there still had not been a CAF meeting and concerns were being raised by other professionals.  There was no visit or contact with Child Z, even after these concerns were raised, until 10 days later.  At the home visit the FIW stated that a different FIW was to take over the case.  Child Z and M4’s wishes and feelings were discussed with them.  The case transfer did not outline the concerns of professionals.  In supervision three weeks later the new FIW was asked to do a CAF to review the role for Early Help.  The Family Nurse Partnership (FNP) is a specialist service for young mothers aged 19 or under.  They offer intensive therapeutic support focused on supporting mothers to build a positive relationship with their child and also support mothers with other needs which can be wide ranging.  These include for example, housing, education, drug and alcohol.   They                                                       6 http://www.barnardosrealloverocks.org.uk/about/ 16  provide four weekly visits to begin with, then fortnightly, then six weekly.  The programme has a strengths based ethos and is based on focussed research. The Family Nurse (FN) was based in the health authority area covering LA1.  The FN made a home visit in early December 2016 and saw Child Z alone.      Early in her pregnancy Child Z’s anorexia ameliorated and she reported that she was feeling well.  She was now 16.   CAMHS services are commissioned up to 16.  A few weeks after her birthday, CAMHS decided to discharge her after three years of their involvement.  Child Z was also in receipt of care from a Young Parent Midwife (YPM).  She told the FN that her new boyfriend M4 wanted to be involved and bring the baby up 'as his own'.  She had had no recent contact with the father, M3, who still lived in another city.  Child Z was feeling positive about the pregnancy and the FN concluded that there were no safeguarding concerns.  In a FN visit a few days later, Child Z was seen alone and she shared how she felt excluded when her father died, as he had another partner and younger children.  Up to this point she had been having regular and significant contact with her father’s new family and this stopped on her father’s death.  She also mentioned that M4’s parents were against his relationship with her.   At the CAMHS discharge meeting shortly after this, it was agreed that there was no role for LA1’s Early Help, as the FNP would be providing intensive support for the family.  A full history was now shared with the FN by the psychiatrist.   MZ was stated by the CAMHS psychiatrist to be a significant protective factor.   Child Z had experienced a sustained recovery and was not self harming or having suicidal thoughts.  She was optimistic about the pregnancy and now doing well in college. The family felt that mental health support was no longer required.  Child Z would have consistent support, including weekly appointments and work on healthy and unhealthy relationships.   If there were further mental health concerns, the FN would liaise with the GP, or refer to adults’ mental health services.   The CAMHS psychiatrist said that Child Z had, in the past, used health issues to get her needs met and that that may manifest again after the baby was born.   She described the peri-natal period being one where there would be a high risk of relapse in her mental health.   The possibility of additional support from Homestart was explored as Homestart works with young mothers to build confidence and skills and break isolation7.  Homestart was offered and was initially declined by MZ who did not want strangers in the house when she was not there.                                                         7 https://www.home-start.org.uk/Pages/Category/our-programmes 17  As time went on, the FN found MZ to be difficult to work with and controlling.   She found BZ to be intimidating.   She learned from the psychiatrist that BZ was a significant carer for Child Z from a young age as MZ worked long hours.   By mid March 2017, Child Z's mental health had become less stable.  Child Z was readmitted to hospital with nausea and pain.  MZ said that Child Z was not eating or drinking and thought that she not coping, but linked this to the pregnancy rather than her mental health.  The FN spoke to the YPM and sought advice from CAMHS.  It was clarified that, as she was now 16, CAMHS would not be appropriate and an adult psychiatric referral would be the appropriate route.   Child Z’s baby boy (CZ) was born in late April 2017.  M4 was recorded on the birth certificate as the child’s father.  Child Z accepted a Homestart volunteer but only for breast feeding support.   At approximately three weeks old, CZ was admitted to hospital after Child Z and M4 took him to the GP describing two recent floppy and unresponsive episodes.  The story was confused and reports that he had stopped breathing were later contradicted by MZ, who believed the incidents were less serious.  Child Z and M4 were unable to detail CZ's feeding record.  The FN reported that Child Z’s care of the baby was "lovely and there are no concerns".   CZ was recorded to be well supported by M4 and Child Z. Child Z visited her GP in late May for anxiety and depression.  She had concerns about M4's mental health and his not engaging with services about this.   Child Z reported constant arguments with M4.  She denied any physical abuse but said that there had been emotional abuse.  Both were unhappy living with MZ and BZ and asked about their eligibility for housing.  M4 said that he had arguments with MZ and that she drank too much.  The GP restarted Child Z’s anti-depressant and noted that she was awaiting talking therapies. Shortly after the FN’s concerns about the case had escalated, she received a call from M4 to report that he had left MZ's after an incident.  M4 said that MZ was drunk and CZ was present when MZ verbally assaulted him.  He pushed her and she responded physically.  There was then a fight between M4 and BZ.  M4 left the house and the police were called as the violence spilled into the street.  M4 said that CZ remained inside cared for by MZ during the fight.  M4 felt unable to return to the house and, after a few days, Child Z and her son went with M4 to stay with a male relative of his. The FN passed on her concerns, including over future housing, in a referral to the Public Service Hub and this was passed on to CSC1 who commenced a social work assessment.  Age 16 and no permanent home On leaving her home Child Z contacted CSC1’s OOH as she did not have anywhere to stay.   She, CZ and M4 had stayed at M4’s male relative’s home with CZ but felt that this was not appropriate.  Child Z agreed to return to MZ’s house for one night and this was clarified by 18  the OOH social worker to be acceptable to MZ.  Later CSC had a call from M4 advising that he had arranged to go to his parents.   MZ later said that Child Z had told her at this time that M4 had slapped her in the face.  She also expressed concerns that M4 was mentally unwell and had threatened suicide.  Initial checks were completed by a CSC1 social worker.  It was decided that further assessments were needed. The behaviour of M4’s relative meant that they had to move again and three days after leaving MZ, Child Z, her son and M4 had moved in with his parents in LA2.  They then presented as homeless as they were unable to stay at M4's parents.   When M4 and Child Z presented at an LA2 Housing Association seeking somewhere to live, the Housing Association became concerned about Child Z.  They told CSC1 that M4 was ‘speaking for her’, indicating his exercising a level of control.  During the review process it was learned from Child Z that M4 had become jealous and restrictive of her interactions with her mother and had issued the ultimatum that she had to choose either a relationship with him or with MZ.   Child Z phoned CSC1 to see if she still had a social worker and to ask for support.  They told her that the case was closed.  CSC1 referred her to LA2’s Multi Agency Safeguarding and Support Hub (MASSH). The social work assessment undertaken in LA1 had concluded that the case would be transferred to LA2.  It recorded their decision as due to the ages of the couple and needing permissions to accommodate ‘the family’ who were currently residing in LA2 and not wanting to return to LA1. A few days later Child Z was admitted to hospital in LA2 after another collapse, and planned to go and stay with her son at her mother’s when she was discharged.  Her son was being cared for by M4 and his parents while she was in hospital.   The hospital contacted the FN who challenged the safety of the plan for Child Z to go to her mother’s house given what was known about MZ's alcohol use and BZ's temper.  Child Z did not think that taking her son there might be unsafe because it would only be for one night, and because MZ and BZ were looking forward to seeing him. At this point CSC2’s MASSH were in the process of collecting background information.  They spoke to Child Z by telephone and established she had been admitted to hospital after collapsing and felt that this was due to stress.  She had left her son with M4 and had moved to M4‘s parents as it was not safe staying with her mother because she drank alcohol and was aggressive.   She said that M4's parents wanted them to move out that day and they had nowhere to go. The social worker spoke with the FN who said she knew the family very well and had previously referred the family to CSC1. She said that she was waiting for the 19  outcome of the CSC1 social work assessment and was unaware that this had been completed and the case closed.  The FN was concerned about Child Z's unstable mental health and reported a history of anorexia, suicide attempts and self-harm and said that her case had been recently closed by CAMHS.   Child Z, her son and M4 were all allocated to the same CSC2 social worker and a social work assessment was commenced.  Once it was clarified that they were not a sibling group, M4 was allocated a separate social worker.  Child Z and her son remained with the same social worker.  They were not eligible for a tenancy as they were not yet 18.   The FN was also called by M4.  He said that Child Z had ended their relationship the previous evening and attempted to throw herself in front of cars.  Her son was being cared for by M4’s parents. The CSC2 social worker had a telephone case discussion with the FN.   They both then spoke to Child Z who said that she had been stressed recently and was unsure if she wished to remain in a relationship with M4.  Child Z said that M4 was controlling.    She confirmed the account of problems at her mother’s house and that agreed it was not a safe place to be with her son.  The FN noted that Child Z seemed very 'torn' and unsure what to do.   She was asked to consider a mother and baby placement but agreed to a short-term return, with M4, to his parents’ home.  The FN noted her concerns about the extent to which Child Z was being pressured.  Following this meeting, the social worker, team leader and service leader identified the issues for assessment.  These were homelessness, mental health and eating disorder, and the impact on her parenting of growing up in a household which featured domestic abuse and alcohol misuse, Child Z being a child who has had a child, and would need support to successfully parent.  It did not identify the risks to Child Z and her son presented by M4’s controlling behaviour and his unstable mental health. The immediate actions agreed were for a psychiatric liaison and assessment team (RAID)8 assessment of Child Z to consider her capacity to care for her son, to explore housing options and to seek legal advice if necessary. The RAID assessment noted low risk to self, low risk to others, low risk of self-neglect, low risk of exploitation and vulnerability and no suicidal thoughts.  She was therefore discharged.  The notes on discharge indicated that she had expressed that she wished to go home that night and had spoken to a social worker about housing.  Child Z informed staff that she would stay at M4’s parents’ house. The following day, CSC2 obtained new information about the circumstances of their stay with M4’s male relative in LA2.  M4's father intervened to collect M4, Child Z and her son as                                                       8 https://www.local.gov.uk/sites/default/files/documents/pennine-care-pdf-12-pages-bb4.pdf 20  he thought that this was not a safe arrangement.  On arrival, M4’s relative had barricaded M4, Child Z and her son in the property and would not let them leave.  The police attended to resolve the situation. A few days later, the FN informed the social worker that she had visited Child Z and her son at MZ's home that morning and M3 was sitting with Child Z and cuddling CZ.  The FN expressed surprise at this, as when Child Z was pregnant M3 was insulting to her and they had not been in contact until the previous week.  Child Z and M3 then went with MZ to get a paternity test which confirmed that M3 was CZ's father.   Only one week after the occasion when M3 was cuddling CZ, MZ shared her worry with the FN that Child Z had been spending long periods out with M4 and keeping CZ out late.   The FN noted that Child Z was reluctant to talk in front of BZ and that he would not give them privacy.   She also found BZ's manner intimidating.  He was saying that he needed to monitor discussions between her and Child Z and make "corrections" to any misinformation.  BZ was described as continuing to intimidate Child Z while she was talking to MZ on the phone.  An Initial Child Protection Conference was convened in late July 2017 in respect of CZ.  The focus was upon achieving stability for CZ.  A Child Protection Plan (CPP) was agreed for CZ under the category of neglect.  The chair talked to Child Z who felt she had no other option than to live with M4.  The conference explored other options including a possible refuge placement.   Later that day, CSC2’s OOH service mediated between Child Z and MZ to reach a calm resolution of another argument and they obtained Child Z's agreement for her and her son to stay with MZ until the social worker had set up somewhere for her to stay.   This was all repeated two days later after a further argument. Age 16 in the refuge A few days later, Child Z was moved with her son, by her social worker, into a specialist young mothers’ refuge in another local authority.  The referral had been made by the FN but the arrangement was underwritten in a contract by CSC2.  CZ had been made the subject of a CPP six days earlier and Child Z was being managed as a Child in Need (CIN) at Team Around the Child (TAC) level.   The refuge did not have access to the case history but staff were aware, from the referral, that there were allegations of domestic abuse and violence in MZ’s home and were told about MZ’s daily drinking and her brother’s violence by Child Z.   When later interviewed, the refuge managers thought that Child Z might have had a better chance of being a successful parent if placed in a mother and baby unit or foster placement.  They saw that Child Z was physically and emotionally exhausted by the chaos of her life, to the extent that she frequently felt overwhelmed.  Child Z was described as desperate to leave her son at times as she was a child herself and wanted her own space.  The refuge 21  managers recognised that she required a level of care and support that they were unable to provide.   The social worker agreed for Child Z and her son to spend two nights a week at M4’s home.  At the time, Child Z was adamant that she wanted to spend more time with M4 and to move in with him when she was 18.   Child Z’s perception, when later interviewed, was that the relationship with M4 had been abusive and controlling and that she had no alternative options.   She felt unable to cope on her own and needed relief from caring for her son from both M4 and MZ.  On one of the occasions when Child Z and M4 split up, he threatened to kill himself and was detained under a mental health section. A core group meeting for CZ was held.  Child Z presented as anxious and upset.  She disclosed an incident where she had been coerced and sexually exploited by the male relative of M4 who they had stayed with in LA2, while her son was in the next room.  She had accepted money from M4’s relative.  With Child Z's consent, this was reported to the police.   Child Z had said that, despite having some money from social care, she was in debt to various friends.   It was agreed that a foodbank voucher would be arranged for her.   The core group decided that Child Z was to be re-referred to the sexual health service as she had stopped taking the contraceptive pill.  The FN said that Child Z was frequently away from the refuge and therefore the support and attitudinal work that she had planned had been ineffective. Following the allegation against M4’s relative, the alleged perpetrator was arrested.  As part of the investigation, Child Z's phone was examined and the police referred Child Z to the Sexual Assault Referral Centre (SARC) for counselling, including support from an Independent Sexual Violence Advisor (ISVA).  Initially a decision was made not to proceed as text messages were believed to undermine the case, but subsequently the matter was reviewed and a decision is now awaited from the CPS.  The CSC2 social worker explored further financial support for Child Z to ensure that she had enough money to live on, given the circumstances of the alleged offence.  Child Z was allocated a CSE2 social worker from the LA2 complex safeguarding team, who formed a very positive working relationship with her and supported her through the interviews related to this allegation. A few days before her 17th birthday, Child Z became pregnant again.   Child Z texted her social worker to say that she needed to be living with M4 as living in the refuge on her own was not working and M4 now had his own accommodation.  The refuge reported concerns about her care of her son and that she had frequent absences from the refuge.   The refuge said Child Z should be on a child protection plan and have her own social worker.  In response the social worker and manager did consider this, but decided that introducing 22  another professional to Child Z, given her difficulties with multiple professionals, would not be helpful.  The Social worker advised that Child Z did now have a CSE2 social worker to support her alongside the allocated social worker.  A CSE2 social worker would have no case-holding responsibilities so this did not address the issue raised.  On reflection CSC2 agreed Child Z should have had her own social worker. Age 17 and living in the refuge Over time, it became clear that CSC2’s expectations of the refuge were contrary to its remit.  What was being requested by the social worker in terms of monitoring, support and structure was more akin to what would have been provided by a mother and baby residential or foster placement.   In interview, Child Z said that on arrival at the refuge she had been surprised that it was not a mother and baby unit as she had expected.   In early September 2017, in response to concerns about Child Z’s care of her son, CSC2 decided to escalate the case of CZ to be discussed at a legal gateway meeting and to explore whether a mother and baby unit rather than a refuge might more appropriately meet the needs of both Child Z and her son by assisting with routine and offering parenting advice to Child Z in a more appropriate way.   Around this time, in mid September, Child Z miscarried and was very distressed.  She still wanted a baby with M4.  Child Z and her son were by this point spending weekends with M4 at his flat with the agreement of CSC2.  Through engaging with Child Z, the refuge managers also became aware of the impact of the highly dysfunctional and volatile relationship Child Z had with M4, and highlighted this repeatedly to CSC2.  The refuge managers expressed their concerns that Child Z did not recognise the risk posed to her son by M4's poor mental health.   They were very concerned about the risk M4 posed to Child Z, and the risks of occasions where he had sole care of CZ.  Once they were both away from the refuge for five consecutive nights.  The refuge thought that their concerns were not appropriately responded to, and that there had been no timely assessment of the risks.   In early October, ahead of the review child protection conference for CZ, Child Z and M4 told the FN that they felt unfairly judged and unhappy with the restrictions of the child protection plan. At the conference, it was noted that M4 lived close to his relative who was the alleged perpetrator of the previous assault on Child Z, and that a safety plan had been put in place.  The arrangement where Child Z and her son were spending every weekend with M4 was said to be ‘going well and ... allowing Child Z some respite’.  It was recorded that there were still concerns about their relationship and some controlling behaviour by M4.  The IRO felt that if Child Z and M4 wanted to live together this needed further discussion at the legal planning meeting, along with the issues about security of housing as only M4 could apply.  The IRO commented that Child Z needed to accept that she would need help to care for her son, 23  particularly as the couple had so little family support.  The conference agreed that the child protection plan for CZ should continue under the category of neglect. The following day, at the Legal Gateway Panel, it was decided to initiate the Public Law Outline (pre proceedings protocol) for CZ.  The option of a mother and baby foster placement was suggested as an alternative to the refuge. Two weeks later, Child Z and M4 split up again.  M4 was angry with Child Z and went to the police with his relative to withdraw his witness statement about the relative’s alleged assault on her when they were staying with him in LA2.  By late October 2017, the FN described Child Z as disengaged and preoccupied with concerns about M4, who had threatened suicide and been detained under Mental Health Act 1983. Shortly after this, the refuge reported to the social worker their concerns that Child Z had been seen by other residents to be meeting men who were sexually exploiting her, including one occasion when her son was present.  She denied these allegations and gave various different accounts. The following day a CSE assessment was commenced. When the pre proceedings meeting was held to plan for CZ, Child Z, who was legally represented, was encouraged to think again about the benefits of a mother and baby foster placement, but by this point she did not want to move somewhere new and declined the offer.  MZ was identified to be assessed as a potential alternative carer for CZ.  A referral to the fostering team for a mother and baby foster placement was made by the social worker as this would continue to be an option for Child Z should she change her mind.  It is not clear that the benefits of this for her were explained. Child Z’s GP had contacted CAMHS reporting that she was under increased stress and was redirected to the Community Mental Health Team (CMHT).   Her PTSD symptoms were increasing and she was having thoughts of self-harm and fleeting suicidal thoughts.  Child Z had continued to attend A&E frequently, both in relation to her own health and to minor issues with her son’s health.   Following the GP’s concerns, near the end of November 2017 a letter was sent to Child Z offering an assessment appointment with the CMHT.  Child Z missed this appointment, and a subsequent one, and the referral was then closed. As part of the viability assessment of MZ as an alternative carer for CZ, the social worker met with both MZ and BZ.  The outcome was a positive assessment and it was agreed that Child Z and her son were to spend time overnight each week at MZ’s home.  Subsequently Child Z and her son stayed after she had an appendix operation and it was then agreed that they should stay over Christmas.   Child Z decided that she did not want to go into a mother and 24  baby unit. At this point, M4 was still under a mental health section and Child Z was repeatedly messaging him.  The refuge suggested a move because of Child Z’s concerning interactions with other residents.   Shortly after Christmas the CSE assessment was completed by the CSE2 social worker.  The assessment identified a high risk of exploitation and identified a plan of work around consent, healthy and unhealthy relationships, understanding CSE, understanding vulnerabilities, safety planning and internet safety.  Work with her began and Child Z found it was very helpful.  The worker had formed a good relationship with her Child Z said she felt listened to.  Child Z expressed surprise that the worker was there for her as, since his birth, professionals had seemed to her, to be there only for her son.  In late January 2018, the refuge terminated the placement because of an incident where Child Z invited men to a refuge dispersed property, exposing herself and other residents to exploitation.   Age 17 at home The social worker spoke to Child Z who wanted to take her son to her mother’s home.  Initially MZ refused to agree to this but was persuaded by the social worker that Child Z could return with clear expectations in place.   She returned to her mother’s home.  The FN contacted the CSC2 team manager.  She was concerned about risks presented by MZ's alcohol use and controlling behaviours and felt that risks from BZ's volatile temper appeared to have been minimised.  The levels of observation and support that she felt were crucial to keep CZ safe in Child Z's care had gone with the move back to live with MZ, who was working long hours and not therefore directly supervising.   Child Z recalled that her mental health declined during this period.   She felt lonely and isolated at home caring on her own for her son.  As her mother was at work all day, she was alone in the house for long periods.    She felt that she did not have any friends or support and had expected that she would have more contact with services than she did. The FN expressed, to CSC2, her strongly held view that the arrangement was inappropriate and that both Child Z and her son were at risk in MZ's care.   She believed that both CZ and Child Z should be Looked After Children (LAC).   A few days later the social worker, in a home visit, observed that MZ provided all CZ's care during the visit and Child Z did not interact with her son at all.    As Child Z was now living with her mother in LA1 the CSC2 social worker referred Child Z to CSC1 on the basis that she was now a child in need in their area.    Three weeks later, in a session with the FN, Child Z reported that she was settled and now getting on well with MZ and BZ.  The FN attempted to do an assessment of Child Z’s parenting but this required her to observe a full five minutes of parent and child focused interaction.   Child Z was unable to sustain this, so she was unable to complete the 25  assessment.  Although the FN noted no hostility to her son, Child Z was mostly focused on her own issues. Shortly after this the CSC2 social worker told a TAC meeting that CZ was safe and well and Child Z was interacting with him.  CZ was noted to be in a good routine.  Short breaks care for CZ had been arranged so that Child Z could attend sessions with the CSE2 social worker.   MZ spoke for Child Z in the meeting as she was said to be anxious and unable to speak.  The social worker stated in her record of the meeting that Child Z was clear that she was not returning to live in LA2.  At about this time Child Z’s GP recorded that Child Z had restarting self-harming and the GP had prescribed an antidepressant, and then increased the dose when her low mood continued.    Following the concerns raised by the FN, she was invited to a joint reflective supervision session with the CSC2 team manager who was overseeing both cases and the social worker.  In interview the FN recalled that this session focused entirely on plans for CZ who was in a process where he would eventually become a LAC.  Her challenge that Child Z needed to be a LAC was not dealt with in this meeting, nor was her concern about the impact on Child Z’s mental health of being back in the same situation with MZ.  The social worker did not contact Child Z’s GP and was unaware of  the significant deterioration in her mental health after returning home, which included her re-starting her self-harm. Age 17 in the adolescent psychiatric unit In the early hours of the morning, in mid March 2018, Child Z was reported missing to police by MZ.  She had left a suicide note.  When she was found she said that she would run away again if she was left at home with MZ.  She also said that she would end her life one way or another at the first opportunity.  OOH records show that the police initially advised MZ to lock Child Z in the house, as they felt her presentation was behavioural, and that if she was taken to hospital, she would be likely to be sent home.   MZ felt unable to control the situation as Child Z was threatening to self-harm.  The police advised MZ to ring the CSC2’s OOH as MZ and Child Z were in need of support.  The OOH social worker challenged the police officer’s view and said that it was not a police decision whether Child Z needed a mental health assessment.  A discussion followed between the police officer and the OOH social worker where the officer shared his previous experience of working with mental health services.   The social worker shared a little of Child Z’s background that might make hospital admission more likely.  The police then took Child Z to a hospital in Oldham under section 136 of the Mental Health Act 1983, from where she was transferred to an adolescent mental health unit in another area of Greater Manchester.   She was subsequently detained under section 2 of the Mental Health Act 19839. In interview MZ later spoke about how important she believed the intervention of the OOH social worker was in ensuring that Child Z was not left at continuing risk.                                                       9 http://www.legislation.gov.uk/ukpga/1983/20/section/136 26  An early diagnosis suggested that Child Z was suffering from complex emerging emotionally unstable personality disorder10.    In the days following the detention, the CSC2 manager had made a decision to issue care proceedings for CZ and they intended to transfer his case to CSC1 at an appropriate point in proceedings.  They also planned to seek to transfer responsibility for Child Z to CSC1 ‘imminently’.   CSC1 responded by requesting a date for the next Child in Need meeting for Child Z.   The date suggested was two days later and too soon for them to organise attendance.  They requested two weeks notice and asked for date, time and venue for a transfer meeting.   A date and time was suggested in the first week in April but, because there was no response from the CSC2 social worker to an email from CSC1 asking for details of the meeting, the contact was closed.  The CSC2 social worker had been on leave when the email was received so had not been able to respond to finalise arrangements for attendance at the meeting.   On her return from leave she found that CSC1 had rejected her online referral on the grounds of insufficient information.  The referral had then been closed as a contact by CSC1 and the referrer asked to re-refer when she returned from leave.   The CSC1 online referral system did not facilitate referrers in retaining a copy of the information that they had sent, so the CSC1 social worker was not able to check and amend it.  A new online referral was done and a CSC1 social worker was allocated to the case.  A meeting was then scheduled for mid April 2018.  Records indicate that, in communications between the CSC2 social worker and the SARC, the social worker spoke about to the difficulties of providing care for Child Z four and a half months from her 18th birthday when she would be expected to reside in LA1 after discharge from hospital.    While Child Z was in hospital, the CSC2 social worker recorded that MZ was caring for CZ successfully and developmental assessments by health had evidenced that he was meeting his milestones.   A later record by CSC2 reported CZ as ‘thriving’ with his grandmother.  The CSE2 social worker contacted CSE1 to find out if they could support Child Z and was told that they do not work with anyone over 18 and this would make any work very time limited.  Other options for counselling would require her to join a long waiting list. Not long after being detained, Child Z was being threatened by a man in the locality of the unit, who was attempting to exploit her after she had sent him an inappropriate photograph.    A CSE2 assessment assessed the risk of CSE as medium.   The transfer meeting for Child Z was held at the adolescent mental health unit and chaired by the CSC2 social worker.  The CSC1 social worker attended the meeting which explored the                                                       10 Borderline Personality Disorder BPD Mind the mental health charity. Help for mental health problems.  Mind.org.uk 27  options and planning for Child Z.  CSC2 recorded that the CSC1 social worker agreed to assume case responsibility from the meeting onwards and to arrange a CIN meeting.  CSC2 therefore closed the case.   CZ was later made subject to an Interim Care Order and was to remain with MZ while assessments continued.  As agreed at this first Court hearing CSC2 closed CZ’s case. Shortly after this, the CSE2 social worker visited Child Z in the adolescent unit for a final session. There had been a serious incident just prior to her arrival, where Child Z had tried to attack another young person.  Staff reported that Child Z had been talking to herself recently, saying she could hear voices.   The CSE2 social worker then received an email from the CSC1 social worker advising that CSC1 had not yet decided if they were accepting Child Z's case.   Three days later, a decision was made by the CSC1 team manager and service unit manager that they felt that Child Z should remain the responsibility of CSC2.  This was based on the facts that; she remained under a section at the adolescent unit and was homeless, she did not have a LA1 address and she had had an allocated social worker from CSC2 at the time of her being detained.   Their decision was that until CSC2 had provided support to Child Z around her discharge plans and homelessness, they should retain case responsibility.  If Child Z was supported by CSC2 to secure an LA1 address, then CSC1 would accept case responsibility.  Days later, in early May 2018, a CSC1 social worker and manager attended a discharge planning meeting at the unit.  Information was shared that Child Z had run away from staff into the road, attempted to harm herself, had threatened others and was hearing voices. The treating psychiatrist had determined that she had Post Traumatic Stress Disorder (PTSD) and a possible psychotic illness as a result of her experiences of domestic abuse and sexual assault.  A possible discharge date of the end of May was set.  The same day, Child Z made an allegation that she had been having a sexual relationship with a unit staff member.  The police PPIU attended to investigate but Child Z did not wish to engage with the investigation until six weeks later when she provided a full account, stating that she had wanted the contact and did not wish to be involved in any court process.   The staff member denied any inappropriate contact.  Child Z’s discharge date was postponed and several weeks, later a download of Child Z's phone revealed no material to support Child Z's account.  It also revealed regular contact with males through chat rooms and dating sites and the exchange of inappropriate images in the period before she became a patient. In interview, Child Z alleged that the exchanges had been in a type of message which is not retained on the phone, and that the staff member had continued to contact her after her subsequent discharge. 28  One week after the discharge planning meeting, the CSC1 social worker emailed advising CSC2 that " After much consideration about the case status of this case CSC1 will not be accepting this case, it appeared to have transferred prematurely without the consideration of other options for Child Z, this is also dependent on her mental health and support she is still receiving in hospital.  Child Z is still in hospital and there also needs to be consideration of adult social care becoming involved within the next few weeks. The case will be rolled back to CSC2."   The CSC2 social worker responded "I am very concerned that we held the transfer-in meeting 3 weeks ago now and this was when I closed the case to CSC2 so I don’t think this will be as easy as the case ‘rolling back’ to CSC2. We had lengthy discussions at the transfer-in meeting with various professionals, including the FN and the unit mental health staff about Child Z’s needs and what options there were for her on discharge.  Professionals involved shared our considerations for other options and for an adult social care referral with you at this meeting and you were going to discuss and consider these options with management.”  The CSC1 social worker further responded that the referral to CSC1 was ambiguous and this was the reason that senior management had decided not to accept the case. Discussions followed between team managers from CSC1 and CSC2 regarding case responsibility.  The matter was finally resolved with an agreement that CSC1 accepted responsibility and contacted adult’s social care to begin transition planning given the proximity of Child Z’s 18th birthday. In late May 2018, a CIN meeting took place for Child Z at the unit.  It was stated that the priority was to secure her accommodation rather than undertaking any CSE work.  There were concerns raised by CSE1 about introducing another professional into Child Z’s life for a short period of time to then end involvement at age 18.  They said that if she was not in a settled place emotionally, this might trigger a relapse.  The team manager agreed with this rationale.  MZ has later said that CSE1 did not see the importance of engaging with Child Z and also that extending the service past 18 would be invaluable for vulnerable young people.  The meeting could not resolve where Child Z would be discharged to.   In mid June 2018, the unit informed CSC1 that it was no longer clinically appropriate for Child Z to remain on the ward.   They raised concerns about her sexualized and risk taking behaviours, alongside her clear vulnerabilities.  Incidents of this type of behaviour were increasing on the ward and could result in Child Z’s immediate discharge.  Her planned discharge date was now near the end of June.  There was a joint discharge planning meeting.  This involved a wide-ranging discussion about possible placement options, none of which were immediately -.  No decision was made as to which had the potential to be a good solution for Child Z.  Potential funding was also discussed and not resolved.  The options considered were for her to go into care or to present as homeless and seek emergency accommodation.  The psychiatrist said he did not feel that Child Z needed mental health supported accommodation on discharge, and that 29  her mental health needs could be met through having support from the Home Treatment Team in place upon discharge, with twice weekly care coordinator visits, weekly therapy and four to six weekly psychiatrist appointments.  The psychiatrist recommended CBT or interpersonal therapy.   Child Z’s solicitor, who had been appointed for her appeal against the section to the unit, then joined the meeting.  The solicitor queried who would be funding any further placement and questioned whether the professionals really believed that Child Z would be supported enough with just twice weekly visits and weekly therapy.   The meeting had been told that Child Z would be accommodated.  A plan was made at that meeting that CSC1 would provide support and family support and encouragement to Child Z to use volunteer/distraction activities.  Safeguarding work, particularly around CSE, was to be undertaken by the local authority.  Records indicate that there later had been a case management decision by CSC1 stating that Child Z ‘had been accommodated by the local authority upon her release from hospital on the 20th June 2018, which has allowed for further assessments and monitoring to take place around her needs, strengths and vulnerabilities’.   The case notes discuss her being accommodated but LAC pathways, procedures and processes were not followed.   In fact, the decision to accommodate Child Z was not implemented.  A CSC1 manager spoke to MZ suggesting that Child Z return home on discharge.   Although MZ initially agreed, she became concerned that she could not cope until Child Z’s mental health improved.   The Children’s Guardian in CZ’s proceedings also objected and the matter was not pursued further.  The social worker was instructed by her managers to source accommodation for the next ten weeks up to Child Z’s 18th birthday.  Beyond this, the social worker was told that there would be no funding.   The issue of accommodating her under Section 20 of the Children Act 1989 was not on the agenda, having been ruled out by management. The social worker’s options were limited.   Two days later, the psychiatric unit stated that Child Z needed to be immediately discharged because she had disclosed a relationship between herself and a 15 year old male on the ward.  He had been discharged and Child Z had been contacting him after his discharge and had arranged to meet him.  Child Z had attempted to self harm following some boundary setting from staff around her behaviour.  She then assaulted three members of staff.  Their plan was to discharge Child Z the following day.  30  A request was made to the unit to delay the discharge but this was declined.   The ward social worker shared the information that Child Z had threatened to take her own life once CZ’s court case has come to an end.  The following day, Child Z was discharged from the unit and placed in an over 16 semi-independent, unregulated placement. The discharge notes written later, at the end of July 2018, confirmed the diagnosis of emotional and behavioural dysregulation and emerging emotionally unstable personality disorder.  They identified Child Z as having had significant traumatic experiences and episodes of impulsive behaviour, reactive low mood, ideas or acts of self harm and intermittent preoccupation with care eliciting behaviour.  There was no evidence of a psychosis or formal psychiatric illness apart from possible PTSD. Age 17 and living in unregulated semi-independent accommodation The adult Community Mental Health Team (CMHT) recorded that the risks around sexual exploitation remained and, following the incident at the unit, that there was a potential risk of Child Z trying to form inappropriate relationships with younger males.  Support staff at the placement were advised to manage her social media by her CSC1 social worker.   Child Z engaged with a plan that she could use her mobile phone for two hours per day in the communal area.  Staff at the placement were to do CSE work with Child Z and CSE1 were to provide resources and offer support and advice to staff if needed.    Days later, Child Z had attempted to commit suicide at a bridge.  She said she heard commanding voices telling her to jump and this was prevented when members of the public intervened.   Child Z was taken to hospital but as she stated that she had no plans to kill herself she was discharged.  The semi-independent accommodation then wanted to terminate Child Z's contract as they felt that her needs were too complex for their service.   However, they were persuaded by the hospital RAID (A&E mental health liaison) team not to terminate the placement.  The RAID worker expressed concern that Child Z had not yet been allocated within the CMHT and was being supported by the duty system. In a telephone call between the social worker and the adults transitional social worker, there was agreement that the CMHT were the best team to support Child Z.   Two weeks after the incident at the bridge, the placement reported to the social worker that Child Z had self harmed and was having inappropriate relationships with males that she did not know well.  Very soon after this, the police were contacted by Child Z who stated that she had been assaulted by a new partner (M5).  She later alleged that she was raped by him and another 31  male in his flat.  She continued to go to M5's flat after the alleged rape.  The incident was recorded by the police as domestic abuse and due to the severity of the crime the risk was deemed to be high.  Child Z was subsequently referred to a Multi-Agency Risk Assessment Conference (MARAC).   Following the incident, she was found at her mother’s home.  This was one of several instances where she was recorded as missing overnight from the placement.   It prompted a risk assessment to be completed on the risks of Child Z being at same property as her son.   On another occasion, she was with a friend, and was taken to A&E after drinking alcohol which reacted with her medication so that she became unconscious.   Child Z described having unprotected sex with multiple males, and CSC1 decided to undertake a Section 47 investigation (Child Protection). The investigation concluded that Child Z was at continuing risk of significant harm.  Due to her mental health difficulties and social vulnerabilities she was not able to show insight into her actions.  She had been further influenced by alcohol which, combined with the medication she was taking, could be fatal.  The report stated that when she reached the age of 18, Child Z would be homeless and reliant on non-intensive adult services.   The FN contacted CSC1 to express her concerns.   She found it difficult to understand how it could be that Child Z was still not a LAC.  CSC1 contacted housing advice to see if they could offer something similar to the placement as there seemed a probability that the placement would not be able to continue.  They asked that the CMHT explore their housing options as Child Z was almost an adult. Two days later, in late July 2018, Child Z had taken an overdose and was threatening to throw herself under moving traffic.  The ambulance service were assisted by the police to take her to hospital.  She had been with a number of other young people and was again missing from her placement. The police flagged the case as for adult protection even though she was still a child but did refer the case to CSC.  In August, the CMHT became concerned that when Child Z left the placement she would have little support. They had observed that Child Z did not take her medication and needed prompts and reminders or she would choose to go out and drink.  A CIN meeting discussed the risk of her becoming homeless when she turned 18.   Child Z’s auditory hallucinations had increased.  An application had been made for her for mental health supported adult homeless accommodation which could provide up to two visits a week, but it was felt that she required more support than this at that time.  Later MZ revealed that she had strongly challenged this plan as she felt that this provision would further expose her daughter to dangerous individuals.   32  The homeless accommodation suggested had no availability and the only option available was bed and breakfast accommodation when she turned 18.  Child Z was reported to be increasingly distressed by these plans. Child Z was unable to return to her mother's house due to the presence of CZ and his Children’s Guardian’s concerns over his safety if she was present.  It was concluded that she needed 24 hour supported accommodation with mental health support due to her vulnerability.    The CMHT continued to search for a supported accommodation place for Child Z and found a place becoming available in mental health supported accommodation locally.   This was dependent on the creation of a robust risk management plan and the CMHT organizing where Child Z could stay for a short, interim period to ease the transition. Child Z had told the social worker that she would be going missing in a few weeks because she had been offered a ‘lucrative opportunity’.   Three days before her birthday in late August, concerns were raised with police by care staff in relation to her relationship with a 25 year old male (M6) whom they believed was sexually exploiting her.   The same day there was a serious incident at the placement, where Child Z was intoxicated and threatening to commit suicide and had self-harmed.  She was taken to A&E.  Separate information was also received that Child Z had disclosed to a member of staff that she had had sex with a male she did not know. There were also reports that on the same night, Child Z ‘went upstairs’ with M6.  Child Z reported that he was procuring girls for other men. She described him as speaking to her in a racist and derogatory manner.   Her statements were reported to the police by staff at the placement.  A police officer attended Child Z’s address in early September 2018 and identified M6 as a sex offender who was on a tag for drugs offences and was suspected of human trafficking.   M6 knew where Child Z was living and had walked past looking into the property.   She later disclosed that she was offered alcohol and substances in exchange for inappropriate sexual acts.  It was agreed that it would be beneficial for Child Z to be moved sooner to her new placement and she should not make this man aware of her future whereabouts. The CMHT recorded that Child Z lacked capacity in regard to her sexual relationships.  When later asked about incidents of self-harm she stated that when her mood lowered the voices became more intense and they state derogatory remarks.  When she was asked whether the voices were asking her to harm herself recently she had said that they sometimes ask her to, but one is always positive.  Age 18  Child Z (hereafter Z as she was now an adult) exhibited extreme behaviour on her birthday and was detained by police in order to take her to hospital.  The adult mental health practitioner thought that a section was appropriate but was unable to obtain the necessary authorisation.   33  In the weeks after her 18th birthday Z continued to exhibit extremely high-risk behaviour and self-harmed on a number of occasions.  She was drinking heavily and had multiple partners.   The manager at her semi-independent placement felt that Z was becoming too high risk to remain at the accommodation. An attempt had been made to convene a strategy meeting to discuss incidents which had occurred prior to Z’s 18th birthday but the meeting did not happen.   It was agreed that Z would move into adult supported accommodation in early September 2018.   Two days before the move, Z was found by a member of the public in a distressed state.   She was taken to hospital and her friends informed the police that she had been raped.  During the initial investigation Z informed the police that she had not been raped.   Z was then referred to MARAC as a high-risk victim of M6.  Z changed her account twice and although, ultimately, she did allege that she had been raped, the police believed that they had evidence that undermined the prospect of any successful prosecution.  This included her phone communication with M6, and the previous reports of rape that Z had made to the police, this incident being the third one in 2018.  Age 18 in adult mental health supported accommodation Shortly after Z moved into the adult supported accommodation, she reported a further sexual assault by men associated with M6.  When, on one occasion, she refused to meet M6 she alleged that he threatened to kill her and her mother.  The police arrested M6 and told her about his drug trafficking.  They advised her that she could request to access M6's history and also seek a restraining order, if she wished.   Staff at the placement continued to be concerned about missing episodes and her failing to take medication while spending time with another boyfriend (M7) and with her mother.   At this point the timeline for the serious case review ended.   34  Analysis  Age 14 The review did not cover the period up to, and immediately following, the loss of Child Z’s father.  Later interventions failed to identify the significance of this event or the extent of any other trauma that she suffered before the age of 14.  The SCR panel considered the area of bereavement support and believed that timely interventions to support children suffering bereavement or loss require further development.   Professionals also need a clearer understanding of the pathways to these services.   For children, later problems often have a root in early loss and associated trauma.  Risk-taking is a normal part of adolescent development.  However, for young people whose lives have exposed them to risk factors such as traumatic loss and difficult relationships with parents, or where parental substance misuse or mental ill health is an issue, there is an increased chance that risk taking will become a safeguarding issue.11  Research highlights the complex nature of safeguarding adolescents who engage in risky behaviour.12 It was not until work undertaken with Child Z by the refuge, that it was understood that, with the loss of her father, Child Z had also lost her valued contact with his new family with whom she had previously been spending weekends.   This left her entirely reliant on her problematic relationships with her mother and brother.  An earlier exploration of the effect of this loss on Child Z’s lived experience was required.   Although Child Z’s bereavement occurred before the timeline for this review it seems, from what she has later said, that more effective bereavement counselling around that time might have lessened her trauma and altered the course of what became a mental health issue. The SCR panel further reflected on the importance of articulating and developing what is available for children who suffer loss and bereavement.  In some areas, there is access to services such as those provided by Gaddum13, a charity offering specialist bereavement counselling to parts of Greater Manchester but not available in LA1. It was acknowledged by the SCR panel that there is a need to develop further the services in LA1.   This would include the consideration of commissioning to improve the offer of services to promote early mental well being, such as Place 2 Be14 which is not currently available in schools in LA1.                                                          11  sscb.safeguardingsomerset.org.uk/wp-content/uploads/2016/06/CSE-Risk-taking-adolescents-and-child-protection.pdf 12 https://cycj.org.uk/wp-content/uploads/2017/02/Safeguarding-Adolescents-Camille-Warrington.pdf 13 https://www.gaddumcentre.co.uk/child-counselling-services/ 14 https://www.place2be.org.uk/what-we-do/where-we-work/where-we-work.aspx 35  At the time of the allegation of sexual assault at age 14 by M1, Child Z was not directly spoken to and afforded the opportunity to consider a complaint.  MZ’s voice was heard, but an opportunity for CSC1 to hear Child Z’s voice on a serious and traumatic incident directly was missed.  On reflection CSC1 thought that a strategy meeting with the police and health services should have been convened. CAMHS noted that Child Z's then boyfriend (M2 age 16) may have committed a sexual offence in the past.  MZ said that they were never left unsupervised and that she would contact CSC if she had any concerns.  This was the second highly unsuitable boyfriend, and MZ’s assertion to CAMHS that she could manage the situation, when it was clearly not within her control, was accepted without sufficient professional curiosity.  An opportunity to discuss the risks with CSC was missed. Age 15 up to the decision to assess During the period of her eating disorder and diagnosis of anorexia, Child Z had extensive CAMHS involvement.  She was receiving support from a dietician, and hospital admissions to stabilise her weight.  She also received counselling from a CAMHS care coordinator and, with different workers, she had CBT.   The involvement was successful to the extent that the risk posed by her anorexia was managed well, and this is no small matter as this was a critical risk to her life.  In interview, Child Z, when reflecting on her experiences, recalled some aspects of the service being more helpful than others.  She felt that the counselling had not given her the opportunity that she had wanted to talk about her problems.  Although the counsellor spent a lot of time with her, unfortunately a good therapeutic relationship did not evolve.  Because she found speaking at CAMHS review meetings in front of a number of professionals very daunting, she felt unable to contribute this view.  Child Z did feel that she benefitted from the CBT work.   CAMHS counselling did identify the father’s death and the assault that had happened at the age of fourteen as triggers but did not reach any clarity about the issues that had existed before these events.   The SCR panel considered the medical model15 of mental illness which treats mental disorders in the same way as a broken arm i.e. that there is thought to be a physical cause.  Symptoms are seen as outward signs of the inner physical disorder.  It is believed that if symptoms are grouped together and classified into a syndrome the true cause can be discovered and appropriate physical treatment administered.   There is a risk with this approach that social origins of conditions strongly associated with trauma and abuse might remain relatively unaddressed.                                                       15 https://www.simplypsychology.org/medical-model.html 36  In Child Z’s case the exploration of the social aspects of her presentation remained superficial, notwithstanding the later interventions of many services, including social work assessments.  Her context remains not fully understood. What is known about Child Z from her initial engagement with CAMHS services is that she experienced low mood and intermittent suicidal ideation.  She was largely isolated at home due to poor school attendance but had regular appointments and hospital inpatient stays.  Her mother did talk about the pressure she felt, and the CAMHS consultant informed the GP that the home situation was stressful and that MZ had little support in her own right and was feeling the pressure of being the sole carer for Child Z given her complex needs.  This was a missed opportunity for either CAMHS or the GP to pass on concerns to the Public Service Hub.  While it is unlikely to have met the threshold for social work allocation and assessment it should have resulted in signposting to relevant support services.    The severity and extent of Child Z’s presentation to CAMHS should have been sufficient to trigger a discussion, more broadly across services, about the context in which she was living, the pressures on her parent and the difficulties of her parent managing her behaviours safely.   The normal mechanism for seeking the involvement of CSC is by referral.  At the time the prevailing culture within LA1’s CSC and Public Service Hub was to maintain very high thresholds and this can be clearly seen in their response to later attempts to refer serious safeguarding concerns.   The SCR panel considered how circumstances, including thresholds, can create blocks to professional communication and limit the sharing of professional knowledge.  There was a consensus that professionals needed opportunities to come together to discuss complex and problematic situations.    What might have helped at an early stage of CAMHS involvement would have been the existence of an appropriate forum in which individual cases could be discussed so that any concerns about family context as a factor in children suffering from mental health issues associated with trauma, or families struggling to cope, could be explored.  This could have provided an early alert to problems which were much more serious when referred later.   The SCR panel were aware of examples of such consultation processes working in practice and noted that they can have the effect of lessening professional anxieties and supporting more effective management of high risk situations. In the early years of Child Z’s engagement with services there seems to have be a pervasive mindset that her problems were purely a mental health or behavioural issue.  When CSC1 was contacted in January 2016 by the hospital via the Public Service Hub it received and 37  logged the information, but the reason that the hospital saw it as a CSC issue was not explored.    CSC1 took reassurance from a belief that the issue was ‘mental health’ and was covered by the involvement of CAMHS.  They saw this as negating a role for social work.  This was a missed opportunity to assess and identify the underlying family issues and consider what support might assist. Child Z’s mother was an interested but struggling parent who needed support and was out of her depth with her daughter’s increasingly extreme presentation.  She did take up support from Healthy Minds when she was signposted to it.   She may well have benefitted from earlier advice and support on managing her relationship with Child Z.    There is research evidence16 of a genetic link with anorexia but many sufferers have also experienced difficult family circumstances, and early trauma or abuse.  It is likely that the roots of Child Z’s mental health issues will not be known.  Work with the family on improving the family dynamics in the early years might have reduced the likelihood of her anorexia and anxiety transforming into emerging borderline personality disorder (BPD)17. Some recent research indicates that new insights into the disorder, leading to new, more effective treatments, may make the prognosis for someone with BPD more promising18. With the right support, some professionals believe that most people with BPD can learn to regulate their overwhelming emotions, stop self-destructive behaviour and improve their lives.   Symptoms often become prominent in adolescence, or even earlier.  It is thought by some professionals that treating BPD as early as possible might lead to better long-term outcomes, as well as lowering the risk of dangerous or suicidal behaviour. In mid April 2016 Child Z was discharged from hospital after a Paracetamol overdose and the issue of her mother’s concern that she was being groomed by an adult male was discussed with CAMHS.  MZ’s confidence that she would be able to protect was taken at face value and there was a missed opportunity to escalate the concerns about grooming to CSC1.   A referral was made in late April 2016 to the LA1’s Public Service Hub by the school who were concerned about Child Z’s suicidal ideation and self-harming.  There were concerns about parental alcohol misuse and that Child Z was being groomed.  The Hub logged the information and referred Child Z to the sexual health service.  CSC1 acknowledge that this response was insufficient.  The case needed to progress to a social work assessment.  Again Child Z was not spoken to.   Her lived experience was neither explored nor understood.    CSC1 have acknowledged that there was a prevailing culture at that time in which extremely high and inconsistent thresholds had to be met to access social work services.  This was                                                       16 https://www.ncbi.nlm.nih.gov/pubmed/23999524 17 https://www.nhs.uk/conditions/borderline-personality-disorder/symptoms/ 18 https://childmind.org/article/borderline-personality-disorder/ 38  reflected by Ofsted in their 2016 inadequate judgement.  Since that time there has been a significant increase in the resourcing of the social work service, and improvements in processes and pathways.  However, health partners, in particular, believe that although there have been improvements, there continue to be challenges in meeting thresholds.   This was triangulated by contributions to the review through the practice learning event, practitioner interviews and contributions by SCR panel members.  In fact, the thresholds are the agreed thresholds of the safeguarding partnership in LA1.  The effective use of the threshold requires each agency to understand them, and to explicitly use them in referrals to CSC1.  If this is done CSC1 is responsible for agreeing or disagreeing and this decision can be challenged through the appropriate escalation processes. Currently these escalation processes are poorly understood and infrequently used. The school nursing service continued to engage with Child Z in a way that she recalls as extremely helpful.  She developed a trusting relationship with them and was consequently able to share her thoughts with them.  They proactively passed on what they knew of her distress and her difficult home situation and communicated well with CAMHS.   In mid May 2016 MZ made a phone call to CAMHS as her daughter was hearing voices and expressing thoughts of wanting to jump in front of train.  CAMHS spoke to MZ and it was agreed that she could supervise appropriately at home.  Given the previous suicide attempt, the risks of relying on MZ’s un-assessed capacity to manage seem to have been unacceptably high.  Child Z was admitted to hospital on several occasions after self-presenting at A&E.  She reported that she felt safe in hospital.   On one occasion she was admitted after reporting that she had been coughing up blood, but no blood was ever observed by health professionals.  In interview, MZ said that her daughter had often enjoyed the experience of being in hospital.  The SCR panel thought it likely that her repeated presentation with health issues was, at least in part, a cry for help.  She used hospital as a safe haven where she could experience a high level of attention and would have a sense of being cared for.   When, in late May 2016, Child Z had run away from home and was admitted to hospital with suicidal ideation, the hospital again referred the case to CSC1.  The referral identified a high level of risk and a family environment in which Child Z could not be kept safe.  An opportunity had already been missed by CSC1 when they declined to attend a multi-agency partners meeting to discuss how to meet Child Z’s needs.  A decision had already been made to refer the case to LA1’s Early Help.  The multi-agency meeting would have been a ready forum to test the appropriateness of only following that pathway and to ensure that there was a full understanding of the case by the professionals involved.   The meeting clarified the issues and risks and was able to present them again in a forceful enough manner to prompt allocation for social work assessment. The hospital’s persistence in pursuing the issues was a good example of appropriate professional challenge and did result in the case being passed on for social work assessment by CSC1.   39  Age 15 during the assessment  When Child Z told CAMHS that she felt she had benefitted from time away from her mother, she was pointing to her home circumstances as a significant aspect of her hospital presentation.   Throughout the period of the assessment, Child Z suffered a number of unexplained collapses and was admitted to hospital repeatedly.   The suggestion that the cause was functional19 is credible, given the considerable stress evident in Child Z’s relationships.  The collapses continued to be a feature of later acutely stressful periods in her life such as homelessness in LA2.    During the assessment period Child Z became involved with M3 online.  MZ’s response, in accompanying her to visit him, gives insight into her difficulties in managing  her daughter’s behaviour and the difficulties in their relationship.  Her instinct was to protect, but facilitating the relationship increased the risk, and indeed this relationship led to the conception of CZ. Child Z was receiving support and advice on contraception from the sexual health service.  She later reflected that the approach of the service meant that she could speak to the practitioner there about anything, not just sexual health.   She reported that she found that very helpful.   Notwithstanding this, she resisted long term contraception.    She may have wished to fill an emotional void in her life by having a baby.    Unfortunately, the CSC1 social work assessment lacked sufficient regard to Child Z’s home circumstances.  It relied heavily on self report from her mother.  Concerns about her mother’s capacity to protect Child Z from her impulsive and self-destructive behaviours were known, but not addressed.   There was insufficient consideration of whether Child Z was beyond parental control or suffering neglect or emotional abuse.  MZ was concerned that her daughter was putting herself at risk online.  This was not seen as an issue for work by the CSC1 social work team but something that required the input of the CSE1 team, but a referral to CSE1 had been declined.   The social work service had perceived that there was a child protection risk.  They thought that the sexual exploitation threshold had been met.  The fact that the CSE1 team decided that the threshold was not met meant that the social work team’s response needed to sufficiently deal with the outstanding risks.   The potential for CSC1 to deliver a service beyond referring on to others was not considered.  The potential of social work to impact on Child Z’s lived experience was not understood or realised.                                                         19 https://jnnp.bmj.com/content/76/3/307 40  It is perhaps worthy of note that at the time, had CSE1 accepted the referral, they would have become responsible for all aspects of the management of the case, something which would have weighed heavily on a small and specialist resource.  This was subsequently recognised as an inappropriate system and the system now ensures that the lead remains with the social work team supported by specialist input by CSE1.   Further developments since this time focus on contextual safeguarding20 and a broader understanding of risks that arise outside of the family environment and require more sophisticated responses to the issue of place.  CSE1 is being reviewed currently in the light of these developments. The CSE1 threshold issue aside, Child Z still needed protection from sexual exploitation and to be in a safe home with her needs appropriately met.   At the time CSC1 were under considerable pressure, in terms of both low levels of experience in the workforce, and high workloads.  The social worker was recently qualified, and was operating in a system where moving to rapid case closure wherever possible was a priority.   There was a sense that the application of the threshold was about resisting and redirecting rather than identifying cases which needed to be worked with.  In a system under as much pressure as this one was at the time, managers responded from a workload management perspective rather than from an ethical application of threshold based on children’s needs.  Ofsted found this to be a problematic area in December 201621. The social worker was directed by the manager to close the case after a referral to Early Help had been made.  On later reflection the social worker thought that it would have been better to spend more time with Child Z to get to know her.  If this had been done more about her lived experience may have been shared.                                                        20 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf 21 Ofsted ‘For some children poor application of thresholds resulted in: multiple repeat contacts to CSC, children receiving services at the wrong level of need, allegations of abuse that were not investigated in accordance with statutory guidance, and children at risk of CSE receiving services that were not informed by appropriate assessments of need.  As a result the risk to these children was not adequately identified, responded to or reduces, and some remained at risk of significant harm for too long before effective action was taken.  Senior leaders’ initial responses to concerns raised by inspectors in individual cases did not demonstrate an understanding of the detrimental impact on children of poor practice and thresholds for intervention that are too high.’  41  Age 16 after case closure When, shortly after case closure, YOUthink contacted the CSC1 manager, it is clear that YOUthink were uncomfortable in leading the response in such a high-risk case, and thought that the matter should come under the lead of CSC1.  There had been no significant change in Child Z’s situation, so the challenge by YOUthink was appropriate and rather than a suggestion to re-refer, it should have prompted a reconsideration of the decision to close the case.    The challenge from the CAMHS psychiatrist to CSC1 was appropriate and clear.  It identified the risks to Child Z that could not be managed or treated by the intervention of mental health services.   It was a good example of how to formulate a challenge by putting the issues clearly in writing.  The response from the social worker did not properly address the concerns raised.  It demonstrated that the social worker had not reconsidered the safeguarding risks in the light of the challenge.   The psychiatrist, relatively new to the role at the time, later reflected that the response to their challenge should have prompted a further escalation to senior management or directorate level and has done this in similar circumstances since.   Child Z then moved from having active mental health service involvement to a period where she was thought not to need transitional services, due to the short-term improvement in her mental health, so the issue of transitional mental health services did not arise.  Age 16 to leaving home There was a further missed opportunity for CSC1 to consider the sufficiency of their earlier response and to undertake further assessment when the re-referrals arrived at the LA1’s Public Service Hub.  This was not done.  Instead, a referral was made by the Hub to LA1’s Early Help.  On allocation, the Early Help worker was not given all the information they needed as they were not informed what the referrer had wanted to be done.  This practice has since changed and the agreed recommendations are now transferred on case allocation.  There were delays in the FIW meeting the family and then in coming to an understanding of the case.  Despite concerns by professionals, delays continued and the case was passed to a new worker without an adequate transfer.  There was a missed opportunity to build on the work already undertaken by CAMHS who had been leading the CAF process, rather than starting a new CAF.  This meant that no meaningful intervention had been done by the time that the FNP, which would offer much more intensive support, became involved.   There was no role for Early Help.   We learnt through the practitioner event that practice standards for Early Help now require much tighter timescales in contacting and visiting families so the delays which were manifest in this case should not occur today. 42  CAMHS are currently commissioned to work with children under 16, so their work with Child Z was due to finish.  Mental health services beyond 16 require referral to adult mental health services and in this case the pregnancy had resulted in an improvement in Child Z’s mood and behaviour.  She was happy to be pregnant and would have benefitted from the hormonal effects of early pregnancy.  Her anorexia became less of a feature of her presentation.   However, the CAMHS psychiatrist warned that there was a high chance of a mental health relapse after the pregnancy.   CAMHS recognise that the service ending at 16 is far from ideal, and indeed did continue until a few weeks after Child Z’s 16th birthday.  In reality, even if the improvement due to pregnancy had not happened, they would have had to discharge Child Z and refer to adult mental health.   Local CAMHS practitioners would like to extend their remit to beyond 16 and there is a national and Greater Manchester drive to do this.   The relapse anticipated by the CAMHS psychiatrist happened later in the pregnancy and intensified after the birth.  Child Z’s situation may have been made worse by the presence of M4 in the home with his own mental health issues, and controlling and abusive behaviours.  The FN, who had been positive about MZ’s support initially, began to see some of her behaviour, and that of BZ, as controlling too.  There was an inevitable breakdown of these volatile living arrangements. We leant from Child Z later that, even when they were living in the same household, she felt pushed by M4 not to talk to her mother without him being present.  Ultimately, when the altercation occurred, he demanded that she make a choice between him and her mother.  Age 16 and no permanent home There is evidence of good mediation, on two occasions, by the CSC2 OOH social worker, between MZ and her daughter in order to prevent a further deterioration of the home situation.  MZ, when interviewed, commented that this had been really helpful. It was also good practice that the FN remained with the case despite Child Z and her son being temporarily out of the area where the FN was based in LA1.  This saw both mother and child having a level of consistency of service.  The FN was therefore able to build up, over time, significant knowledge of the issues and risks relating to both children.  However, there is some evidence that the social workers and managers did not fully understand the role of the FNP and regarded its work as just with the baby.  The FN’s challenges of both local authorities’ plans at different times were dismissed partially on the grounds that Child Z was not within the FN’s area of responsibility.  As a professional with considerable knowledge of the family she had a valuable contribution to make, and Child Z’s welfare fell within her remit which was to support both mothers and the babies.  Both CSC departments may wish to engage with the FNP to ensure that their managers and social workers understand the FNP model.   43  At the time when Child Z presented as homeless in LA2, a social work assessment had just been opened for her by CSC1, but instead of considering this temporary situation as part of their assessment, they presented it as a permanent move and CSC2’s responsibility to respond to.  CSC1 closed the case and told CSC2 that they had no involvement. Section 12 of the Greater Manchester Safeguarding Protocol22 dealt with cross boundary referrals.  The protocol invited consideration of what was in the best interests of the child.  It seems unlikely that if this had been considered, CSC2 would have taken responsibility from an adjoining authority who already had knowledge of the child and family.  In this case, in the first instance, Child Z and her son were children from LA1 presenting as children in need in LA2.  The person with parental responsibility for Child Z was resident in LA1.  The protocol, now updated in 201823, but along broadly similar lines on case transfer, allows for an assessment to be done by the local authority where the child presents as in need, but the overriding consideration should be the welfare of the child.  As the move had been to an adjoining local authority, distance was not a bar to CSC1 continuing to be involved.  Child Z’s housing in LA2 was known, from the initial referral, to be temporary and unstable.  Child Z was already known to LA1, indeed a decision had already been made to undertake an assessment.  There was no welfare basis for CSC1 to seek a transfer at this point.  In fact, the protocol specifically cautions that consideration must be given to the possibility that the move to the new area could increase any previously identified risks, or introduce new ones.  CSC2 responded to the referral to Child Z and her son as children in need in their area.  There was insufficient challenge of what was clearly a temporary and unstable situation being passed on by an adjoining local authority.  In accepting the referral, CSC2 began a process which did not appropriately address Child Z’s needs.  The opportunity to transfer brought the assessment in LA1 to an abrupt close on the grounds that she was now a resident of LA2.  This was done without a full understanding of the circumstances, and without informing relevant professionals.   From the perspective of CSC2, a complicating factor was that Child Z, M4 and CZ appeared to CSC2 to be in a ‘sibling group’ and then a ‘family group’ with M4 as the partner of Child Z.  Initially it was thought that he was the father of CZ.  M4 was a long-term resident of LA2, as                                                       22 The Greater Manchester Safeguarding Protocol, applicable in 2016, stated that ‘if the referral relates to a child who is temporarily visiting the area of another LA or is in a hospital or looked after outside of the local area, the LA/police for the area where the child actually is at the time have prime responsibility for the initial response to the referral.  Before undertaking enquiries (into any immediate protective action necessary) the child’s home authority must be consulted, and agreement sought on who is best placed to undertake the enquires.  Where this is consistent with the child’s immediate protection needs it may be agreed that the child’s home authority will respond to the referral.’   23 https://greatermanchesterscb.proceduresonline.com/pdfs/nw_proto_moving_la_boundaries.pdf 44  were his parents.   This notwithstanding, insufficient regard to the protocol meant that they too readily assumed full responsibility for all three children, allocating the same social worker to Child Z and her son and a different social worker to M4.  The motivation was to respond to them as children in need presenting in their area but the effect of treating them collectively as a ‘family’ was to not address their individual needs as children.   Child Z and M4 were responded to as adult parents of CZ.  If Child Z’s needs had been in focus, it would have become apparent that she was a child with extensive needs and vulnerabilities requiring her own robust plan.  Her mental ill health combined in potentially destructive ways with the mental ill health of M4, and there were allegations of violence by M4.  His controlling behaviours were already evident in the relationship.    As children, neither M4 nor Child Z were old enough to apply for a tenancy and this point should have highlighted the problems with treating them as an adult couple.  They were too young to be considered financially responsible as well as too immature to take on adult responsibilities. Child Z saw herself as having no good choices.  She had a difficult relationship with her mother and an abusive relationship with M4.  There is considerable misunderstanding among professionals about what constitutes the ‘child’s voice’.  It is often only recorded as what the child has said but it should also be a description and analysis of what it is like for the child to live each day.  Without a professional understanding of this, it is impossible to appropriately develop an effective plan for a child. While Child Z said that she wanted eventually to live with M4, this needed to be understood within the context of her lived experience.  She was in a coercively controlling, sexually, violently and emotionally abusive relationship with someone who was himself mentally unwell.   Her safety, and that of her son, were compromised by this. Quite quickly after returning to MZ’s house, Child Z had contacted M3.  This may have been a search for another relationship at a time where she needed alternative options.   A week later she was back spending long periods of time with M4, and told her son’s child protection conference chair that she felt she had no choice but to go and live with M4.  The focus of the conference was her child and Child Z’s safeguarding needs were not addressed.  It is acknowledged by CSC2 that she was responded to as though she was an adult parent.   Child Z rejected offers of formal accommodation by LA2, but this was in the context of it being put forward as in her son’s best interests in a legal meeting in relation to her son, and while Child Z’s mental health and instability was affecting her ability to prioritise him. LA2 have expressed a view through this process, that actions were sufficiently taken to discharge their responsibilities under section 17 of the Children Act, but recognised a need to accommodate.  Child Z was prepared to be placed by LA2 as was seen when she cooperated with the move to the refuge.  The implication of Section 20 (3) of the Children 45  Act 198924 and subsequent case law25 could be seen to be that placing a child who was otherwise homeless, might have had the effect of accommodating her.  There was multi-agency agreement that Child Z be placed in the refuge and she was taken there, with her son, by her social worker.  LA2 may wish to explore further whether this therefore constituted accommodation.   Age 16 and living in the refuge When the FN’s representations to CSC2 that both Child Z and her son should be LAC were not acted on, the refuge represented an option that the FN could access.  In a Mother and Baby Unit, greater monitoring of her movements would have been possible.  The higher levels of staffing and different approach would have come closer to fulfilling some of Child Z needs than a refuge could.  Another approach could have been to voluntarily accommodate Child Z and place her and her son in a foster placement.  The success of this would have depended on the skills of the foster carer to engage with her.   The plans that were put in place also took too little account of how unstable and dysfunctional Child Z’s relationship with M4 was.  While M4 was still living with his parents he lived close to the relative against whom Child Z had made an allegation.  This was not a safe area for her to visit.  When M4 got his own property, the social worker agreed to Child Z’s stated wishes that she spend weekends with him there with her son with the ultimate plan of her moving in with him when she was 18.   This may have been Child Z’s stated wish, but it was high risk for both her and for her son because of M4’s instability and violent and abusive behaviour.    The refuge and the FN rightly queried whether Child Z should be on a child protection plan and have her own social worker.  The response that she had a CSE2 social worker did not recognise that the CSE2 social worker was not in overall charge of her plan and that there was a clear conflict of interest in one social worker being allocated to for both Child Z and her son.  CSC2 have subsequently accepted that Child Z needed to have had her own social worker and her own plan.  CSC2 have confirmed that their process today would ensure separate allocations and plans in similar circumstances.    While it offered her a break from the situation at home, the refuge was ill equipped to meet Child Z’s high level of needs and was not the most appropriate placement.  Notwithstanding this, the practice of the refuge in working with Child Z and in alerting CSC2 to the risks with clarity and insight was outstanding.   Given that Child Z’s placement in the refuge was on the basis of the risks presented by MZ and BZ, it seemed somewhat contradictory to the refuge staff that CSC2 later were arranging                                                       24 http://www.legislation.gov.uk/ukpga/1989/41 25 R (G) v Southwark [2009] UKHL 26  46  long periods of time for her and her son at home, both when she was recuperating from an appendix operation, and at Christmas.    It is unclear whether a proper assessment of the risks was ever done to support such a decision.  In the event, the decision had a major impact for Child Z as this was ultimately where she went when her behaviour deteriorated to the extent that she was asked to leave the refuge.  A downward spiral in her mental health now began which would ultimately lead to a mental health section.  Had CSC2 undertaken a thorough assessment it should have been possible for them to have gained an understanding that a return home was not in Child Z’s best interests. The refuge had provided a coherent analysis of the risks presented by M4 and by MZ and BZ.  CSC2, on reflection, acknowledge that the depth and analysis of the case history and the exploration of known risks was not sufficient.   Child Z continued to attend A&E regularly both in respect of her health and that of her son.  It is recognised by the hospital that an opportunity was missed to continue to refer concerns about the frequency and nature of Child Z’s presentations and what that was telling professionals about her lived experience.  The FN and the refuge noted a deterioration in Child Z’s mental health at this time.  The FN remembers her becoming almost mute.  The social worker’s response to her concerns was that the decision for Child Z to spend time with MZ was pragmatic.  A pragmatic decision needed to take into account the risks involved to Child Z’s mental health.   Following the GP’s concerns about Child Z’s deteriorating mental health, a letter was sent to her offering an assessment appointment with the CMHT.  Child Z missed this appointment, and a subsequent one, and the referral was then closed.  Child Z was now in an adult’s process where she was responsible for choosing whether to engage with the mental health service.  Child Z demonstrated, over time, a profound need to elicit care.   This manifested in multiple ways.  Her anorexia had elicited care from CAMHS and involved regular hospital visits and admissions.  She also had many A&E visits, including later taking her son to A&E.  She had a series of boyfriends who she became very involved with while often knowing little about them.  She did not use contraception and became pregnant with CZ in order to have someone to love her.  She sought to become pregnant again, despite her difficulties in coping with the care of her son and again following her miscarriage.  MZ said that after the birth of her grandson she recognised, in her daughter, signs of the post natal depression that she herself had experienced as a mother. She needed support for herself to help her daughter, but experienced that support as very limited.   As her daughter engaged with CAMHs, the sexual health service and other 47  supports such as the FNP, she felt an increasing sense of disempowerment as a parent.  She felt excluded from being able to know about, and influence, her daughter’s choices.   Once CZ was born, she saw Child Z as being treated as the adult responsible for him and was no longer afforded the status of a child herself.   She recalled challenging this with the CSC2 social worker and FN but remembers the response as being, that in respect to her son, Child Z was the ‘adult’.   Age 17 at home The FN noted no hostility to CZ, but Child Z was mostly focused on her own issues and uninterested in engaging with him. The CSC2 social worker’s view that CZ was safe and well and that Child Z was interacting with him, perhaps represented an overoptimistic view, that fitted with the plans already made that this was a suitable arrangement, notwithstanding the concerns of the FN and the refuge.    The reason for such opposing views may be that the social worker relied on MZ’s account of Child Z’s interaction with her son and the family situation.  At this point Child Z was in rapid decline and the arrangement with her mother was about to break down.  Child Z almost literally had no voice and could not influence events.  The CSC2 social worker’s recording that Child Z would not be returning to LA2 was an indication that the issue of whether the case should transfer was the priority.  The focus on Child Z’s presentation and needs had, to an extent, been lost as the plan developed.   Age 17 in the adolescent psychiatric unit When the crisis occurred it was the good practice of the CSC2’s OOH social worker which ensured that Child Z was taken to hospital.   The intention of the police officer to return Child Z to her mother’s home would have left a situation of risk that MZ knew she could not manage.   While Child Z was in hospital, plans went ahead for the transfer of her son’s case in accordance with the proceedings protocol.  Child Z had left her son with her mother in LA1 when she went into hospital.   CSC1 accepted that they would take responsibility for CZ once proceedings had commenced for him.   A separate transfer request was made by CSC2 for Child Z while she was in hospital. While the original acceptance of case responsibility by CSC2 may have, over time, been seen by them as an error, the passage of time and the delivery of services had seen Child Z accepted as a LA2 child and without a viable LA1 address following an assessment that her son was at risk if living with her.  The ultimate outcome was that CSC1 took over Child Z’s case four months before her eighteenth birthday and while she was still a secure inpatient with no address planned for discharge.    48  At this point, far more was known about Child Z’s circumstances by CSC2 and she had started to develop a significant professional relationship with her CSE2 social worker.   A transfer was clearly not in Child Z’s interests and it left her without a satisfactory plan to meet her needs and in close proximity to her discharge and 18th birthday, where children’s services would end.  Child Z was recorded by a CSC1 social worker to have stated that she was happy for her case to be managed at CIN level.  It seems unlikely that this was an informed decision and that she was given a full picture of the implications of this for her future.  On later reviewing what had happened, CSC1 found that there was no evidence that the Southwark protocol26 was followed with regards to a detailed discussion of the options, and there had been no exploration of whether Child Z had the capacity to make that decision.   They further found a lack of compliance with their own CIN processes and that the manager who attended the meeting at the hospital referred to Child Z needing to be made LAC because of her level of vulnerability.  A placement request form was completed and sent to the children’s placement team.  This would only have been done if the intention was to accommodate Child Z under section 20 of the Children Act 1989. While initially Child Z’s behaviour settled down in the psychiatric unit, it was not a long term solution to her problems.   The decision to discharge her when her behaviour worsened and she began to pose a risk to staff and other patients was, in itself, not unreasonable.  However, the psychiatrist’s view, shared in the multi-agency meeting, was that Child Z did not need mental health supported accommodation on discharge.   He said that he believed that her mental health needs could be met through having support from the home treatment team in place upon discharge, with two weekly care coordinator visits, weekly therapy and four to six weekly psychiatry appointments.   The psychiatrist recommended CBT or interpersonal therapy.     The effect of this opinion was that Child Z would not be eligible for mental health supported accommodation.   The only options available would not have the expertise to deal with her difficult behaviours.    The work with her that Child Z needed to enable her to be safe outside a secure hospital setting proved to be significantly understated and the psychiatrist’s opinion was one of the reasons that the multi-agency plans were insufficient to avert further crises.  The psychiatrist had been led to understand, by the CSC1 manager, that Child Z would be accommodated by them.  He believed that safeguarding, particularly around CSE work was to be undertaken by the local authority.   This may have influenced his view of the mental health input she would need on discharge.  She could not stay in the unit.  Although CSC1 then accepted case responsibility they had no appropriate provision for her.                                                        26 https://southwark.proceduresonline.com/chapters/pr_mgmt_yp_homeless.html 49  SCR panel members discussed what options are available for young people like Child Z, as a further section was not appropriate at this juncture.  The local authority could have sought to use secure detention under section 25 of the Children Act 1989, but this would have been inappropriate as these secure placements are not therapeutic, and do not differentiate between welfare and criminal placements.   The authority could have asked the courts to consider the use of inherent jurisdiction, which would have invited court scrutiny of the developing situation.   This route would have placed considerable pressure on all involved to find the best solution to the problem.  The local authority did not explore this possibility.      As Child Z approached 18 the local authority’s legal options were rapidly running out.   The suggestion by a CSC1 social work manager that Child Z return home on discharge could only be made to MZ on the basis of a lack of understanding of the history, and in particular the recent history, of the case.  Earlier statements that Child Z would be accommodated were then set aside and a solution for the next ten weeks was to be sought.  It is difficult to see how this could be seen as an appropriate or sufficient discharge of the responsibilities of the local authority in ensuring that Child Z’s needs were appropriately met.  As she was not accommodated under Section 20 she would have no entitlement to leaving care services or oversight of her transition to adulthood.  The focus was on ending involvement and passing on responsibility, rather than any integrated planning.  Had she been a LAC she would have had additional protections as she approached her 18th birthday.  She would have had a plan which was overseen by an IRO with the potential to escalate any issues of concern.   The FN’s challenge of CSC1 at this point, about their having not made Child Z a LAC, was the last of a number of attempts by professionals to influence planning by CSC in both authorities.  The Greater Manchester Safeguarding Children’s Board Procedures, chapter 3.5, contains the Resolving Professional Disagreements/Escalation Policy27.  This was the subject of amendment in June 2018, but at the time still offered advice to professionals on a problem solving approach to be adopted by those who were challenging, and by those who were being challenged.  It also contains a mechanism for ultimately obtaining a resolution in all cases. It is critical that professionals fully understand the policy and are clear when they are invoking it in professional discussion and in writing.  In this case, concerns were not resolved nor were solutions found.  Challenges were, in effect, dismissed.  Professionals became increasingly frustrated with each other and professional trust and confidence were undermined.                                                         27 https://greatermanchesterscb.proceduresonline.com/chapters/p_resolv_prof_dis.html 50  Many issues will be resolved without recourse to any formal procedure, but where dissatisfaction or unease remains, it is important to follow a formal structure so that professionals cannot get into a routine of just dismissing challenge with little thought. The SCR panel considered the sufficiency of support to social work staff on the issue of respectful challenge.   A particular focus needs to be on how to invite, receive and respond to challenge in order to improve practice.  Training is ongoing on this and over 300 CSC1 staff have participated already.  A further opportunity to deliver might be to embed it within existing training on the Family Model in LA2 and Signs of Safety in both local authorities.   Child Z was found a place in an unregulated semi-independent placement which was ill equipped to meet her needs.  This arrangement therefore left the plans for Child Z without the scrutiny of an IRO and without the provision of LAC planning.   CSC1 have acknowledged that this was unacceptable, and that Child Z should have been afforded the status of a LAC.   The situation had become more difficult to address due to the passage of time, during which LA1 not reached firm ground on the legal basis of its, necessarily intrusive, engagement with Child Z.  It did not address its lack of parental responsibility and its lack of delegated authority.    The Mental Capacity Act 200528 offered no solution for Child Z.  Whether she had capacity was addressed by her hospital psychiatrist who thought that she did, although acknowledging no significant legal authority on the matter.  The application of the Mental Capacity Act also offered no practical advantage in terms of influencing a more positive outcome as it does not seem to provide any further protections for her specific vulnerabilities.   The evidence that further detention in a secure hospital would not have assisted was perhaps that, after an initial period in a psychiatric ward in hospital, Child Z became increasingly oppositional, disinhibited and destructive, harming herself and others.   She acknowledged, when interviewed, making a choice in her behaviour at that time. What might have helped, at this point, would have been a multi-agency comprehensive and intensive package of community-based support, including community mental health services, social care and services to address her vulnerability and sexual exploitation.  The offer would have had to be far greater than that offered by the CMHT alone as it would have had to replace and supplant the time and attention of those minded to exploit her.  It would also have needed to be sufficient to address her profound need to elicit care.  Age 17 and living in unregulated semi-independent accommodation Unregulated accommodation is not regulated by Ofsted but can be the right choice for some children approaching adulthood.   The behaviour that Child Z had displayed in the psychiatric                                                       28 http://www.legislation.gov.uk/ukpga/2005/9/contents 51  unit made it highly predictable that her risky and impulsive behaviours would continue.  Child Z was still a child and it should have been clear that CMHT support alone would be insufficient to safeguard her from these risks.   CSC1 have since identified that at the time, where Child Z was placed did not meet the criteria for approval by the local authority, and that the staff did not have the skills to manage a young person with such complex needs.  Her transition was not managed in accordance with her best interests. The unsuitability of the placement for Child Z was emphasised when the staff raised concerns with CSC1 that they could not meet her needs and had to be persuaded by RAID not to terminate her contract.   During her time at the semi-independent accommodation, Child Z was being actively and regularly exploited.   The CSE1 team’s reluctance to work with Child Z directly was a missed opportunity as her vulnerability to exploitation had clearly been one of her highest risks.  There was a four-month opportunity for them to undertake intensive support in hospital and after discharge.  Their offer to advise the placement provider was an insufficient response to her needs.  The other option which should have been considered was that of CSC1 contracting in the support of the CSE2 social worker, with whom she already had a very good relationship.    The CSC1 social worker who made the decision for the support staff to control Child Z’s access to social media did it because of a wish to reduce the risks that she would expose herself to, but because of the local authority’s decision not to formally accommodate, had no delegated parental authority or legal basis to do this.    Decisions for Child Z were crisis led rather than being led by best interest planning.  Had she been a LAC there would have been a requirement to undertake transition planning.  This did not occur. There were a series of very worrying encounters with a number of males over a short period of time.  One of these encounters led to an initial complaint by Child Z of a serious assault by two males, but she later refused to support an investigation as she continued in a relationship with one of the males, and the police were unable to take this any further.  The police responded appropriately, and correctly referred her to MARAC and the Integrated Sexual Health Services (SARC) who responded appropriately.  They identified Child Z’s wish not to use contraception.  This pointed to her wanting another baby as one aspect of her inappropriate behaviour. The outcome of the MARAC was that Child Z was thought to need specialist housing provision.  CSC1 appropriately convened a strategy meeting to consider the child protection risks arising from Child Z’s vulnerability, and undertook a child protection investigation.  The investigation found that Child Z was at continuing risk of significant harm and was not able 52  to show any insight into her actions.  It identified that her actions were further influenced by alcohol which could be fatal if combined with the medication she was taking.    Despite having a good understanding of Child Z’s behaviour and the risks to her, CSC1 continued to pursue the option of homeless accommodation.  Their options were very limited as some placement providers would be unlikely to accept her because of her risk-taking behaviour.  A decision was made by CSC1 to continue to fund the current placement beyond her 18th birthday.  They understood it to be unsuitable but had not found a better option.  After further very serious high-risk incidents, including one resulting her being detained under police powers on her 18th birthday, it was positive for Z that the CMHT located much more appropriate mental health supported accommodation.    Age 18 and living in adult mental health supported accommodation Z has said that she feels that this was the right place for her to go and a place where she has felt safer.  This notwithstanding, her life continued to be very difficult. CSC1’s decision that Z will now receive services as a care leaver will be a significant and much needed additional support into early adulthood.  CSC1’s response to their own analysis that Z should have been made a LAC and the actions that they have subsequently taken have been extremely positive for Z.    53  Recommendations The SCR panel makes the following recommendations to the LA1 Local Safeguarding Children’s Partnership. Recommendation 1 CSC1 should urgently consider negotiating with LA2 in order that they might provide a CSE2 social worker to resume work with Z in accordance with her wishes. Recommendation 2 CAMHS commissioners for LA1 should consider the appropriateness and sufficiency of their current offer which sees 16 to 18 year old children directed to adult mental health services which treat them as adults. Recommendation 3 The LSCP for LA1 should consider commissioning a mapping exercise to identify the appropriateness and sufficiency of services available to children and young people who have suffered bereavement, loss and trauma. Recommendation 4 All children who themselves have children should have their own social worker and their own separate plan for the avoidance of conflicts of interest. Recommendation 5 Where the child of a child is made the subject of child protection plan, there should always be formal consideration as to whether or not the child parent should also be the subject of their own child protection plan.   A decision that they do not require their own plan should be signed off at a level above that of team manager/team leader. Recommendation 6 The use of the Greater Manchester Resolving Professional Disagreements/Escalation Policy should be widely publicised to increase awareness of its potential to help resolution and agreement.  Professional challenge is part of a healthy system.  Recommendation 7 CSC1 should consider the development of regular forums to create routine opportunities for the sharing of professional expertise in relation to health and safeguarding cases. Recommendation 8 All CSC decisions on case transfer should be made by a manager who has an understanding of the proper use of the appropriate case transfer protocol.  All transfer requests should be based upon the child’s best interests.   54  Recommendation 9 CAMHS should consider, on a case by case basis, how vulnerable children might best be enabled to participate in discussions about them, taking care not to assume that they are necessarily comfortable to speak in front of professionals in groups.    