Intrafamilial sexual abuse and neglect of four girls in an extended family over a number of years. Learning focuses on: identification of intrafamilial child sexual abuse; harmful sexual behaviours and siblings; intrafamilial sexual abuse by women; enabling children to talk about child sexual abuse and responding appropriately; understanding help seeking behaviour; the sexual abuse of disabled children; recognising the importance of safe adults and the non-abusive parent and family; understanding the motivations and behaviours of adults who pose a sexual risk to children; responding to adult disclosures of sexual abuse in childhood; responding to the needs of parents with learning disabilities; assessment of the connection between parental learning disability and neglectful parenting; the importance of understanding family history. Makes many recommendations including: consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse; reinforce the importance of children's access to appropriate therapy while police investigations are continuing; develop guidance regarding complex and historic abuse investigations; remind Police of the importance of considering a range of risk management measures including sexual risk orders; local and regional safeguarding procedures regarding child sexual abuse need to include the requirement to undertake criminal injuries compensation processes and raise with children and their parents the Victims Right to Review scheme.
      
    Serious Case Review No: 2022/C9361  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.    1  Official Child Safeguarding Practice Review  Anya, Rosa, Whitney and Lena1  Jane Wiffin  1 Anonymised names  2  Official  This child safeguarding practice review is dedicated to the bravery of all the children involved who were able to speak out to their family or professionals about the sexual abuse that they were subject to by a member of their family. Of course, they should not be responsible for alerting others to the being subject to sexual abuse; it is the responsibility of both family and professionals to recognise the signs and indicators, think about history and behaviour which might indicate sexual abuse and to act appropriately on those concerns. This review is a call to action to address intrafamilial child sexual abuse.  3  Official Introduction  Reason for this Child Safeguarding Practice Review (LSCPR)  1.1 This independently led LSCPR2 (will be referred to as this review going forward) was commissioned by the Local Child Safeguarding Partnership because Paul3, an adult, was found to be in possession of, and sharing, indecent images of children. A police investigation was started, and it became clear some of the images were of his daughter Whitney (aged 3).  Subsequently Rosa (when aged 14), Anya (when aged 15) who were Paul’s sisters, and his niece Lena (aged 4) spoke about being sexually abused by Paul. Whitney also reported that her father had sexually abused her. This review has focussed on these 4 children because there are known concerns that they have been sexually abused by Paul. There remain concerns that there may be other children who have been sexually abused by Paul and other family members in the past and in the period covered by the review, but this information is not known. It was only when Paul was convicted did Rosa and Anya make allegations of sexual harm by their mother.  1.2 A police investigation took place over a 20-month period; during this time, Paul was in the community, sometimes out on bail with conditions not to have any contact with children aged 16 and under. He eventually plead guilty to several sexual offences against children and received a substantial custodial sentence.  Safeguarding action was taken regarding all 4 children and they and their siblings are now living safely with family. They are receiving therapeutic support in recognition of the significant harm they have experienced. It is important that this therapeutic support continues.   1.3 A wider review of  Paul’s extended family circumstances provided a picture of long-term concerns about intra-familial child sexual abuse, child neglect, adult learning disabilities, alcohol misuse, domestic abuse, mental health concerns and chaotic family circumstances.   1.4 There are also allegations that Paul was domestically and sexually abusive to the women he formed relationships with and that these women had either learning difficulties, physical disabilities and mental health needs. This review does not cover their circumstances, but appropriate adult agencies have been alerted to their needs and enquiries conducted to ensure their safety and any needs emerging out of the harm they experienced are addressed.    1.5 The agreed focus of this review was agreed to be:   2 A Child Safeguarding Practice Review (previously known as a Serious Case Review (SCR)) is undertaken when a child dies or has been seriously harmed and there is cause for concern as to the way organisations worked together. The purpose of a child safeguarding practice review is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children. 3 The family are white/British  4  Official • understanding and responding to complex historical and current inter-generational child sexual abuse, sharing risk assessments and information.  • Working with and protecting children and adults with a physical and/or learning disability  • Use of Police bail conditions.  • Use of chronologies in risk assessments. • Actions following child sexual abuse medicals.  • The use of challenge and escalation in multiagency decision making and application of thresholds. The extent to which these were relevant concerns is addressed in the findings section. 1.6 The timescales were agreed to be from March 2017 when there was the first  indication that Rosa was being sexually abused to November 2019 when Paul was convicted of sexual offences against children. This timescale was then extended to include the court judgment made in the care proceedings for Anya and Rosa in June 2020 and the further allegations of sexual harm made by Rosa and Anya in 2020 and 2021 as these incidents were considered of relevance to the review.   1.7 The review was led by Jane Wiffin, an independent reviewer who is responsible for authoring this final report. A panel of senior managers representing the agencies involved with the children and their families provided support, information and critical challenge to the development of the report findings. This has not been an easy task, particularly during the public health requirements emerging from CV-19. I want to thank everyone for their dedication, support and enthusiasm for learning. The process was effectively and sensitively chaired by the local designated nurse and ably overseen and managed by the partnership manager as well as the coordinator for the Safeguarding Children Partnership.  1.7 There were many professionals involved with the children and families under review. They have all contributed to the review process through several group interviews and I want to thank them for their time and thoughtfulness. There were also some professionals who had no longer worked for the organisations providing services to the family, and they also wanted to talk about their reflections and perspectives. Working to address the safety of these children took its toll on many of them and the impact of working with complex child abuse cases is discussed in the findings section. 1.8 Specialist advice was provided to the review by Triangle; an organisation with an in-depth knowledge of the needs of children who have been sexually harmed. We thank them for their help Family involvement 1.9 All adult and older children within the different families were invited to contribute to the review. This was facilitated by the social workers involved with the children and managed sensitively. For reasons of privacy, it is not necessary to outline exactly who  5  Official agreed to meet with the lead reviewer and chair. The information they provided chimed with all the other information provided. Their views are incorporated into the review. I want to thank them for spending time with us and for discussing what were clearly painful subjects.  About the children  and their families 1.10 The family is white/British and although they were described as living in impoverished circumstances, without work, but there is little available information  about their economic circumstances.   Rosa and Anya:   1.11 At the start of this review period Rosa and Anya were living with their mother, father, and some grown up siblings including their brother Paul. Rosa and Anya’s parents had (undiagnosed) learning disabilities and some health needs. There is evidence that Rosa and Anya’s needs were neglected from early childhood by their parents. Historically, support was provided, their living circumstances and the parenting they received seemed to improve and support would cease. There would be a deterioration in living circumstances or a crisis that needed attention from specialist services and support would be increased. Anya and Rosa lived their lives in a household characterised by chaos, violence, alcohol misuse, with many adults present about whom there were concerns regarding sexual abuse. These concerns were often communicated via anonymous referrals to children’s services and were superficially assessed; the conclusion was that the concerns were not substantiated, and no action was necessary. This review does not focus on the issue of anonymous referrals, but there is growing concern nationally about the lack of guidance regarding referrals of concern related to children by members of the community. 1.12 Anya (aged 11 at the start of the review period) is quite shy and reserved, but when she meets new people, she likes to talk to them. She loves animals. She has communication and learning needs and communicated partly verbally and partly through sign language in her early years, though now has become fully verbal through her own hard work and appropriate support. Neither her parents nor her wider family ever learnt to sign so this limited her opportunities for communication. The sexual and emotional abuse she has experienced over many years has had an impact, and there are times when she feels sad, confused and angry; therapeutic support is helping her make sense of the harm she has experienced. 1.13 Rosa (aged 12 at the start of the review period) is a friendly and lively young person who loves animals and enjoys drawing and crafting. People who know her well say she has a good sense of humour.  Like her younger sister, she has communication and learning needs and communicated partly verbally and partly through sign language in her early years, though now has become fully verbal through her own hard work and appropriate support. Neither her parents nor wider family ever learnt to sign so this limited her opportunities for communication in her early years. The abuse she has experienced over many years has had an impact, and there are times when she feels  6  Official sad, confused and angry; therapeutic support is being provided to help her make sense of the harm she has been subjected to. 1.14 Anya and Rosa are currently living in a small residential unit supported by a small group of staff they have known for a few years. They have supervised contact with their parents, grown up siblings and their nieces and nephews. This family time is very important to them.  Whitney  1.15 Whitney (aged 4 at the start of the review period) lived her early life with her mother who has some learning needs and her father (Paul) who was domestically abusive to Whitney’s mother which had a negative impact on her mental health. The parents separated when Whitney was very young, and Whitney’s contact with her father (Paul)  was supervised by his mother at her home. Whitney’s mother also experienced  coercion and control by members of the wider family and this brought Whitney into contact with unsafe and alcohol fuelled chaotic situations and adults of concern.  There were concerns about Paul’s alcohol misuse, poor mental health and chaotic lifestyle. The previous history of concerns that Paul may have been sexually abused as a child, may have subjected his siblings to sexual abuse and others to sexual assault was not part of the analysis when thinking about the circumstances in which Paul should see Whitney and where. The reasons for this are considered in the analysis section of the report.  1.16 Whitney (aged 3 at the start of the review period) is described as a happy and friendly child who likes playing with her friends and loves school.  She has some speech delay but is catching up quickly through help and support; she is doing well at school.  She sometimes feels angry, upset, confused and has nightmares about what has happened to her, and she is receiving therapeutic support to help her in the process of recovery from the harm she has experienced.  1.17 Whitney’s mother has moved to another area and Whitney has started a new school. Whitney’s mother receives support from her wider family.  Lena 1.18 At the start of the review period Lena was living with her parents and siblings. Her mother had learning disabilities and her father had some physical disabilities. Lena’s mothers learning disabilities were significant and Lena’s father was asked to be the main carer for the children by children’s services. This decision did not take account of concerns about domestic abuse and coercion and control; something picked up in the findings section.  Referrals were made to adult services to provide Lena’s mother with support, but she was always assessed as an individual who did not meet the criteria for help. This is discussed in the findings section. The family were very dependent for help on the maternal extended family; this brought Lena and her siblings into contact with unsafe, alcohol fuelled chaotic situations and adults of concern. Paul is Lena’s uncle.  7  Official 1.19 Lena (aged 4 at the start of the review period) is friendly, chatty and likes running around with her friends.  She has some communication and learning needs for which she receives support and appropriate help. She is receiving therapeutic support, and this is helping her feel settled at home. 1.20 Lena and her siblings spent some time with a foster family but are now living with father’s extended family. They see their mother in a planned and supervised way but have no contact with their paternal grandparents or extended family.     8  Official  2. Timeline of professional involvement with four children in this large extended family 2.1 This is a high-level overview of the involvement of the children and their families with services. Inevitably much of the hard work of so many organisations and individuals are not included, but there is evidence of concerted efforts to meet the needs of all the children.  2.2 A timeline of the separate family groups is provided because professionals were not initially aware of the extent of the different family’s interconnectedness, particularly that Whitney, Lena and siblings were looked after by their grandmother (Paul’s mother) and spent large amounts of time in her home with Anya and Rosa; Paul was also resident in this home until August 2018.    Anya (11) & Rosa (12) Whitney (3)  Lena (4) 2017 May/ June  Referral of concern that Rosa was subjected to harmful sexual behaviour4i. After enquiries were undertaken by children’s services it was agreed no action was necessary.  Paternal grandmother alleged that Whitney was being neglected by her mother. An assessment5 was completed and a child in need plan6 started. Lena and her siblings were receiving support through an early help plan7 because of ongoing concerns about neglect and their mother’s ability to cope. 2018 Feb There were safeguarding concerns about the baby of a member of the extended family who lived away from home. Rosa and Anya’s parents and one of their grown-up siblings put themselves forward to be assessed as possible family carers. These assessments8 provided a worrying picture of a history of chronic neglect, chaos in the home and the presence of intoxicated and suicidal adults. There was reference made to the long involvement with children’s services, including concerns about Rosa and Anya’s parent’s poor supervision of their children over time  4 Harmful sexual behaviour (HSB) is developmentally inappropriate sexual behaviour displayed by children and young people which is harmful or abusive 5 A Child and Family Assessment addresses the central and most important aspects of the needs of a child / young person, and the capacity of his or her parents or care givers to respond appropriately to these needs within the wider family and community context. 6 This is a plan that sets out what extra help children’s services and other agencies, including health and education, will provide for a child in need and their family. The plan should be drawn up in partnership with the child and their family after a child in need assessment.  7 An early help plan is an action plan to meet the assessed need of a child, young person and their  family. 8A local authority viability assessment considers the likelihood of carers being able to meet the physical and emotional needs of the children now and throughout their childhoods; whether they will be provided with stability and boundaries and whether they will be safe. Police and medical checks are initiated.  9  Official and leaving them with adults who posed a sexual risk. Neither Rosa’s parents nor the grown-up sibling was deemed suitable alternative carers.  Feb to April  Rosa and Anya moved to a residential centre. Two days after arrival there were concerns reported by Rosa’s sister of sexual touching (sibling sexual abuse).  Child in need support was being provided to Whitney and her mother. There were concerns regarding bruising to Lena. A child protection medical9 was undertaken and concluded that “a non-accidental cause” could not be completely excluded, despite some plausible explanations by the parents. This medical took place in isolation from information about the wider family circumstances. June  The police received information that Paul had uploaded indecent images of children10. Paul was bailed into the community whilst an investigation was ongoing, with conditions to have no unsupervised contact with children under the age of 16 and not to return to his family home; he moved in with his girlfriend. Children’s social care were notified because of Paul’s contact with his own children and children within the family. Soon after Paul’s bail conditions expired, and a working agreement was signed by family members not to allow him to have unsupervised contact with any children. June  There were concerns about Rosa and  Anya ’s distressed and sexualised behaviour. They were made subject to child protection plans for sexual abuse and there were Keep safe work11 was carried  out with Whitney; she reported sexual abuse by Paul to her social worker. It is not clear how this was responded to. It did not lead to any immediate action. Lena and her sisters continued to be looked after by their maternal grandmother.   9 A child protection examination is carried out to look for signs that a child or young person has been abused or neglected. This is different from a clinical examination, which aims to establish what is wrong with the child or young person and what treatment may be needed. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/protecting-children-and-young-people/child-protection-examinations 10 Taking, making, sharing and possessing indecent images and pseudo-photographs of people under 18 is illegal. making’ can include opening, accessing, downloading and storing online content; ‘sharing’ includes sending on an email, offering on a file sharing platform, uploading to a site that other people have access to, and possessing with a view to distribute. https://www.gov.uk/government/publications/indecent-images-of-children-guidance-for-young-people/indecent-images-of-children-guidance-for-young-people  11 The nature of this work was not defined.  10  Official significant concerns about neglect. Historical issues regarding a long history of  inappropriate adult sexual behaviours  and poor sexual boundaries in the family home were discussed.  August  Indecent images held by Paul were found to be of Whitney and allegations that Paul had raped Lena were made by other adults in contact with Paul. Paul remained on bail and subject to bail conditions.  August Two strategy meetings12 were held to discuss all the children’s circumstances. Health professionals were not invited to the first meeting but were to the second. A comprehensive referral was made for medical assessments of all children.  August/Sep Anya and Rosa were already subject to child protection plans13.   Anya and Rosa exhibited extreme sexualised behaviour at school and care proceedings14 were initiated.  A joint police and child protection enquiry was started and led to an initial  child protection conference.  There was uncertainty about whether Whitney’s mother had been protective. Over time it was established that she was. The role that paternal  grandparents (Paul’s parents) played and how well they kept Whitney safe was not discussed. A child protection inquiry was started for Lena and her siblings. It was decided that the children would be made subject to child in need plans because they had no contact with Paul. Significant concerns about neglect remained.  The role that maternal grandparents (Paul’s parents) played and how well they kept the children safe was not considered.  12 The purpose of a strategy discussion is to decide whether the threshold has been met for a single or joint agency (police/children’s social care) child protection enquiry, and to plan this. They happen when it is believed a child has suffered, or is likely to suffer, serious harm. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 13 A child protection plan is drawn up at a child protection conference when it has been agreed that a child is suffering or at risk of suffering form harm. The plan is a written record for parents and carers and professionals which sets out what work needs to be done to reduce concerns about a child(ren), what support and services will be provided and expectations of family members.  14 If children’s services have good reason (‘reasonable grounds’) to believe a child has suffered, or is likely to suffer significant harm, they may start care proceedings. This is the process of applying to the Family Court for a care order or supervision order.  11  Official Sep The Community Paediatrician made a referral for consideration of a child safeguarding practice review because of concerns about all the children. Nov  Children’s services held a single agency meeting to map family connections and to bring together historical information. Good practice suggests that the family circumstances should have been considered under the complex abuse procedures15 and comprehensive chronologies commissioned.  Nov  The referral by the Community Paediatrician was discussed at the group responsible for LSCPR’s locally. The decision was that although there was a long history of concerns, immediate action had been taken to safeguard all the children. There was agreement that there was no need for a historic review and that a police investigation was ongoing. Updates were sought over the next 18 months.  Nov  An interim care order16 was granted for Rosa and  Anya. They continued to have supervised contact with their parents and members of their extended family.  Whitney remained subject to a child protection plan. Whitney’s mother was supported by her social worker to renew connections with her own family, and this was helpful for her.  Concerns emerged that Paul was having contact with Lena and her siblings, and they were made subject to child protection plans.  A further working agreement17 was signed. 2019 Feb Anya and Rosa remained in residential care and the care proceedings were ongoing.  Whitney’s mother continued to seek help and support and provided safe and nurturing care to Whitney. Lena’s parents separated. There was insufficient thought given to how mother would cope parenting three young children on her own.   April  It is not clear whether Lena’s sister allegation of sexual touching by Rosa was discussed with her.  Lena’s sister reported sexual touching by Rosa at her paternal grandmother’s house in the past. This was subject to police/children’s  15 https://www.londoncp.co.uk/organised_complex.html 16 This is a short-term court order which means that a child becomes looked after in the care system. An interim care order is often made at the start of care proceedings. It will usually last until the court is able to make a final decision. It can be ended before then if the court decides that the order is no longer necessary. 17 The purpose of a written agreement is to clearly set out required actions a family should undertake to ensure the safety and wellbeing of the child in the case.  12  Official services enquiries.   April    Lena and her siblings came into care under a voluntary agreement due to evidence that their mother was being harmed and exploited by several men, and they were being exposed to harmful, scary and dangerous situations. May  There were concerns that Paul was seeking to gain access to children through masquerading as a member of staff at a swimming pool and adventure park, but although information was sought, precise details could not be established May to August  Rosa started talking about witnessing sexual activity by adults when living at home, being sexually abused by Paul and witnessing him sexually abuse Whitney.  Whitney made an allegation of sexual abuse by Paul and reported that Rosa and paternal grandmother were present. This was shared with the police. Lena indicated that paternal grandfather had behaved in an inappropriate way. A confused picture emerged. The police were involved, and Lena was spoken to, but there was no clarity about what exactly had happened.  Sep Achieving Best Evidence Interview of  Rosa (ABE18)    Nov Paul was charged with rape of a child and the distribution of indecent images of children; he plead guilty to these charges and received a lengthy custodial sentence.  Rosa and Anya remained living at the residential unit. Whitney and mother moved to a new area and Whitney started at a new school. Whitney was provide with Lena and her siblings moved to live with extended family members. Therapeutic support was provided.   18 Achieving best evidence interviews are conducted by police officers or social workers who are specially trained to plan and carry out interviews with children with the aim gathering evidence for use in criminal proceedings and where they are video recorded (VRI) to be used as part of the examination in chief of a child witness. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1051269/achieving-best-evidence-criminal-proceedings.pdf  13  Official therapeutic support 2020: Rosa and Anya  January  Rosa makes allegation of child sexual abuse by her mother, including that her mother and father colluded with Paul in his abuse of her. These allegations are under current investigation. June  A full care order19 was granted for Rosa and Anya, and they remained living in residential care. There was a judgement made  that Paul had sexually abused Rosa, Rosa had witnessed the abuse of Whitney causing her emotional harm and Rosa and Anya’s parents had failed to protection them, despite being aware that Paul posed a risk to children. The conclusion was that the parents were not aware of the sexual risk he posed.  August  The family circumstances were again considered , and a child safeguarding practice review agreed and commenced.   Anya and Rosa have continued to talk about being sexually abused by Paul and their mother, actively not being protected by their parents (who are grandparents to Whitney and Lena) as well as witnessing the abuse of their nieces in their family home. The allegations of abuse by their mother are subject to ongoing police enquiries.   19 Care Proceedings begin when children social care has a serious child protection concern about a child. They can go to court to seek a legal order to remove the child from its parents’ care. With a Care Order children’s shares parental responsibility for a child(ren) https://www.legislation.gov.uk/ukpga/1989   14  Official  3. Analysis and key Findings  3.1 The purpose of any child safeguarding practice review (LSCPR) is to identify any improvements that need to be made locally and nationally to safeguard and promote the welfare of children and to seek to prevent or reduce the risk of recurrence of similar incidents occurringii. This Review was commissioned to look at multi-agency practice in the context of inter-generational historical and contemporary child sexual abuse to establish learning about the identification, risk assessment, understanding and management of complex abuse cases.  3.2 The initial impetus for the review was concerns that Paul had sexually abused at least four children including his siblings, daughter and niece. What has emerged is a picture of these children also being subject to emotional abuse and neglect, and witnessing adult behaviours such as domestic violence, inappropriate adult sexual behaviour, adult alcohol misuse, some indications of adult drug misuse, and adult mental health needs expressed in chaotic ways. These must have been frightening circumstances for them all. It is likely that other children have been harmed, and there are allegations that adults in the family, including Anya and Rosa’s mother (grandmother to the other children) and that adult family members were aware of the abuse taking place and did not inform professionals of those concerns.  3.3 The review has focussed primarily on a two-year period from 2017 to 2019, but there is information available dating back almost 25 years of concerns about poor sexual boundaries, possible sibling sexual abuse , domestic abuse, and neglect. It is likely that Paul and his siblings were subjected to sexual abuse by their siblings, relatives and family friends when they were children. This is likely to have had a negative impact on them as adults, including their wellbeing, their health, ability to form healthy relationships and become effective functioning parents.  3.4 This intergenerational history of child sexual abuse reminds us of the importance of improving the professional response to intrafamilial child sexual abuse. The key finding of this review. There are three other key practice themes or findings that have emerged regarding the effectiveness of the professional response to these children and their siblings which are also likely to impact on the circumstances of other children locally and nationally in the future if not addressed. These are addressing child neglect, working with parents who have learning disabilities and how well a family history is incorporated into a contemporaneous understanding of children’s needs and circumstances.  Finding 1: Working effectively to address intrafamilial child sexual abuse. 3.5 The first key finding of this review is the extent to which these four children were provided with an effective response in the context of intrafamilial child sexual abuse. Child sexual abuse has had a high profile in recent years, but there are still far more children being sexually abused than professionals are currently  15  Official identifying and safeguarding. A recent analysis of data from a range of agenciesiii reveals that more than one in ten children had been sexually abused by the age of 16; this is much higher for girls (15%) than for boys (5%)iv v. The number of child protection plans for sexual abuse has decreased significantly; there were just 2,600 children on child protection plans under the primary category of sexual abuse across the whole of England in 2019/20. This was despite there being 87,992 identifiable child sexual abuse offences recorded by the police in the same year, and 30,460 children assessed as being at risk. At the same time, there were fewer prosecutions and fewer convictions in 2019/20 than three years ago.  3.5     Researchvi and inspectionsvii have highlighted several challenges in this important work.  • Key professionals working with children have been insufficiently supported to gain the knowledge, skills and confidence needed to identify and respond effectively to concerns of child sexual abuse. There is longstanding inconsistency in the availability, accessibility, breadth, and quality of training on child sexual abuse, as well as peer support and supervision in social work, health, education, and policing.  • Serious Case Reviews/Child Safeguarding Practice Reviews relating to intrafamilial child sexual abuse identify common themes such as professionals failing to spot signs and indicators of child sexual abuse, not feeling confident to ask children about child sexual abuse or to support children to talk about sexual abuse and being reluctant to pursue concerns of child sexual abuse when an alternative hypothesis, often neglect, is present.  • There is lack of clarity about the appropriate professional response to sexual abuse perpetrated by children such as harmful sexual behaviours (HSB) and sibling sexual abuse.  • The sexual abuse of children by women is underestimated by professionals, and therefore concerns related to women as abusers are not always addressed.  • There is too much focus on the needs of the criminal justice system. The vast majority (more than four-fifths) of police investigations into child sexual abuse do not progress to charge and prosecution, or out-of-court resolutionviii. Despite the very low numbers of cases of child sexual abuse that do progress through the criminal justice system, there is undue attention paid to the need to ensure that talking to children or providing them with interventions does not ‘contaminate evidence and this often inhibits professionals from effectively identifying and responding to sexual abuse; police action can happen separately from the safeguarding response with poor communication and sharing of information.  • There is poor identification of “safe adults” or non-abusing parents, an insufficient understanding of the importance  16  Official of assessment and analysis of these adults’ ability to be protective, making sense of what undermines this and what support is needed for them.  • There is limited understanding amongst safeguarding professionals (not specialist sexual offending professions) regarding the motivations and behaviours of those adults who pose a sexual risk to children/young people, but who are not paedophiles.   3.6 These factors, which are seen nationally, were largely all present in this LSCPR and will be explored in the context of what we know about Rosa, Anya, Whitney and Lena. This finding covers a number of different aspects of the professional response to child sexual abuse including: • Identification of intrafamilial child sexual abuse. • Harmful sexual behaviours and sibling sexual abuse. • Recognition of intrafamilial sexual abuse by an adult in a family context • Intrafamilial sexual abuse by women. •  Enabling children to talk about their worries and particularly child sexual abuse and responding appropriately.  • Understanding help seeking behaviour: Supporting children to seek help from professionals. • Recognising and responding to the impact of child sexual abuse  • The sexual abuse of disabled children. • Recognising the importance of safe adults/ the non-abusing parent/family • Understanding the motivations and behaviours of those adults who pose a sexual risk to children/young people. • Support to families after child sexual abuse has been identified. • Responding to adult disclosures of sexual abuse in childhood. Addressing non-recent child sexual abuse.  • The multi-agency response to child sexual abuse.  Identification of intrafamilial child sexual abuse  a)  Harmful sexual behaviours and sibling sexual abuse  3.7 Official statistics suggest that between 20% and 33% of all reported child sexual abuse in the UK involves other children and adolescents as those who have  17  Official sexually harmed. Official figures may, however, under-estimate the true scale of the problem. Sibling sexual abuse is thought to be the most common form of intra-familial child sexual abuse, perhaps up to three times as common as sexual abuse of a child by a parentix. 3.8 Harmful sexual behaviours (HSB) are defined as “Sexual behaviours expressed by children and young people under the age of 18 years old that are developmentally inappropriate, may be harmful towards self or others, or be abusive towards another child, young person or adultx.” (Derived from Hackett, 2014xi). Sibling sexual abuse is a form of HSB with the added complexity of complex family relationships. Language is critical; children20 should not be referred to as “child sex offenders” young abuser’ or ‘an adolescent perpetrators but as children who sexually harm and a child who has been sexually harmed. These are children first. What is important is for there to be an appropriate assessment of the circumstances, relating both to the child who has harmed, and the child who has been harmed.  3.9 Rosa and Anya came to the attention of professionals in 2017 when there were concerns that Rosa had been inappropriately sexually touched by a peer from school and then a much younger friend. A referral was made to children’s social care. The information was reviewed, and a decision made that no action was necessary. Given no assessment was completed, by any agency it is hard to evaluate the seriousness of this concern across the continuum of normal sexual exploration to sexually harmful behaviours. Yet contextually there had been an anonymous referral two-years earlier about Paul being a “paedophile” and living at home with Anya and Rosa. Three years earlier there had been many concerns about Anya and Rosa’s sexualised behaviours which led to child protection plans for neglect, not risk of sexual abuse. The current concerns should have been contextualized alongside earlier concerns of a similar nature. This was not possible because a chronology was not held for the children on the electronic system (an issue picked up in Finding 4 about history) and because of changes to the electronic recording system and the migration of data, some records and assessments were not easily accessible.  3.10 When there were further complaints made about a young child being sexually harmful to Rosa and Anya, it was agreed that no police action was necessary, but a child and family assessment was completed, and Anya and Rosa were made subject to child in need plans. However, the nature of the sexual harm was not established, and links were not made to historic information about Rosa’s sexualised behaviour and the long history of concerns about poor sexual boundaries in the home and allegations of previous harmful sexual behaviours, sexual abuse and historic sibling sexual abuse. This incident was not seen as a possible indicator of sexual abuse which required more exploration. The child in need plan and process got sidelined into concerns about education with a secondary focus on neglect; both pressing  20 When the word child is used, this includes everyone aged 18 and under.   18  Official issues, but the question about whether there were indications of sexual abuse was not asked and the meaning of the harmful sexual behaviours not addressed.  3.11 In April 2018 Rosa and Anya moved to a residential school. Anya immediately (2 days in) spoke about Rosa touching her in a sexually harmful way. Although immediate action was taken, there was insufficient analysis of the possible meaning of this sibling sexual abuse. A further assessment was completed but it did not address or name concerns about sexual abuse; most importantly why it was occurring, what the impact was likely to be and what needed to be done about it was not addressed. An initial child protection case conference was convened, and Rosa and Anya were made subject to child protection plans for sexual abuse, but there was no discussion of sibling sexual abuse and what needed to be done to address it, or the meaning of it in the broader context of Anya and Rosa’s needs. 3.12 Over time Lena has also spoken about Anya being sexually harmful to her and there were concerns that Lena was sexually harmful to her sibling. These incidents were taken seriously, but little actual action was taken to address the concerns, understand the cause of this harmful sexual behaviour in the context of them having been potentially sexually abused, and what action needed to be taken to understand the impact and address the harm.  3.12 There were many concerns of Rosa being sexually harmful to children in her family, and although acknowledged as of concern, but no specific assessment or intervention plans initiated. The evidence is clear that harmful sexual behaviours and sibling sexual abuse needs to be taken seriously, needs to be assessed, understood and addressed.  3.13 Contemporary practice for Anya and Rosa mirrors the professional response to this extended family from many years earlier. There were continual allegations of both sibling sexual abuse as well as children in the wider family being subject to harmful sexual behaviours. These were responded to in superficial ways and there was no assessment of the meaning or action to address the concerns. This shows that professionals need to feel both better equipped and more confident to identify and address harmful sexual behaviours and sibling sexual abuse.  b) Recognition of intrafamilial sexual abuse by an adult in a family context 3.14 As has already been covered in the report, the sexual abuse of children by adults is more prevalent than is being currently identified; more children are being sexually abused than professionals are safeguardingxii. This is in part due to professionals relying too heavily on children to report abuse; the evidence suggests that it is important to take a whole family approach to build a picture of a child’s circumstances, including children’s behaviours as indicators of distress and harm, adult behaviours of concern, family history and the grooming behaviour of adults who want to abuse.   19  Official 3.15 In 2017 there were concerns of sexualised behaviour exhibited by Whitney (aged 3) that the nursery she attended believed fell outside of developmental norms. It was good practice that they highlighted this. Whitney’s mother also was concerned and some “keep safe work” with Whitney was undertaken by her social worker, but there was no further assessment or exploration of what this sexualised behaviour was about, who Whitney was in contact with or why it was occurring. There was insufficient reflection about whether this behaviour of concern might be an indication of sexual abuse which required exploration. The complexity of access to the children’s social care and family support recording system made it difficult to access historical records and only a partial picture was formed. Earlier concerns about Paul’s possibly sexually abusive behaviour were not known nor the family history of poor sexual boundaries. The connection with paternal grandmother was not explored and there was a lack of awareness of the concerns regarding Rosa and Anya.  3.16 Concerns emerged in June 2018 regarding Paul viewing indecent images of children (IIOC) rather worryingly referred to as “child pornography” by several professionals from different agencies; the appropriate phrase is indecent images of children (IIOC). There were also concern about Paul engaging in fetish behaviour which focussed on content specifically associated with infants / very young children and extreme vulnerability of sexual partners. There emerged differences of opinion at the strategy meeting to discuss this between social workers and health professionals; a view was expressed (but not recorded) that adults were entitled to engage in whatever sexual activity they wished with consenting adults21; the concept of consent and whether it existed was not discussed. This was challenged by the community paediatrician in the strongest terms and although this was not acknowledged, this challenge appears to have had an impact and a comprehensive referral was made for sexual abuse medicals. This referral provided a good and clear outline of historical concerns. This view that all sexual behaviour is acceptable, and that consent can be perceived without asking pervades this review; the women involved were subjected to emotional, physical and sexual abuse. Consent needed to be questioned. There was a lack of understanding in the original strategy meeting of the existing evidence. Taking a holistic view; there were poor sexual boundaries across this family, which by now were well known. There was a history of sexualised behaviours from children which were of concern and could have been seen as indicators of abuse. There was evidence of past sexual abuse by Paul and concerns about who else had been abused.  3.17 At the first child protection conference for Rosa and Anya it was reported that “there is concern regarding adult sexual behaviour between family members dating back to 2001”. Social workers have been worried about how sexual relationships are managed, supervised and understood by the family and there seems to be an “open house” approach at the family home. This was a clear and  21 Something shared as part of the interviews within this review  20  Official explicit expression of the potential risk of sexual harm to Anya and Rosa though which did not lead to action to explore sexual abuse with them. This is an important reminder of professionals’ being able to consider sexual abuse as a hypothesis and seek a whole family assessment including family history. c)  Intrafamilial sexual abuse by women 3.18 In 2018-19, 3.8% of all child sexual abusers were female, based on police reports, Office of National Statistics data showsxiii. This is an underestimation of the nature of the harm children are experiencing. Little is known about the sexual abuse of children by women in a parental rolexiv. The evidence suggests that professionals rarely see or consider this type of abuse, in part due to a lack of knowledge, as well as stereotypical ideas about the role of women in family life and this has led to poor assessment and action for childrenxv. Since 2020 Rosa has made several allegations that her mother sexually abused her. These have been heard by the residential staff that look after her, and her social worker has sought to get action to address these concerns. Rosa was interviewed by the police, but she was not asked about sexual abuse by her mother and action was not taken to address this. There is now an ongoing investigation regarding this.  d)  Enabling children to talk about their worries and particularly child sexual abuse and responding appropriately.  3.19 There is clear evidence that professionals rely far too heavily on children to tell them that they are being sexually abusedxvi. That is why thinking about signs and indicators regarding the child’s behaviour and wellbeing is important.  3.20 Research suggests there are many barriers to children feeling able to tell someone that they are being sexually abusedxvii. This includes feelings of shame and embarrassment, fear that they may not be believed, or they may not have the language or the capacity to communicate verbally. Children may also not recognise the experience as abusive or are being threatened or manipulated by the person who has abused them. These barriers to talking about sexual abuse are compounded by professionals’ worries about supporting children to speak out. This includes lacking confidence and skills and worries about saying the wrong thing or fears about contaminating evidence in any future criminal proceedings. Children find it hard to speak out and professionals find it hard to discuss sexual abuse with children. This professional reluctance needs to changexviii. 3.21 Children communicate in several different ways about their distress. This is particularly so where children have developmental delay and speech and language difficulties. This was the case for these four children. Whitney and Lena were both quite young and both had speech delay. Rosa and Anya both had mild learning disabilities and used a mix of verbal language and signing. No one in their family had learned to sign, despite being asked to on several occasions in the context of child in need and child protection plans. There was no discussion of whether the parents would be able to learn to sign because of their own learning disabilities and  21  Official no action was taken to address this. This effectively meant that Rosa and Anya were denied an opportunity to communicate.  3.22 When Whitney was exhibiting sexualised behaviours in 2017 it is unclear the extent to which professionals supported her to talk about whether she was being sexually abused. There may have been many causes for this behaviour, but it appears that the approach was to see this as a problem of sexualised behaviour which needed addressing through protective behaviours work, rather than understanding the root cause.  3.23 When there were concerns about harmful sexual behaviours for Rosa and then sibling sexual abuse by Rosa to Anya, it remains unclear the extent to which they were encouraged and supported to speak about sexual abuse. There was a lack of professional recognition of the potential links between sibling sexual abuse/harmful sexual behaviours and intrafamilial sexual abuse. 3.24 It is notable that the school Whitney attended noticed that she was found in the toilets looking over and under the toilet doors at other children. This was a cause for concern and appropriately recorded and shared with other agencies, but she was not spoken to about this by any professional. This meant that the meaning of this behaviour was not known, and the lack of discussion meant that she did not know that someone had noticed her and her behaviour and was concerned about it. This was also true when the family support worker met her at Anya and Rosa’s home. Whitney attached herself to the worker and would not let go. This was noted in records and shared appropriately, but Whitney was not asked about this behaviour, its meaning was not established, and she was not made aware that someone had noticed what appears to be distressed and help seeking behaviour.  Best practice suggests that as well as recording concerns about children’s behaviour, it is important to take action to seek to understand its meaning or to have everyday conversations with children about how they are and how they are feeling ( see recent guide to communicating with children: Centre of Expertise for Child Sexual Abuse 2022xix). e)  Understanding help seeking behaviour: Supporting children to seek help from professionals 3.25 It is a core ambition of the safeguarding system that children and young people feel able to talk to family, friends, and professionals about any concerns they have. This concept of help-seeking behaviour is important. Help seeking behaviour is a core part of child development, where children learn over time how to seek help, get validated for that help seeking behaviour and learn who can be trusted. It is an essential skill. It is a developmental task which develops over time and is supported by the response of parents/adults. This starts in babyhood when a baby cries and someone responds. Children who are abused, neglected or who receive inconsistent care over time are likely to have underdeveloped help-seeking behaviour or are actively discouraged or prevented from seeking help through threats, intimidation,  22  Official or suggestions of impact on family. It is essential that professionals respond to children’s help-seeking behaviour generally, but specifically in the context of children raising concerns about safeguarding matters. The research evidencexx suggests that children will “test out” the response of professionals before making more serious allegations of harm. It is essential that in a child-centred system children’s concerns are listened to and responded to.  3.26 In 2018 an assessment of Anya and Rosa’s needs was completed in preparation for the initial child protection case conference. This assessment made clear the extent to which Anya and Rosa felt unable to speak to the social worker. Anya told the social worker that she thought her role was to take children away; this was she said her family’s experience. Rosa constantly sought permission from her mother to tell stories of family life, despite overall these being about everyday events. The social worker noted that Rosa and Anya seemed quite nervous when Whitney’s name was mentioned and they said their mother had told them not to talk about Whitney, or any of the other children. On another occasion Rosa spoke about Paul hurting her and when asked how by the social worker it is recorded that she became very anxious. Anya gestured to Rosa “shhshh” putting her fingers against her lips. Rosa responded by saying that the social worker was there to help; Anya said that they would get into trouble if they spoke. This is all made explicit within the assessment but does not feature in the discussion in the subsequent child protection conference22 or in the danger statements23 or child protection plans24. This may well be because all professionals for child protection case conferences locally are required to read the reports provided to the conference in the 30 minutes before the conference starts. This is caused by guidance not always being followed regarding submitting reports days in advance enabling all to prepare. This means that it is difficult for all professionals to fully understand complex circumstances such as outlined for these 4 children. The issue of Anya and Rosa being coached not to speak and being again effectively silenced was not addressed in the plan going forward.  3.27 It is notable in this review that so many children were brave enough to speak about the abuse that they were experiencing, but they were not always heard, or their concerns not always acknowledged and from their perspective not responded to. So often the children’s testimony was branded incoherent, unclear and confused. Of course, in the context of criminal proceedings the burden of proof is set at beyond reasonable doubt. This makes the criminal proceedings a challenge. However, there needs to be more thought about how children’s help seeking behaviour is acknowledged and congratulated. This requires children being told what action is being taken, or not, with an explanation why. There was evidence of this here. Anya and Rosa’s social workers have sought to provide feedback about why action could not be taken and to seek  more action to gain testimony. The focus must be on what can be done rather than what cannot; after all, if you take the risk to speak out it is dispiriting to know that no action is possible. It is also important that children are reassured that what happened to them was wrong and that some sort of repair takes  22  23  24   23  Official place. Rosa and Anya’s mother and father have been required to write an apology for failing to protect them. This is an appropriate step. There needs to be discussion by professionals about how the outcomes of abuse investigations are communicated directly to children when they talk about any form of abuse, and this leads to no action (not just criminal action) against those adults. f)         Recognising and responding to the impact of child sexual abuse  3.28 The impact of child sexual abusexxi on children and young people’s development and wellbeing is serious and can last throughout childhood and into adulthoodxxii. Sexual abuse can impact every area of a child’s world including their cognitive, social, emotional, behavioural, physical and sexual development.xxiii. 3.29 It is good practice that all the children in this review who have been subject to sexual abuse are now receiving appropriate therapeutic support. This was not an issue for these children, but their circumstances serve as a reminder that some custom and practice has developed where there is a belief that children cannot be offered therapeutic support whilst criminal proceedings are ongoing. This is incorrect, and guidance25 makes this clear. It is also important to recognise the necessity of providing the whole family (excluding the adult of concern|) and especially to siblings’, support and activity to rebuild family relationships.  3.30  However, there is some evidence that the children’s distressed behaviour was not always recognised as an impact of the harm they were subjected to. It is critical for children that professionals take a trauma informed approach. This means recognising and understanding children’s reasonable and normal response to abnormal circumstances. For example, in the reports for the child protection conferences Whitney was described as “trying to take over and dominate” and “she is showing some difficult behaviours”. She is described as presenting as “needy” at times. These description are all in the context of child sexual abuse. At a review conference Whitney is described in a report to “lack emotional resilience and resorts to crying easily and she likes to be in control. Whitney is attention seeking and likes attention from adults”. This was not questioned by the chair of the conference or any other professional. 3.31 When Lena was discussed at an initial child protection conference where concerns were considered about possible child sexual abuse, she was described as presenting with “tummy hurt” or “I feel sick” which was seen as out of character, but also described as “possible attention seeking”. If the phrase “attention needing” had been used instead, this might have led to an approach where this out of character behaviour was explored with her more fully and her appropriate need for care and attention addressed.  3.32 Rosa and Anya have exhibited significant distressed behaviour whilst in residential care. This was of a physically violent nature, and they have also been extremely  25   24  Official verbally abusive, using violent and aggressive sexualised language. This is indicative of the harm they have experienced. The residential unit has established a caring regime to help Rosa and Anya manage their emotional regulation. This behaviour is described as “heightened” rather than “distressed”. The most recent letter to both Anya and Rosa from their independent reviewing officer focusses on their behaviour, rather than the underlying reasons for it and is not sufficiently trauma informed in its approach. Action is being taken with the local authority to promote child focussed recording. 3.32 There were alco continuing concerns about Rosa’s sexually harmful behaviour to herself. This led to visits to hospital on a regular basis. These actions were distressing for Rosa and for everyone supporting her. These incidents were clearly signs of distress and a way of coping. Yet no clear action plan was developed to address this, and this repeated behaviour came to be seen by some as “attention seeking” or at worst annoying. This was not an easy situation to deal with; dealing with children’s distress has an impact on all professionals. Rosa was a care experienced child with the local authority as a corporate parent. Support was put in place in the form of therapeutic support, but the harmful impact of the sexual abuse Rosa had experienced became more of a problem to be solved. A problem of and for her. There is a danger that when professionals are working with children who have been sexually harmed26 that the focus can be on “what is wrong with the child”, as opposed to what “has happened to the child”. 3.33 Anya, Rosa, Whitney and Lena have been provided with appropriate therapeutic support. Their emotional needs are significant because of the severity of the harm they have been subjected to. This support is helping them make sense of their past, their present, understanding the sexual abuse they have experienced and exploring attachment relationships and boundaries. Therapeutic relationships have been built. This support is provided by an external provider and funded by the local authority as part of the children’s ongoing care plans. The resourcing of this support is managed through the local authority funding panel which meets quarterly to agree funding. Therapeutic support needs a six-month warning that funding will change or be withdrawn leading to the end of the therapeutic relationship. It is important to match resource funding arrangements to therapeutic needs for appropriate staged endings for children and young people. g) The sexual abuse of disabled children  3.34 There is clear research evidence that disabled children are more likely to be sexually abused and less likely to be subject to safeguarding processesxxiv. Too often, signs and indicators of potential sexual abuse in disabled children go unrecognised or are dismissed as being caused by their impairments, even when there is no relation between the two. It is therefore important to understand what  26 Or harmed in anyway   25  Official the disability means for the child and their day-to-day functioning, learning style and communication. 3.35 All the children in this review had some form of learning and/or physical disability. They were all receiving appropriate help and support from a range of professionals to address their physical and health needs. There was something of a separation between the work of those professionals seeking to address the children’s disability and health needs and the actions of the safeguarding professionals. There was a wide range of expertise available to safeguarding professionals to help them understand the children’s needs, understand their communication style and to advise on the best way of maximising this. This opportunity was not taken. This needs to be a core requirement of strategy meetings/discussions regarding children with some form of disability (meaning the vast majority); that those needs are discussed, advice is sought from someone who understand their disability needs, what this will mean for any further enquiries, interviews and assessment and how children will be supported to communicate in their preferred style.  3.36 At the child protection conference for Rosa and Anya in 2018 it is recorded that mother was aware that “the girls had a mental age of 4” and this phraseology is used on several occasions in reports. This was an inaccurate report. This description did not enable an accurate understanding of their needs.  3.37 The children’s disabilities and health needs were often quoted as a reason that criminal action could not be taken. Although care was always taken to provide the children who were subject to Achieving Best Evidence (ABE)/Video Recorded Interviews(VRI) with an intermediary, and thought was given to rapport building and meeting beforehand, there was insufficient discussion of the needs of these children arising from their disabilities. Advice was not sought from the residential workers who knew Rosa and Anya well nor from the social workers or those providing therapeutic input. All these professionals had to some extent adapted their approach to enable effective communication. It is not that children with disabilities do not communicate, it is that professionals need to take time to communicate with children in a way that meets their needs. This is particularly important in the context of a trauma informed approach. When Rosa was seen by police officers and an intermediary in 2021, she was able to remember their previous meeting a year ago and outline exactly what they talked about including holidays and pregnancies. When she was then asked, “do you know why we are here” she said “no”. This was interpreted as her not understanding or remembering, rather than this was a difficult and painful subject. We need a more trauma informed approach. 3.38 It is important that advice is sought about the exact nature of a child’s disability, what it means for them, their day to day, their identity, contact with professionals and how effective connections can be made by professionals and disabled children. There is evidence that those that knew all the children well took these steps, but it  26  Official was not consistent across assessments, child protection enquires  and strategy discussions.  h) Recognising the importance of safe adults/ the non-abusing parent/family. 3.39 When there are concerns about sexual abuse of children, it is critical that safe adults or non-abusing adults are identified, their needs assessed, their vulnerabilities understood, and their support needs consideredxxv. It is critical that there is an assessment of the non-abusing parent’s ability to protect and believe children. Researchxxvi indicates that feeling believed by your main care giver is one of the strongest mediators of the long-term mental health issues caused by sexual abuse. This parent/caregiver will need to play a central role in protecting their children from the person of concern, implementing safety plans and managing risks; they will need to support their child with the immediate and longer-term impacts of their abuse.  3.40 It is also important to understand any vulnerabilities that can be exploited by an adult to make sexual abuse possible. Non abusing parents may be groomed, with those who pose a risk of sexual harm making use of unmet needs for financial and emotional support or they may be being coerced and controlled through domestic abuse. It is important that the non-abusing parent has all the relevant information and that they understand the process of likely adult sexual offending to be equipped to address it. Adults who pose a sexual risk to children often undermine the non-abusing parent’s parenting capacity, seeking to make use of any difficulties they have such as mental ill health, depression and low self-esteem. They can try to become a better substitute parent figure whose role is essential to family life. This requires a good assessment of these factors; understanding the needs and circumstances of the non-abusing parent, considering what of their needs are being met by the adult who poses a sexual risk, what role that adult plays in family life, financial contribution, emotional support and supporting parenting. There is likely also to be a process whereby these adults who pose a risk undermine non-abusing parent/child relationships as well as other family relationships. 3.41 The recent Ofsted thematic review of sexual abuse in the family environmentxxvii has highlighted that there is not enough attention played, or assessments completed regarding the needs and circumstances of a non-abusing parents. There is often insufficient attention paid to evaluating the non-abusing parent capacity and willingness to keep children safe from sexual abuse and their vulnerability to grooming and exploitation which can undermine that safety.  3.42 When concerns arose about Whitney being sexually abused by Paul in 2018, there was a focus on whether her mother had been able to protect her, had known about the abuse and colluded with it. There was no specific assessment completed; this was because no tools or frameworks currently exist locally, and there is inconsistent use nationally of assessment tools to assess the safety provided, needs and circumstances of a non-abusing parent in the context of intrafamilial child  27  Official sexual abuse. A clear plan of action was put in place and Whitney’s mother demonstrated that she was a safe adult and a protective parent. Although work was completed by the social worker to reunite Whitney’s mother with her family to provide support, the overall impact of the sexual abuse of Whitney on her mother was not sufficiently considered. She sought out mental health support herself and was offered group-based support. She attended sessions and found that a member of the group was known to the wider family. This made it impossible for her to talk about what had happened, and in other group sessions she realised that talking about the sexual abuse of a child was not necessarily appropriate. More thought needs to be given to the support needs of the non-abusing parents of children who are sexually abused.  3.43 In contrast to the focus on Whitney’s mother, there was less attention on Whitney’s grandparents and how safe and protective as adults they were. Whitney’s mother sought to separate herself from these adults, who she did not consider safe. However, for a period after it became known that Paul was under investigation regarding the sexual abuse of children in the family and the sharing of indecent images of children, the grandparents were helping look after Lena and her siblings and Anya and Rosa were living in the home.  The paternal grandparents were also involved in providing care to other children in their family network without sufficient reflection on whether they were safe adults.  3.44 Rosa has made various allegations about both her mother and father. She has said that her father knew that Paul was sexually abusive and did not alert any professional to this behaviour. Rosa says her mother knew what Paul was doing and was angry with him; Anya agrees with this. Rosa goes further to suggest that her mother was collusive with Paul, helped him to abuse her and was also sexually abusive. This has not been sufficiently addressed before this review but is now being investigated. 3.45 There was insufficient thought about which adults were non-abusing and could provide safety in the context of sexual abuse. There was a dependence on “working agreements27” to set boundaries. These pieces of paper were meaningless, lacked any legal standing and did not take account of  family history, adult intentions and their capacity and willingness to provide safety to the children. The evidence suggests that over time many of the adults in this family were either unable to, lacked capacity to or were unwilling to keep children safe. This should have been subject to greater assessment and analysis. i)  Understanding the motivations and behaviours of those adults who pose a sexual risk to children/young people. 3.46 When addressing child sexual abuse, it is critical that professionals consider, assess and analyse the behaviour of the adult about whom there are concerns about sexual  27   28  Official abuse. Adults in this situation are often described as “paedophiles”; but paedophilia relates to a specific disorder where there is a preference for sexual activity with a prepubescent child.  3.47 Paul was often described as a paedophile, rather than that he had a sexual interest in children, post pubescent children and vulnerable adults. He is part of a group of adults about which there is little research, who sexually harm children and adults. Of course, this group bring their own experiences of trauma, but in addressing their sexually abusive behaviour it is important to understand their motivations, needs and behaviours.  3.48 It is critical that safeguarding professionals are familiar with the evidence base around adult sexual abusexxviii. The most often used framework is Finkelhors 4 preconditions modelxxix. This suggest that there is a process that adults who pose a sexual risk to children go through. The first precondition is motivation to abuse. This can include emotional loneliness, intimacy and relationship problems, hostility and anger towards women, a desire for power and control, poor impulse control, using sex as a coping mechanism and a possible sexual attraction to children. Adults are using sex to get these needs met. The second stage is overcoming internal inhibitors. An adult needs to overcome their internal inhibitors, such as knowing what they are doing is wrong. Professionals need to understand factors that disinhibit behaviour. This can include the use of alcohol or drugs and the development of cognitive distortions to validate behaviour. The third stage is overcoming external inhibitors, finding opportunities to offend, and gaining access to children. The final stage is finding ways of abusing the child, overcoming their resistance. This is achieved through grooming, exploiting vulnerabilities such as a young age, disability, the need for a special relationship as well as threats and coercion.  3.49 Paul abused children and adults. However, he was consistently described as a paedophile. The focus on paedophilia meant that his bail conditions were about children under 16 and he was free to live with a vulnerable adult, without thought that he might sexually abuse and assault her. This was not recognised by most professionals as a concern and consequently not challenged. This was recognised by the Community Paediatricians attending the second strategy meeting who recommended a safeguarding adult referral for the vulnerable woman he was living with while on bail. 3.50 There was considerable concern regarding Paul being out in the community and the impact of this on how safe Whitney felt, and her mother and school were concerned about the impact of this. Paul also sought to gain access to children whilst awaiting police action. This was inevitable. More thought needed to be given to the risk that an adult such as Paul posed to adults and children. The police  29  Official could have considered the use of a civil order such as a Sexual Risk Order(SRO)28. A lack of discussion regarding this was likely caused by changes made to policing locally, including the loss of expertise because of officers with child abuse experience being moved into a wider safeguarding team with attendant loss of expertise.   3.51 There also needed to be more discussion in the many safeguarding meetings and processes about the risks Paul posed to the community, and the impact of the delay in the investigation on the safety and wellbeing of the children he had abused, and the parents charged with keeping them safe.  j) Support to families after child sexual abuse has been identified 3.52 There is significant evidence that the discovery that a child is being sexually abused has a profound impact on the child and the whole family. In parents and extended family this can include feelings of guilt that a child was not kept safe, anger at the adult who has sexually harmed, and complexity in family relationships caused by grooming behaviourxxx. Adults who sexually abuse children can deliberately seek to disrupt family relationships, pick out a child for special attention, or scapegoat and marginalise children from trusted adults. This all has an impact on family relationships. 3.53 Once child sexual abuse has been identified,  there will be children’s services and police inquiries for the child to cope with, and this also will have an impact on the whole family. 3.54 When concerns became known that Whitney had been sexually abused by Paul, she and her mother was provided with support through a social worker, the school and the health visitor. Whitney’s mother was supported by her social worker to rebuild relationships with her family who provided good support. Whitney is now safe, her mother has provided safe and effective care, and there are no specialist services involved. What is clear, is that as a family they are still coping with the aftermath, and locally and nationally there are limited specialist resources available to address the long-term impact of child sexual abuse on the family, parenting a child who has been sexually harmed, rebuilding relationships and trust. 3.55 In the period when it became clear that Anya and Rosa had been sexually abused by Paul and before allegations were made against their parents of sexual harm, the parents were provided with specialist support to help them understand the impact of sexual abuse on children; the aim was to enable them to respond appropriately to Rosa and Anya’s trauma needs. This was good practice, which has only been undermined by the increasing evidence that the parents knew about the risk Paul posed, may have colluded with him , and in the case of mother may have joined in the abuse.  28 A Sexual Risk Order is an order made by the Court which imposes restrictions on a persons' behaviour that the Court deems necessary for the purposes of protecting the public from risk of sexual harm. https://www.legislation.gov.uk/ukpga/2003/42/part/2/crossheading/sexual-risk-orders-england-and-wales  30  Official 3.56 There were concerns that Lena had been sexually abused by Paul and subject to sexually harmful behaviour by Lena, they were about to come into foster care. Lena and her sisters have now been placed with extended family, and specialist support has been provided. It is important that the long-term impact of child sexual abuse on family relationships and future parenting is kept in mind and planned for. There is a lack of resources locally and nationally to help families understand what the impact in the future will be and where to seek help when issues and concerns arise. k)  Responding to adult disclosures of sexual abuse in childhood. Addressing non-recent child sexual abuse  3.57 The difficulties that professionals have in identifying child sexual abuse have already been highlighted, and alongside children feeling unable to tell others about being sexually abused, it is not surprising that only 1 in 8 children who have been sexually abused come to the attention of servicesxxxi. Many children go into adulthood without telling what has happened to them, and without receiving any help and support. This can lead to those adults experiencing poor mental health, substance misuse and difficulties coping with relationships and workxxxii xxxiii.  3.58 The reason this LSCPR was initiated was because of the sexual abuse of children by one adult in this wider family, and allegations that other adults have abused children. What has emerged is a complex family history where several adults have talked about being sexually abused as children. Those adults were assessed as parents, were seen by their GP, assessed as adults with possible care and support needs, and some were frequent attenders at accident and emergency departments because of alcohol misuse, feelings of depression, violence and suicidal ideation. There is inconsistent evidence that they were asked (where the circumstances permitted) about whether anything had happened in childhood that was impacting on them negatively as adults and for this to be factored into an understanding of their needs. 3.59 Paul did talk to some professionals about the abuse he had been subject to, as did Lena’s mother. This abuse was never explored in detail; usually because it was disclosed at a time of crisis when Paul and Lena were extremely intoxicated or distressed. The adults in this family often did not follow up on signposting after these incidents, and so the issue of their abuse was never addressed. There is an opportunity here for the ongoing meetings and discussion about frequent attenders to consider childhood sexual abuse as one of the factors contributing to frequent attendance at hospital.  3.60 There is good recognition that mental health difficulties, adults being subject to violence and problematic substance misuse can have an impact on parenting and the safety and wellbeing of children. This has led to targeted support and services focussed around helping adults with family life and their parenting role. There is  31  Official little such emphasis on the need to understand and address childhood sexual abuse, its impact on the individual and in their parenting role. 3.61 There is local guidance about dealing with non-recent child abuse which may need review in light of this LCSPR.  l) The multi-agency response to child sexual abuse  Strategy meetings  3.62 Over the course of the review period there were many strategy meetings/discussions convened to consider the circumstances of the four children subject of this review. There is locally a CSA pathway that makes clear the importance of multi-agency attendance at these meetings, including appropriate health and education colleagues. The reason for this is that these professionals can provide expertise generally regarding children’s needs, particularly the requirements of child protection medicals, paediatric assessment and medical examinations in the context of child sexual abuse.  3.63 Multi-agency professionals also provide expertise about the specific needs and circumstances of the children being discussed. This is particularly important where children are to be interviewed through child protection enquiries or police investigations. Information can be provided about a child’s communications needs and style. Education colleagues know children well and can provide a sense of the child’s day presentation and can help ensure the strategy meeting is focussed on the needs of the child. 3.64 Most strategy discussions that took place only included social workers, their managers and police officers. This was despite all the children having extensive contact with health and educational professionals. This meant most of the professionals working with the children were unaware of the detail of the concerns; they knew a strategy meeting had been held and sometimes they knew the outcome. They did not know the detail of the concerns, could not contribute their expertise, contribute to the analysis of the children’s circumstances, or advise about communication style and how best to undertake interviews. This was essential information. These professionals then were left to work with the children and their family in silos, unaware of the seriousness of the concerns, and unaware of the need to look out for signs and indicators of abuse.  3.65 It is also important to note that during the period under review there was inconsistent use of follow up strategy meetings. In complex family circumstances these are essentially for following up on actions, thinking about the outcomes of ABE/VRI interviews ( see that section of this Finding) and seeking to ensure all evidence of child abuse has been collated and understood.  3.66 It is essential that strategy meetings are multi-agency, and that health and education colleagues are enabled to attend. The reasons for this lack of compliance with existing guidance in this situation is not clear. There are pressures on all agencies  32  Official when  strategy meetings/discussions need to be convened at short notice  due to the immediate risk of harm to a child. Reviews nationally have suggested that it can be difficult for health and education colleagues to find cover at short notice to cover essential teaching and clinics. There is no evidence that this was the case here. This matter of urgency can be addressed by follow up strategy meetings after the emergency. Clearly multi-agency colleagues must seek to understand why they were not invited to a strategy meeting when they become aware that one has been held regarding a child they are working with/know. Ultimately use of the conflict resolution/escalation procedures may be necessary. Clearly there is some work to be done about the importance of multi-agency strategy discussion across the partnership. The importance of child protection medical examinations  3.67 A child protection medical, also known as a CP Medical, a section 47 medical or a paediatric medical assessment is completed where there is concern that a child might have been physically or sexually abused or significantly neglected.  The purpose is to establish the holistic health and wellbeing of the child and to establish if there is any medical evidence of abuse or neglect.  This should always be discussed at the strategy meeting held about a child(ren) and as part of any child protection enquiries or police investigation.  3.68 In the context of child sexual abuse a medical examination is required whenever a child has made an allegation of sexual abuse, sexual abuse has been witnessed (because, for example, the child has been identified from online images of abuse), or a referring agency suspects abuse has occurred. Guidance describes a medical examination for child sexual abuse as:  “…[a] comprehensive assessment considering the physical development and emotional well-being of the child or young person against the background of any relevant medical, family or social history … This enables a full evaluation of the degree of significant harm suffered, or likely to be suffered by the child … Evaluating significant harm in sexual abuse includes not only the documentation of any genital and or anal injury but also any accompanying physical injury, the possibility of a sexually transmitted infection or pregnancy and the short/long term psychological or psychiatric sequelae. This assessment must also lead the planning of any ongoing investigation or treatment required by the child and appropriate reassurance for the child and family.”xxxiv  The guidance notes that “the health needs of the child are paramount in approaching any medical examination, whatever the alleged circumstances leading to the need to gather forensic evidence”. 3.69 Medical examinations when child sexual abuse is disclosed or suspected have wide benefits including identifying forensic and evidential findings and providing a holistic assessment of the health and wellbeing of children who have experienced sexual abuse. This includes addressing unmet general, mental and sexual health  33  Official needs, assessing risk (including for self-harm and suicide) and providing feedback and reassurance from health professionals to children and carers. 3.70 There is evidencexxxv that despite the holistic benefits to children of a medical examination, many children are not referred for one. This is due to some misperceptions that their primary purpose is to gather forensic evidence and therefore in situations where professionals become aware of non-recent allegations of sexual abuse or situations where the referral of concern falls outside the timescale for forensic evidence, that a medical assessment is not necessary. Research has also suggested that some professionals feel that the medical examination process may be harmful to children and young people. It’s important that practitioners who engage with children prior to a possible referral for medical examination have the knowledge and confidence to provide information and advice to children and non-abusing parents and carers. Information about the purpose and process of medical examinations has been producedxxxvi. 3.71 In response to concerns in August 2018 that Paul might pose a sexual risk to children, the social worker completed a comprehensive referral for medical examinations for all the children in the extended family he was known to be in contact with. These were comprehensive, provided a full history of what was currently known and the recent concerns. This was good practice.  3.72 When there were concerns about possible harmful sexual behaviours regarding Anya, a decision was made not to refer for a medical, because there “was no need for forensic” evidence.  This demonstrated a lack of understanding of the purpose of the medical assessment which is to ensure the wellbeing of a child. 3.73 In early 2018 there were concerns regarding unusual bruising to Lena. Appropriately a referral was made for a child protection medical. This referral did not include full information about the family circumstances , the long history of neglect, or that there had been historical concerns about child sexual abuse. The medical therefore took place in isolation form all other known information. This separation out of information and making a choice about what information should be shared with whom, what information is necessary, does not represent good partnership practice or promote a holistic approach to children. It is not that there was active withholding of information; more that historical concerns had not been established (see Finding 4) and a belief that information was being sought from a specialist who did not need to know wider information to decide about the nature of the bruising.  3.74 Medical examinations are critical for understanding a child’s holistic health needs, as well as part of evidence gathering. There is no evidencexxxvii that children find them distressing, if the child and family is well prepared, and their wishes and feelings acted upon. It is important that those charged with undertaking the medical assessment understand family history of concern and current known issues, to evaluate medical issues in a holistic way.  34  Official Joint police/social work enquiries and ABE/VRI Interviews 3.75 Within this review there were several occasions where either children made direct disclosures that they had been sexually abused or there was video evidence of the abuse taking place. This led to the decision that there would be a joint enquiry between the police and children’s services, with the police being the lead for the criminal investigation and children's social care the lead for the child protection enquiries into the child's welfare and future safety, in line with existing guidance. There have been falling numbers of convictions for child sexual abuse committed by adults. In 2019 -2020 of all the offences reported, only around 5% proceeded to prosecution, and of those around 4% were prosecutedxxxviii. This was despite a rise in reports from the previous year. It is therefore critical that all joint enquiries for child sexual abuse are carefully planned. This starts with the strategy meeting, and a clear ongoing process for continued information sharing across the enquiry. A picture has emerged nationally and locally of the police and children’s social care enquiries happening in parallel from each other, without information being shared, discussion of how to establish evidence and particularly in the conduct of ABE/VRI interviews. What has emerged in this review and others is not so much joint enquiries between the police and children’s social care, but parallel enquiries, which may intersect, or not, at certain points. What is required is genuine joint working. 3.76 The ABE/VRI is an important part of the evidence gathering process. The process of these formal interviews of children is laid out in guidancexxxix. This guidance makes clear the importance of planning the interviews, including taking account of the children’s developmental needs, cognitive abilities, communication needs and though not stated in the guidance, issues related to trauma. This planning includes decision who should lead the ABE/VRI, a police officer or social worker. The decision is to be made in the best interests of the child, but both parties must be trained to undertake ABE/VRI interviews. Once this decision is made, it is also important to seek advice from those who know a child well, including foster carers, residential workers, teachers, speech and language therapists, CAMHS professionals etc, to seek guidance about the best way of communication with this child and making the most of the interview. Intermediaries may also be used. 3.77 Rosa, Anya and Whitney were all ABE/VRI interviewed. These interviews were only ever undertaken by the police, with the appropriate use of an intermediary. There was little discussion of the role that each child’s allocated social worker would play, and it was never considered that a social worker could and should lead the interview. In fact, the social workers for the children were only included once, and that was to transport a child to the interview. This was caused by custom and practice developing nationally and locally that only the police can undertake ABE/VRI interviews because they are criminal processes. The current picture is further complicated by the fact that very few social workers have access locally and nationally to ABE/VRI training. Thus, a circular problem.  35  Official 3.78 The ABE/VRI for all the children were sensitively carried out, and the guidance was followed by pre-meetings before the interview itself. What did not happen was that advice was not sought from those who knew Rosa, Anya and Whitney well and understood their communication needs and style and were aware of their emotional needs. These interviews took place in total isolation. The transcripts were not shared with children’s services and there was no detailed discussion about the content of the interviews beyond “no disclosures” being made. There remains confusion locally about whether the transcripts of these interviews can be shared. In the absence of the social worker being present, it is hard to know how they can fulfil their role to safeguard a child in the future and ensure their welfare needs are addressed, if they do not know what was discussed.  3.79 This review has found that different professionals were told different bits of information by Rosa. The absence of any discussion about the content of the ABE/VRI interviews meant that information was not triangulated. For example, after one ABE/VRI interview Rosa told the residential workers that she had spoken to the police about her mother abusing her and she may well have believed that she had. In fact, the interview had not covered likely abuse by mother, just whether she knew it was occurring. The social worker was told that Rosa had made no disclosures about her mother, but if she had seen the interview transcript, she would have known that this had not been fully covered in the interview, before Rosa brought the interview to a close. This is provided as an example of the importance of a full discussion of all concerns, and a detailed analysis of what was said within the interview, as well as outside of it. There should always be a discussion about the role of the social worker within the interview process. The initial strategy meeting should be clear about planning the whole joint investigation, including the ABE/VRI interview and the detail of the allegations, and what is already known. There should then be a follow up strategy meeting to explore the information shared. It was only when a full chronology of allegations made by the children to different professionals at different times was completed did it become clear that the ABE/VRI created a partial picture. 3.80 The information for this chronology of allegations included the conclusions and analysis contained in the police crime reports. This was detailed information that was not available to any other professional. The outcome of the criminal investigation was shared, but the detailed analysis of why no further action could be taken was not. There remains confusion locally about whether this information can be shared, once a criminal investigation is over. For these children, the emphasis was on them providing the evidence to enable criminal action to go ahead. The conclusion was always that because of the limited nature of the information provided within the ABE/VRI criminal action was not possible. There was not enough emphasis on the police, children’s services and other professionals working together to pool information and evidence, plan the ABE/VRI and compare notes afterwards. It is the role of the multi-agency group to establish all  36  Official evidence available to support the police enquiries and establish a picture of child sexual abuse using all available evidence, not just relying on the child’s testimony. Victims right to review  3.81  In June 2019 Rosa (aged 14) made an allegation of rape by Paul on several occasions. She was interviewed in September 2019 (a significant delay) and then again in November 2019. This information was shared with the criminal prosecution service (CPS) who decided there was not enough evidence to act. It remains unclear how this decision was communicated to Rosa or whether it was made clear to her that she had the right to review the decision.  3.82 The Victims’ Right to Review (VRR) scheme29 enables victims of crime to seek a review of the Crown Prosecution Service decisions not to start a prosecution or to stop a prosecution. The scheme was launched in 2013 and it is also an entitlement included in the Code of Practice for Victims of Crimexl. There are no age restrictions in respect of those entitled to seek a review under the VRR scheme. There are clear criteria for who can submit a request for review on behalf of the victim, including parents or guardians where the victim is aged under 18.  Referrals can be made from other appropriate persons connected with the child.  3.83 This advice should have been given to Rosa and a discussion held either in the strategy meetings or her “child in care” looked after reviews about how she could be supported if she wished to challenge the CPS. In adult cases of adult sexual assault, there is always a police family liaison officer who would take responsibility for providing this advice. In child sexual abuse cases, no such role exists, and there is currently a vacuum about who should know this right exists on behalf of a child and who should support them through the process.  Criminal Injuries compensation scheme  3.84 One of the key issues emerging in this review is that Rosa and Anya feel there has been no criminal action possible when they have told those adults and professionals around them that they were abused by Paul. The reasons for this are well recorded in the police records and relate to evidential matters. The right to review has been highlighted above, but a further remedy, and a sense of justice for the victims of child sexual abuse is the Criminal Injuries Compensation Scheme (CICS) (2012)xli. This scheme seeks to financially compensate victims of violent crime. A child or young person may be eligible if they have been subject to a physical attack, threats against the person which caused fear of immediate violence or sexual assault to which the child did not consent; these incidents must have been reported to the police, no matter how long ago they took place. The Criminal Injuries Compensation authority provides advice about eligibility.   29 https://www.cps.gov.uk/legal-guidance/victims-right-review-scheme  37  Official 3.85  Applications should always be made as soon as possible and in general, must be made within 2 years of the event giving rise to the claim. However, where the applicant was under 18 at the time of the incident special provision is made regarding timescales as follows: • If the incident or period of abuse was reported to the police before the young person turned 18, a claim will be accepted up to the young person's 20th birthday. • If the incident or period of abuse took place before the young person turned 18 but was not reported to the police at the time, a claim will be accepted within two years of the date when the incident was first reported to the police. 3.86 An application for compensation should be made by the victim. If the victim is under the age of 18, the application must be made by those who have Parental Responsibility. If the victim is subject of a Care Order, the Criminal Injuries Authority will expect any application to be made by the Local Authority named in the order. Where a child is not subject of a Care Order, but may be living away from home, responsibility for making an application rests with those who have Parental Responsibility, whom should be advised to take appropriate advice. This includes a solicitor, Victim Support and the Citizens Advice Bureau. 3.87 The professionals working with Rosa, Anya, Whitney and Lena were not aware of this process. The absence of a family liaison officer from the police in cases of child abuse means this advice is not routinely provided. It is not outlined as a requirement in the local procedures.   Professionals need to be reminded of the requirement to consider children’s rights to criminal compensation, and advice about how to achieve this, needs to be included in local procedures. Use of the Complex abuse procedures  3.88 The local child protection procedures make clear the need to convene a complex child abuse strategy discussion and onward enquiries in situations where there are concerns about abuse involving one or more abusers and several children from different households (or other settings). The Strategy discussion/meeting must carefully consider the children about whom there are concerns, other children who may be in contact with the abusers, vulnerable adults and possible victims who are now adults. The reason to hold this discussion in this way is because mapping exercise will need to be undertaken, several different households considered, and potentially multiple interviews and enquiries undertaken. The emphasis here is understanding the connections and reach of abusers and the implications of this for children. 3.89 When the initial concerns were shared about Paul in 2018 there was a first strategy meeting. This was chaired by an appropriately senior manager from children’s services, attended by all the social workers working with the different parts of this  38  Official large extended family and police officers were present. There was no multi-agency representation. This meeting was an opportunity to bring all the information about potential abusers, the number of children who were at risk of harm and family history together. What emerged at this meeting was that there were at least two abusers, Paul and his female partner, a long history of concerns about family members being sexually harmed by those within the family and outside of it; these alleged abusers were still known to adults and children in the family. This should have led to the convening of a complex strategy discussion. Indeed, this was recommended by the consultant community paediatrician who attended a subsequent strategy meeting.  3.90 It has not been possible to establish why this did not take place. The consequence was that concerns of child sexual abuse within this large extended family were investigated separately, with each individual family considered as a unit on its own, the adults in contact with them were not considered, and connections across this whole group not made.  A superficial mapping exercise was conducted, but no chronology of the family connections and historic and current allegations undertaken.  3.91 An example of the lack of connections being made was concern expressed about a social club for young people/adults with learning and physical disabilities that Paul and Lena’s mother attended. This is where Paul, who did not have either a learning disability or physical disability, met two women with care and support needs who he abused and exploited sexually. As part of the enquiries undertaken as part of the LSCPR it became clear there were more general concerns regarding safeguarding arrangements within the club; as a community interest company these concerns had been difficult to address. This community interest company has now been designated as a relevant agency under the auspices of Working Together 2018xlii and needing to be compliant with local and national safeguarding processes.  3.92 The lack of connecting the family members and adults of concern together also meant that the social workers working with each family were left with what seemed an impossible task, each trying to make sense of the whole family circumstances from the perspective of separate family groupings. There were times that they came together, but there remained, and to some extent remains uncertainty about information sharing requirements in these situations. There was a perception that information gleaned from one part of the family, could not automatically be shared with those working with another part of the family.  3.93 The convening of the complex abuse strategy discussion would have started those conversations, but the absence locally of any guidance for working with large extended families with a history of sexual abuse, physical abuse and neglect, with multiple potential abusers and many children at risk of harm and what information can legitimately be shared, did not help in this situation.   39  Official 3.94 Evidence emerging from this review is that the complex case strategy discussions are now being more routinely convened. The next step is guidance for working with complex extended families. Recommendation 1: The Safeguarding Partnership should develop a local agreement to ensure the correct agencies are part of strategy meetings.  The absence of health representatives from across the health economy and education representatives at these meetings is a serious gap.  Recommendation 2: There is a need to consider the appropriate commissioning of services for children who have experienced child sexual abuse and for families who are supporting children in the aftermath of child sexual abuse. Recommendation 3: There is the need to reinforce the importance of children’s access to appropriate therapy while police investigations are continuing.   Recommendation 4. The Safeguarding Partnership should develop guidance regarding complex and historic abuse investigations   Recommendation 5. Police should be reminded of the importance of considering a range of risk management measures including Sexual Risk Orders. Recommendation 6.  The signs and indicators template commissioned by the Home Office and published by the Centre of Expertise on Child Sexual Abuse should be disseminated to all agencies and its use encouraged by the Safeguarding Partnership.   Recommendation 7.  The communicating with children about child sexual abuse resource commissioned by the Home Office and published by the Centre of Expertise on Child Sexual Abuse should be disseminated to all agencies and its use encouraged by the Safeguarding Partnership.   Recommendation 8.  The meeting the needs of parents and families impacted by the sexual abuse of children commissioned by the Home Office and published by the Centre of Expertise on Child Sexual Abuse should be disseminated to all agencies and its use encouraged by the Safeguarding Partnership.  Recommendation 9.  The local and regional safeguarding procedures regarding child sexual abuse need to be refreshed to take account of communicating with children, building a holistic picture of children’s circumstances, an assessment and understanding of the non-abusing parent, the behaviour of the adult who poses a sexual risk to children, the requirement to undertake criminal injuries compensation processes and to raise for children and their parents the victims right to review.  Recommendation 10: There is a need for a regional look at what “joint” child protection enquiries between the police and children’s services looks like in the absence of a national policy or guidance framework.  40  Official Recommendation 11: An information sharing protocol between the police and children’s social care regionally needs to be established regarding what information can be shared in the context of child sexual abuse. Recommendation 12: The Safeguarding Children’s Partnership should develop guidance about how the outcome of assessments, child protection enquiries and police investigations and their progress are communicated in a child centred way to children. Finding 2: A structured approach to child neglect 3.95 Rosa and Anya experienced neglect from when they were born. Their experiences were persistent and pervasive. Support was provided over time, in the form of family support, child in need plans and child protection plans. It is reported that over time the family circumstances improved, but there is little mention of whether Rosa or Anya’s outcomes improved, and there would quickly be a deterioration. This is a very typical circular pattern with the neglect of children, with short term improvements, followed by a deterioration in circumstances followed by increased support and so on. This leaves children living in chaotic circumstances. 3.96 There were concerns in 2017 that Whitney was being neglected by her mother. These referrals were made by Paul’s mother, Whitney’s grandmother. These concerns were addressed quickly through a child in need plan, with good multi-agency involvement and a focus on supporting mother with her mental health needs, substance misuse and to make sense of the domestic abuse she had been subject to.  3.97 Lena and her siblings also experienced neglect from birth. Their mother had learning disabilities, and father physical difficulties. Support was provided, and much like Anya and Rosa the children’s needs were met some of the time, and then there would be a deterioration.  3.98 What was missing for Rosa, Anya, Lena and siblings was a consistent naming of neglect as an issue of concern and a holistic and detailed assessment of neglect. 3.99 The neglect of children by their parent (primary caregivers) is a serious issue which has a significant and long-lasting negative effect on children’s developmental outcomes, their safety, their emotional wellbeing and the impact often lasts into adulthoodxliii.   Child neglect is a complex area of practice which requires a structured and analytical responsexliv. Professional practice often focusses on one question; is this neglect- rather than thinking there are several key questions to be answered as outlined within the definition in Working Together 2018xlv. These questions are: • Persistence: what is the history, child’s journey and how effective have efforts to create change for children been?  41  Official • What type of neglect are children experiencing and is it global - present across all domains?  o Physical o Emotional o Educational o Supervisory o Health  • What is the known impact on the child?  • What is causing the neglect • Is the neglect an act of passiveness/omission or is there evidence of a deliberate and targeted approach to the child characterised by commission • What other abuse is the neglect enabling? •  3.100 This finding will explore the extent to which these questions were considered in relation to Rosa, Anya, Whitney and Lena’s family circumstances. How persistent and pervasive is the neglect and have services designed to create change been successful 3.101 There is general national reluctance across the professional network to “name” concerns about neglectxlvi and this was also apparent in this review. This meant that the persistent and cumulative nature of it was not understood for these children. This naming of neglect from its earliest manifestations is important to track the development of neglect over time and to be aware of both positive and negative changes in the outcomes for children. It is part of telling a child’s story, but also thinking about whether interventions designed to make a difference have helped. This can be an opportunity to think about the strengths of families to create change, despite how difficult this can be. Or to recognise that efforts to create change have been unsuccessful and need review both in terms of the appropriateness as well as a parent/caregiver’s capacity, ability and willingness to change in the best interest of their child(ren).  3.102 Concerns about the neglect of Whitney were named and addressed. With Rosa and Anya, the focus was on the state of the home, poor boundaries and sexualised behaviour; neglect was named when the children were subject to child protection plans, but overall concerns were often narrowly focussed on home conditions; this was also true for Rosa and Anya.  What type of neglect is occurring? 3.103 It is important to think beyond a child/young person physical environment and how they are physically cared for. Physical care is an important factor and there was evidence that there were problems associated with the physical environment in which the children were living and the physical care they received. This was however just part of the pattern of neglect. There was a general limited focus on  42  Official home conditions for all the children in this review without thinking about their wider circumstances. Rosa and Anya lived in often squalid home circumstances, as did Lena and her siblings. The professional response was to provide support to address this, without seeking to understand in detail what had caused these conditions in the first place.  3.104 Health needs: There were considerable concerns about the fact that Rosa and Anya had not attended the dentist for many years, they often presented with headlice which were not treated. They were underweight and it became apparent that they had no routine around food. Unsurprisingly they gained weight when they attended residential school. Lena was often not brought for routine health appointments. Anya and Rosa’s education needs were not met, they spent time being home educated in unsuitable circumstances. Lena and her siblings appeared at school looking tired and unkempt, impacting on their ability to learn. The supervision arrangements for all the children were of concern. They all spent time at the home of Rosa and Anya’s mother (Lena and Whitney’s grandmother) and there were often parties happening whilst they were there, with many adults, alcohol misuse, and the police being called because of arguments and disputes. When Rosa reported being sexually assaulted by a peer this was not responded to by the parents and over time there was evidence that her parents did not prioritise her safety. In terms of love, care and emotional warmth there were many assertions within reports of Rosa and Anya’s mother’s love for them, without a reflection on the reality that she asked them to keep secrets, not talk about what went on at home, disrupting their help seeking behaviour. There is little information available about the demonstration of good attachment relationships, love, care and warmth for Lena and her siblings by her parents, but there is evidence that their mother would often be late to pick them up from nursery, having reportedly been at the pub, and other incidents where there was an absence of her ability to keep the children’s needs in mind.  What is the impact on the child and what action is intended to address this? How will we know it is working to improve child outcomes? 3.105 It is important to be clear about what the impact of parental neglect is on children to ensure that services and support are addressing these and creating change in their developmental outcomes. The impact on Rosa and Anya of the neglect they were experiencing was not articulated and the impact on their development not fully considered. Their learning needs were accepted as part of who they were, not of the abuse they had experienced. Their small physical stature and low weight was questioned, and thought given to its cause, but failure to thrive in the context of long-term neglect was not considered. It is essential that all assessing health professionals are fully aware of all the concerns about neglect and abuse to recognise the potential impact when considering problems with multifactorial causation. What is causing the neglect and have interventions been targeted in these areas?  43  Official 3.106 It is critical in the professional response to neglect that there is an analysis of why the neglect is occurring to target interventions appropriately and be sure that change has occurred. All the children had some learning disabilities, speech delay and health needs, which were too readily accepted by professionals as genetic or developmental, rather than being attributable to the neglect they were experiencing. For example, there were concerns about Anya and Rosa not gaining weight. Professionals worked hard to establish a medical cause, considering their genetic inheritance, medications for epilepsy, and possible psychological difficulties. Their mother reported that there were no issues at home with food, except that they were “picky eaters”. The issue of whether this lack of weight gain was caused by a failure to thrive because of neglect was not discussed.  3.107 There is little evidence that the “why” or cause of the neglect that these children were subject to was sufficiently discussed. For Anya and Rosa, the neglect could have been caused by several different parental factors. Both their parents had significant learning disabilities. There was evidence of substance misuse and previous domestic abuse. This was also true for Whitney in 2017, whose mother also experienced poor mental health, domestic abuse and substance misuse. Her father had experienced sexual abuse as a child, was the perpetrator of domestic abuse, was violent, misused substances and had mental health crises leading to suicidal ideation. Lena and her siblings lived in a household where their mother had experienced sexual abuse as a child, likely associated mental health concerns, she had significant learning disabilities, was subject to domestic abuse and she misused alcohol. Their father had physical difficulties, experienced depression and was isolated. The professional plans for Whitney did address these parental concerns very successfully. There was also recognition of the circumstances of Lena’s parents, but a lack of connection to neglect and an action plan to address causal factors. The reasons why Anya and Rosa were being neglected by their parents received less professional attention.  3.108 Professionals did recognise that the children’s needs were not always being met, and genuinely wanted to improve their circumstances, but they often jumped into providing concrete solutions, rather than stepping back and thinking about what was causing these difficulties and what needed to be done about it. If neglect is to change these causal factors need to be understood in the context of parenting capacity, relationships with children and attachment behaviour to promote the health and wellbeing of children.  Is the neglect passive or active: omission or commission? 3.109 Neglect is often seen as passive; parents unable to provide appropriate care to their children due to their own individual difficulties such as learning disability, poor mental health, substance misuse or being a survivor of domestic abuse and the attendant impact on self-esteem and wellbeing. There are occasions when neglect is an active process; the child is deliberately not cared for by a parent, seen as too  44  Official difficult and problematic to be able to be parented, and then blamed for the lack of care they receive. This is a serious issue which causes long term harm to children.  3.110 Whitney’s mother recognised that she had not met Whitney’s needs; she understood through support what had caused this and acted appropriately to create change. She at no point blamed Whitney. Less is known about Lena and her sibling’s parents and the extent to which their neglect of the children was entirely passive, an act of commission. There is certainly evidence that they put their own needs to go drinking or to parties at the extended family home, above the needs of the children. Anya and Rosa’s mother often blamed their behaviour for making it difficult to meet their needs and respond appropriately to their care. She told family support workers that they were unkempt due to their disabilities, and that their behaviour was not caused by a lack of boundaries, but their complex needs.  3.111 It is essential that professionals consider whether the neglect of children by their parents is deliberate, targeted and blaming. As professionals we need to imagine what it is like not to receive the care that you need to grow and develop appropriately, and then for this to be characterised as your own fault because you are too difficult or too damaged. Child blame and a parental focus on the child as the problem to be fixed needs early professional attention. Where parents hold these beliefs, services designed to address neglect are often ineffective because the parent perceives the child to be the problem that needs fixing What other kinds of abuse is the neglect enabling? 3.112 The final area of concern or analysis to address is how does the neglect of children enable other forms of abuse to occur. There is a strong connection between neglect and child sexual abusexlvii. This appears to be caused by factors such as poor supervision, lack of quality parent-child relationships, poor sexual boundaries in the home, domestic abuse, coercion and control and adult needs dominating decision making by parents.  3.113 Poor supervision, a lack of sexual boundaries, use of drugs and alcohol, and the presence of several adults, acceptance it seems of sexual activity, all contributed providing the facilitating circumstances to Paul sexually abusing all these children in the home he shared with Anya and Rosa. Anya and Rosa’s mother and father’s evident need to shut down what Rosa and Anya wanted to tell professionals was both neglect and emotional abuse.  3.114 These were all important questions to ask about the circumstances of these four children. Neglect is multi-faceted. As professionals we need to move from a focus on the physical circumstances that the child lives in or the physical care, they are provided with to thinking about how all developmental needs are met, and the likely impact if they are not. Professionals must consider a parent’s understanding of the need for change, why it is necessary and commitment to change behaviours and unhelpful parenting approaches in the best interests of their child; in essence helping parents hold their child’s need in mind.   45  Official 3.115 The local area implemented a neglect framework and toolkit in 2018. It became clear through interviews that many professionals were not aware of it, and it was not used in any of these family circumstances. Given the complexity of neglect, more thought needs to be given locally to what would make a difference to providing a more effective response to situations where neglect is long term, has been resistant to change, is characterised by parental hostility to help, where parents often lie about or mislead professionals about their and their children’s circumstances. It was evident through interviews with professionals that Rosa, Anya’s and Lena’s parents often provided a false and misleading picture, lied to professionals and denied the presence of unsuitable adults or professional concerns.  This was inconsistently acknowledged, acted upon or analysed in the context of both understanding neglect and in addressing child sexual abuse. A culture has grown up around calling this parental behaviour “disguised compliance” as though this is a sufficient explanation of what professionals’ are seeing. What is required is an acknowledgement when parents lie, mislead or avoid, and an analysis of what this means for the child and their circumstances and reflection on the meaning for the parent in the context of their current circumstances.  Recommendation 13: A review and audit of the neglect framework and is recommended to determine its impact on the issues raised in this report. Recommendation 14: The reduced frequency of professionals’ meetings locally has been highlighted. Concerns about the validity of such an approach should be addressed and the guidance regarding professionals meeting circulated to partners.   Finding 3: Responding to the needs of Learning Disabled adults as parents  3.116 Rosa, Anya, Whitney, and Lena’s parents all had learning disabilities and physical disabilities. As a result of the care proceedings undertaken about Rosa and Anya, it was known mid-way through this review that their parents had IQ’S within the low range of a mild learning disability. This low range, an IQ of 52 for father and 60 for mother puts them both in the category of adults with learning disability for whom parenting would be a known difficulty and they would require considerable support. The level of Lena’s mother learning disability was not known, but professionals understood it to be in the low range.  Whitney’s mother had mild learning needs which did not fit the criteria for a learning disability, but which did fall into the category of requiring careful thought about communication and to ensure that information was understandable and comprehensible. 3.117 A learning disability is defined by the Department of Healthxlviii as a   “Significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood and may be mild, moderate or severe in nature.   46  Official 3.118  There is good evidence that adults with mild learning disabilities can be and are good parents; however, when their IQ falls below 62 there are likely to be real challenges in fulfilling the requirements of parenting. This parenting can be further compromised where there are additional concerns about mental health concerns, abuse and neglect in childhood and substance misusexlix. Learning disabled parents disproportionately suffer from depression and poor mental health, partly due to societal attitudes, and often poor social networks, but also due to the increased risk that they will have been sexually, physically abused and neglected in childhoodl. There is also evidence that learning disabled adults, and those that are parents, are disproportionally impacted by exploitation and bullying within the community which can further impact on parenting abilityli.  3.119 Parents may have difficulties with reading, understanding complex verbal communication and abstract concepts, telling the time, remembering appointments, retaining information, problem solving, decision making and organisational skills, struggles to understand other’s needs, including children and verbal reasoning. They may find it takes longer to acquire new skills, such as parenting and managing children’s behaviour, and to make use of mainstream approaches to teaching those skills. In this context they need and are entitled to support to fulfil their parenting role.  3.120  Legislation and Guidance makes clear the importance of ensuring that adults with disabilities are supported to fulfil their parental rolelii. The Convention on the Rights of Persons with Disabilities (2006) article 23 (2)liii states “Parties shall render appropriate assistance to persons with disabilities in the performance of their child-rearing responsibilities. This right needs to be set alongside the duty of the State (through local authorities) to safeguard and promote the welfare of children, as set out in the Children Act 1989liv with the welfare of the child being the paramount concern. In essence the support provided to parents’ needs to be child centred and child focussed. It must not replace the parenting role or introduce several adults into the life of a child which can disrupt attachment and the development of core relationships. The support must be consistent, predictable and reflective of normal family life, as far as is possible. This requires a clear plan detailing expectations and boundaries.  3.121 The Good Practice Guidancelv about working with parents with learning difficulties makes clear what best practice looks like: • Appropriate communication: providing easy read versions of reports including visual aids and supplementing written information with clear and straightforward verbal explanations and not using font size 14 or below.  • Provision of consistency; adults how are concrete thinkers do not need a multitude of advice from different professionals; there needs to be constancy in approach and advice; this  47  Official could include the use of an advice diary when there are multiple professionals visiting the family home.  • An approach which is focused on demonstrating what change looks like and straightforward explanations of concerns and why they are important, particularly in the context of child wellbeing.  • Taking time; parents with learning difficulties need more time to build relationships, learn new skills and understand concerns; practice does not always allow this.  • Parenting with support; research suggests that parents with learning difficulties need longer term support. This means avoiding the “revolving door approach”   • Provision of advocacy   3.122  Addressing the needs of adults with learning disabilities and difficulties and ensuring that there are appropriate reasonable adjustments to services and response is made more complex by the fact that many adults will not have a formal diagnosis. This was the case for the parents of the children in this review. Despite that, all professionals were aware that most of the adults in the family had some form of learning needs and therefore they should have considered the importance of making reasonable adjustments as required by the Equalities Act 2010lvi and the existing best practice guidancelvii.  3.123 There is no evidence that within the early help responses, child in need plans and processes, child protection conferences and plans and looked after reviews that the parents of the children were provide with reports in an easy read format. The current format, small font, single spacing and dense paragraphs would make it impossible for anyone with even a mild learning difficulty, let alone a diagnosed learning disability, to understand.  3.124 When it became clear in 2018 that Paul posed a sexual risk to children, the parents of Rosa, Anya, Whitney, and Lena were asked to sign written agreements not to allow Paul contact. The use of the written medium is not appropriate for parents with learning disabilities and there is no evidence that they understood what the written agreement was about. There is a more general point to be made about the use of written agreements to ensure the safety of children. The fact all the parents signed the documents was interpreted as both an indication of their understanding of the risk posed by Paul, an understanding of the professional concerns and their capacity and willingness to comply. The evidence suggested that none of these factors existed.   48  Official 3.125 Learning disabled children are more likely to be sexually abused in childhood than their non-disabled peerslviii, and in adulthood they are more likely to be sexually harmed, domestically abused, and exploited by partners and others in the community who are more cognitively able than them. This vulnerability to exploitation in adulthood needs careful exploration and assessment in the context of parenting and family life. Lena’s mother talked about being sexually abused as a child, and there was evidence of this in historic records. When she was pregnant with her first child, she was referred to adult services for support as a leaning disabled parent. She did not meet the threshold for services as an individual with care and support needs under the Care Act 2014lix and there remains something of a gap, evidenced by the experiences of several learning disabled parents within this extended family group, of a lack of services targeted at learning disabled parents, and a lack of a protocol or agreement between adult and children’s services. Lena’s mother never got the targeted support she needed. 3.126 More worryingly, Lena’s husband was asked to be the main carer for the children, but also for her. This decision did not take account of how this arrangement might impact on the children, their experience of mothering, or how this enhanced power bestowed on one partner, might exacerbate domestic abuse. There was concern that Lena’s father may have been physically and sexually abusive to Lena’s mother, but there was little analysis of this in the context of his role as main carer. A second family, part of this extended family group, were in the same situation. The vulnerability of learning disabled adults as parents to violence and abuse needs recognition, and an appropriate response.  3.127 The finding in this report looks at the importance of the causes of neglect. It is critical that there is a good assessment of the connection between parental learning disability and neglectful parenting. This is to ensure that the right support is provided, focused on the learning disability itself, including parental understanding of the child’s needs as well as ability to form attachment relationships, but also taking account of other factors such as poor mental health, experience of child and adult abuse, substance misuse, poverty and isolation. A holistic assessment is needed.  3.128 The research suggests that the professional response for learning disabled adults as parents can be to focus exclusively on the learning disability, often seen as a limiting factorlx, and issues such as depression, substance misuse and domestic abuse are not addressed. Both responses are needed. A parent’s learning disability needs to be addressed and reasonable adjustments made, but also other factors impacting on their parenting need to be addressed, in the context of those reasonable adjustments. In this review the learning disabilities were recognised, but not sufficiently responded to. There is also a need to hold parents with learning disabilities responsible for the wellbeing, care, safety and  49  Official love of their children. Researchlxi suggests there are times when learning disabled parents are held to a higher standard than their non-disabled peers, and times when there are lower expectations of care and safety because of the parent’s own needs and vulnerabilities, leaving children at risk of neglect and abuse. It is apparent that both dynamics were at play across this extended family group. Recommendation 15: The Safeguarding Children’s Partnership needs to provide guidance, based on the existing national guidance regarding practical resources for working with and communicating with learning disabled parents. Recommendation 16: The Safeguarding Children’s Partnership should facilitate some discussion between children and adult services locally about how support can be provided to adults with needs that do not met the criteria for adult services support, but where these adults do need help to fulfil their parenting role as outlined within the care Act 2014. Finding 4: The importance of understanding family history to effectively safeguard children and support families 3.129 The final finding of this review related to the importance of history. Rosa, Anya, Whitney and Lena’s parents and extended family have been known to children’s services and the police for over 25 years. This involvement consisted of continuous concerns about neglect, physical abuse and sexual abuse across the generations from Anya and Rosa’s parent’s earliest experiences of parenting to the present day. There is no information available about whether Rosa and Anya’s parents (who were grandparents to Whitney, Lena and her siblings and other children) were themselves known to children’s services and the police when they were children. There is no information about their own family history, or their siblings and parents. This was a significant gap. 3.130 Research and serious case reviewslxii have repeatedly shown that historical information is not given the attention that it should be given in assessing the needs of children. The cause was often because important information was not shared, was missing or lost, particularly when the family moved geographically across boundaries or borders. Or where it was available it was not referred to or not analysed in such a way as to see the emerging pattern of increased risk of suffering harmlxiii. 3.131 When there were concerns in 2017 about the care that Whitney’s mother provided to Whitney, an assessment was completed. The role that the grandparents played in providing care to Whitney was known, but their historical involvement in services due to concerns about their parenting, neglect and sexual abuse was not. This meant there was no analysis about their suitability as alternative caregivers or the safety of Whitney being in their home. It was known that Paul, Whitney’s father, lived in his family home with his sisters, Anya, Rosa and their parents. The  50  Official information about previous concerns about his possible sexualised behaviour, sibling sexual abuse and sexual assault of others was not known. This information was not shared by the parents. This meant that work to increase contact between Paul and Whitney went ahead, with a plan that Paul’s mother would supervise. This lack of information was in part due to changes to the electronic recording system in the local authority some years earlier, which meant some records were unavailable, and partly due to a lack of chronologies and closing reports. There had been a gap of several years since Anya and Rosa and their parents had been formally known to children’s services. The gap was of course a serious one. 3.132 When there were concerns in 2017 about Anya being subjected to harmful sexual behaviours and then evidence of sibling sexual abuse, historical information about the long history of concerns about poor sexual boundaries at home and concerns about Paul and sexual abuse were not known. Anya’s sexualised behaviour and experience of being possibly sexually harmed at school, were seen in isolation from this historical information and the seriousness therefore was not recognised.  3.133 When professionals became concerned about Paul, and the sexual abuse of Whitney, there was discussion of the family history, but there was no mapping across all the different family groups. A comprehensive genogram was not constructed, chronologies of the separate family histories was not compiled, and the connections across the family groupings not highlighted. Many professionals outside children’s services were unaware of the family history and the connections between the families. There were some services, however, who were very aware of the family history, both because they had contact with the adults as children, and because this was a family other families talked about. This information became rumour and supposition, and there was general uncomfortableness across professional networks about what was truth and what was not. Information was often dismissed as being rumour and supposition and this served to undermine a professional analysis of the family history. It is important that professionals check the accuracy of information, and that is why chronologies, closing summaries and transfer records from one service to another is so important. The local authority refreshed its guidance about chronologies, transfer summaries and closing reports in 2020. There has been an emphasis locally on the use of third generation genograms and the importance of family history.  What remains unclear is the extent to which information about one family can be used within the records of another family group to whom they are related. There was concern that this somehow breached GDPR30 requirements. This requires clarification. 3.134  These children’s circumstances highlight the importance of family history in understanding children’s circumstances. In his review of serious case reviews from over 20 years ago, Rederlxiv said “the best predictor of present and future behaviour is past behaviour”.   30   51  Official Given that the guidance regarding chronologies, closing summaries and transfer to other services has been updated, no recommendation is considered necessary.  Domestic abuse and sexual violence  3.135 There is not a separate finding which relates to domestic abuse and violence; there is not one adult female member of this extended family who was not subjected to sexual violence and abuse over the time under review and in the past. These same women were also subject to intrafamilial child sexual abuse. There is little evidence of the assessment of domestic abuse, or its analysis in the context of parenting, the neglect and supervision of children.  Domestic abuse is often referred to as “between the couple, within the relationship or within the family”. These descriptions were inaccurate. Within this extended family there were men who perpetrated abuse, and women were the victims. These descriptions excuse the behaviours of perpetrators, deny the reality of victims, and suggest that domestic abuse is a shared issue, with adults being equally responsible and equally impacted.  The impact of Alcohol and Drugs 3.136 There is also not a finding about the role that alcohol and drugs played in the chaotic and abusive nature of these four children’s lives. There are hints across all the records that this was a concern, and certainly contributed to poor boundaries, adults needing hospital treatment and the police being called, but there is little information within the records of the detail of this alcohol use, what part it played in the abuse and neglect of the children. This makes a finding and analysis difficult to achieve in this report. The absence of detailed information and the insufficient recognition of this as an issue that needed addressing is important. Drug and alcohol misuse by parents and family members in the context of children’s needs is a serious issue. Research highlights the negative impact on children’s lives, the negative impact on their development, the ability of adults to meet their children’s needs and the link with abuse and neglect. A good assessment of the use of alcohol and drugs by parents is needed, including the role it plays in undermining parenting and creating the circumstances for abuse. This was absent here. 52  Official  4.  Conclusion  4.1 This LSCPR has focussed on the sexual abuse and neglect of four children, Anya, Rosa, Whitney and Lena. As the dedication at the beginning says, the review recognises their bravery in telling professionals about the harm they were experiencing. Some of the adults in their lives were responsible for this harm, either by directly abusing them, colluding with the harm, or not telling professionals about concerning behaviour.  Sadly, it is likely that there are other children who have been abused that we do not know about, and there are many adults here who experienced sexual abuse as children and sexual harm as adults. Therefore, the report has focussed so strongly on strengthening the professional response to child sexual abuse and its co-existence with the neglect of children. 4.2 It is important to say that when concerns about Paul sexually abusing Whitney became known, steps were taken to assure all the children’s safety, and over time they have been placed in appropriate homes or residential settings. They have also been provided with therapeutic support to address the impact of the harm on them. There are also many professionals supporting these children as they grow and develop. Too many to name. 4.3 There were many professionals involved with the four children and their families. Many of those professionals were unaware of the complexity of the family circumstances and the historical information. To these professionals all the parents of the children seemed to be well meaning, struggling with their own learning needs, health problems and socio-economic disadvantage. The neglect was not fully recognised, and the sexual abuse not known or not seen. There were many professionals such as social workers, family support workers, police officers, ambulance workers and hospital staff who saw or knew of the distress, the alcohol use, the violence and chaos of the adults and there was insufficient questioning of what this might mean for the children in the background. 4.3 There were social workers, residential staff, health staff and police officers who were involved with addressing the sexual abuse of these children. There was a lot of hard work, and we have heard that at times the task seemed overwhelming. There was not an absence of action here, or compassion, but at times a lack of knowledge about how to deal with issues such as sibling sexual abuse, harmful sexual behaviours, distinguishing what is adult sexual behaviour and what is an indication of poor sexual boundaries, how to build a picture of concern and not rely on children’s testimonies, how to build evidence for criminal proceedings by working as a multi-agency group and the importance of feedback to children along the way. It is striking the extent to which joint enquiries between the police and children’s social care have become independent processes, not benefiting from the work of each other and the way in which social workers are no longer part of the  53  Official ABE/VRI process. These are all local and national concerns that need urgently addressing. 4.4 The lack of a consistent impression or understanding of this large extended family across the professional network was caused by the large amount of information that was viewed or perceived as “gossip” or “rumour” and it was thought that it was not permissible to discuss fully in a professional context, because it was not “official information”. This meant the worries about sexual abuse and poor sexual boundaries were often around but did not surface in professional meetings and their authenticity was not clarified. The other influential factor was that there was lack of open discussion about the concerns that children were often silenced, and that adults did not tell the truth, or actively misled professionals. As one interviewee in the review process said, “if you said the sky was blue, (adult x) would say it was green”. Many professionals talked about this in interview, but it was not present as a concern in records and was not part of the analysis within assessments, child in need reports or plans or child protection reports or plans. This review was not able to explore in depth what this was fully about but represents an important issue in understanding these children’s circumstances and the risks posed to them.         54  Official References   i Hackett, S. (2014) Children and young people with harmful sexual behaviours. London: Research in Practice ii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf iii  iv https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ v https://learning.nspcc.org.uk/research-resources/statistics-briefings/child-sexual-abuse vi https://www.csacentre.org.uk/index.cfm/_api/render/file/?method=inline&fileID=CCB6D637-308F-4C6F-95DF0AC61E61E3AA vii Ofsted (2020) The multi-agency response to child sexual abuse in the family environment Prevention, identification, protection and support https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/862454/Multi_agency_response_to_child_sexual_abuse_in_the_family_environment_joint_targeted_area_inspections_JTAIs.pdf  viii https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ ix https://www.csacentre.org.uk/csa-centre-prodv2/assets/File/Sibling%20sexual%20abuse%20report%20-%20for%20publication.pdf x https://tce.researchinpractice.org.uk/wp-content/uploads/2020/05/children_and_young_people_with_harmful_sexual_behaviours_research_review_2014.pdf xi https://tce.researchinpractice.org.uk/wp-content/uploads/2020/05/children_and_young_people_with_harmful_sexual_behaviours_research_review_2014.pdf xii https://www.childrenscommissioner.gov.uk/report/protecting-children-from-harm/ xiii https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/childsexualabuseinenglandandwales/yearendingmarch2019 xiv Darling, A.J, & Christensen, L.S, (2020). Female child sex offenders. In Child Sexual Abuse: Forensic Issues in Evidence, Impact and Management. Bryce, I., & Petherick, W., Academic Press, Elsevier. 119-134.  xvi https://www.csacentre.org.uk/index.cfm/_api/render/file/?method=inline&fileID=7C7BB562-DB13-4C7E-B8C21D04920D6AEF xvii Allnock D. et al (2019). Key messages from research on identifying and responding to disclosures of child sexual abuse The International Centre (University of Bedfordshire) and NSPCC for the Centre of Expertise for Child Sexual Abuse https://www.csacentre.org.uk/resources/key-messages/disclosures-csa/ xviii https://www.csacentre.org.uk/documents/communicating-with-children-guide/ xix https://www.csacentre.org.uk/documents/communicating-with-children-guide/  xxi Independent Inquiry Into Child Sexual Abuse (IICSA) et al. (2017) The impacts of child sexual abuse: a rapid evidence assessment: summary report (PDF). London: Independent Inquiry into Child Sexual Abuse.  55  Official  xxii Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice. https://www.researchinpractice.org.uk/children/content-pages/slides/intra-familial-child-sexual-abuse/  xxiii Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice. https://www.researchinpractice.org.uk/children/content-pages/slides/intra-familial-child-sexual-abuse/  xxiv Jones, L. et al. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet, 380 (9845): 899-907. xxv https://www.csacentre.org.uk/documents/supporting-parents-and-carers-a-guide-for-those-working-with-families-affected-by-child-sexual-abuse/ xxvi Still, J (2016) Assessment and Intervention with Mothers and Partners Following Child Sexual Abuse: Empowering to Protect xxvii Ofsted (2020) The multi-agency response to child sexual abuse in the family environment Prevention, identification, protection and support https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/862454/Multi_agency_response_to_child_sexual_abuse_in_the_family_environment_joint_targeted_area_inspections_JTAIs.pdf xxviii Allnock D. (2017). Intra-familial child sexual abuse. Dartington: Research in Practice. https://www.researchinpractice.org.uk/children/content-pages/slides/intra-familial-child-sexual-abuse/ xxix Finkelhor et all (2016) The Four Preconditions Model: An Assessment. https://onlinelibrary.wiley.com/dAttenoi/abs/10.1002/9781118574003.wattso002 xxx https://www.csacentre.org.uk/documents/supporting-parents-and-carers-a-guide-for-those-working-with-families-affected-by-child-sexual-abuse/ xxxi https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/Protecting-children-from-harm-full-report.pdf xxxii Independent Inquiry Into Child Sexual Abuse (IICSA) et al. (2017) The impacts of child sexual abuse: a rapid evidence assessment: summary report (PDF). London: Independent Inquiry into Child Sexual Abuse. xxxiii https://www.iicsa.org.uk/reports-recommendations/publications/inquiry/interim/nature-effects-child-sexual-abuse/effects-child-sexual-abuse xxxiv Royal College of Paediatrics and Child Health/ Faculty of Forensic and Legal Medicine (2012) Guidelines on Paediatric Medical Examinations in Relation to Possible Child Sexual Abuse. London: FFLM. xxxv https://www.csacentre.org.uk/documents/the-role-and-scope-of-medical-examinations-when-there-are-concerns-about-child-sexual-abuse-a-scoping-review/ xxxvi https://www.csacentre.org.uk/knowledge-in-practice/practice-improvement/medical-examinations/ xxxvii https://www.csacentre.org.uk/knowledge-in-practice/practice-improvement/medical-examinations/ xxxviii https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ xxxix https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1051269/achieving-best-evidence-criminal-proceedings.pdf xl https://www.gov.uk/government/publications/the-code-of-practice-for-victims-of-crime xli https://www.gov.uk/guidance/criminal-injuries-compensation-a-guide  56  Official  xlii Department for Education (DfE) (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. [. xliii file:///C:/Users/richa/Downloads/Childhood_neglect_and_abuse_comparing_placement_options%20(1).pdf xliv BRANDON, M. et al., 2014. Missed opportunities: indicators of neglect–what is ignored, why, and what can be done? London: Department for Education, DFE-RR404, 46pp. https://repository.lboro.ac.uk/articles/report/Missed_opportunities_indicators_of_neglect_what_is_ignored_why_and_what_can_be_done_/9580058 xlv Department for Education (DfE) (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children.  xlvi https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/419072/In_the_child_s_time-professional_responses_to_neglect.pdf xlvii https://www.researchinpractice.org.uk/children/publications/2016/november/child-neglect-and-its-relationship-to-other-forms-of-harm-responding-effectively-to-children-s-needs-evidence-scopes/ xlviii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/250877/5086.pdf xlix Working Together with Parents Network (2014) Parents with Learning Disabilities – An Introduction. Bristol: University of Bristol, School for Policy Studies. www.bristol.ac.uk/sps/ media/WTWPN_documents/intro-to-parents-with-learning-diffs-july-2014.pdf l Working Together with Parents Network (2014) Parents with Learning Disabilities – An Introduction. Bristol: University of Bristol, School for Policy Studies. www.bristol.ac.uk/sps/ media/WTWPN_documents/intro-to-parents-with-learning-diffs-july-2014.pdf li https://www.mentalhealth.org.uk/sites/default/files/FPLD%20a%20life%20without%20fear%20%28005%29.pdf lii Social Care Institute for Excellence (2007) Working together to support disabled parents. London: Social Care Institute for Excellence. liii https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/convention-on-the-rights-of-persons-with-disabilities-2.html liv https://www.legislation.gov.uk/ukpga/1989/41/contents lv Working Together with Parents Network (WTPN) update of the DoH/DfES Good practice guidance on working with parents with a learning disability (2007) https://www.bristol.ac.uk/media-library/sites/sps/documents/wtpn/2016%20WTPN%20UPDATE%20OF%20THE%20GPG%20-%20finalised%20with%20cover.pdf  lvi https://www.legislation.gov.uk/ukpga/2010/15/contents lvii Ibid. lviii https://learning.nspcc.org.uk/media/1879/parents-and-carers-views-on-preventing-sexual-abuse-of-disabled-children.pdf lix https://www.legislation.gov.uk/ukpga/2014/23/contents/enacted lx Working Together with Parents Network (2007) Top Tips – If You Think a Parent Has a Learning Difficulty or Learning Disability… Bristol: University of Bristol, School for Policy Studies. www. bristol.ac.uk/media-library/sites/sps/documents/wtpn_top_tips_for_workers.pdf  57  Official  lxi https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf lxii https://lx.iriss.org.uk/sites/default/files/resources/Effective%20interventions%20for%20complex.pdf lxiii https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/175391/Munro-Review.pdf lxiv Reder, P, and Duncan, S. (1999) Lost Innocents: A Follow-Up Study of Fatal Child Abuse. London: Routledge.   