Sexual abuse of three girls by their male foster carer. The victims, Grace, Lisa and Carey provided evidence to convict the perpetrator, who was sentenced to 9 years imprisonment. Perpetrator and his wife were approved foster carers from 1998 until their deregistration in December 2014. They had 38 children placed with them; 28 were placed prior to 2011. Grace made several disclosures from 2011 but no action was taken. She was contacted by police investigating disclosures by Lisa and Carey in 2014. Learning includes: mishandled or ineffective investigation of child sexual abuse is especially damaging for the victims and leaves them in greater jeopardy; presentation of perpetrators as pillars of the community and hiding in plain sight; foster carers who have well-established and long relationships with people such as social workers and teaching staff will undermine a child's confidence in talking with anybody about sexual abuse or other maltreatment by that those foster carers; role of local authority designated officer (LADO) has a significant role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or in need of services. Recommendations to LSCB include: ensure that an apology and an appropriate account of the lessons learnt is provided to the three 'children'; ensure that all practicable steps have been taken to identify and contact any other children who were placed with the perpetrator. Recommendations relating to national policy include: professional bodies and regulatory authorities have a role in promoting improved awareness of child sexual abuse and exploitation and the responsibilities of professionals in regard to the protection of victims and prevention of crime.
      
    Serious Case Review No:  2019/C7991  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.   CONFIDENTIAL   Page 1 of 42            A serious case review (SCR) commissioned under  Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006  Independent reviewer and report author Peter Maddocks, MA, CQSW.   May 2019   CONFIDENTIAL   Page 2 of 42   Index  1 Introduction and context of the review ............................................................... 3 1.1 General context ....................................................................................... 4 1.2 Grace, Lisa and Carey’s contribution to the review .......................................... 6 2 Narrative summary of key information ................................................................ 9 3 The learning and analysis from this review ......................................................... 12 3.1 Summary of research .............................................................................. 12 3.3 Impact of poor attachment and neglect ...................................................... 17 3.4 Summary of learning from the agency reviews of practice .............................. 18 3.5 Good practice identified through the review ................................................ 21 3.6 The views, wishes and feelings of the children and responding to their experiences and presentation of behaviour ............................................................................ 21 3.7 Effectiveness of the statutory mechanisms in overseeing and influencing the quality of care provided for the children in placement. ............................................ 24 4 Conclusions and recommendations .................................................................. 29 4.1 Promoting prevention and awareness ........................................................ 29 4.2 The LADO .............................................................................................. 31 4.3 Supervision of foster carers ...................................................................... 33 4.4 Recommendations .................................................................................. 33 4.5 Issues for national policy .......................................................................... 34 5 The methodology of the review ....................................................................... 36 5.1 The agencies who provided information for the review ... Error! Bookmark not defined. 5.2 The key lines of enquiry ........................................................................... 38 6 Summary of the relevant legal and regulatory arrangements ................................. 40 6.1 Supervision, support and review of foster carers .......................................... 40 6.2 Role of independent people ..................................................................... 41 6.3 The local authority designated officer (LADO) .............................................. 42 7 Individual agency action and/or recommendations . Error! Bookmark not defined. 7.1 Children’s social care .................................. Error! Bookmark not defined. 7.2 Child Advocacy and Participation Service ....... Error! Bookmark not defined. 7.3 Clinical Commissioning Group (CCG).............. Error! Bookmark not defined. 7.4 Virtual School ............................................. Error! Bookmark not defined. 7.5 Hospital NHS Trust ..................................... Error! Bookmark not defined. 7.6 Mental Health Trust ................................... Error! Bookmark not defined.  CONFIDENTIAL   Page 3 of 42   1 Introduction and context of the review  1. This serious case review was commissioned by the Safeguarding Children Board following the conviction of a male foster carer (referred to as the perpetrator) on thirteen counts of sexual assault of three female children who had been placed at various times with the perpetrator and his wife whilst approved as a foster carers. He was convicted by a unanimous jury verdict and was sentenced to nine years imprisonment, Sex Offender Registration indefinitely and was made subject of a Sexual Offences Prevention Order (SOPO).   2. The three victims who provided the evidence to convict the perpetrator and to halt his abuse of children are given the names Grace, Lisa and Carey for the purpose of the review. Although all the victims are now over 18, the phrase child or children is used throughout the report.   3. The timeframe for the review is from 2011 when the perpetrator was the subject of allegations by Grace. This provided the first opportunity to undertake enquiries and investigation. The review took account of relevant information prior to 2011 that could or should have caused concerns to be raised about the perpetrator and his wife as foster carers as relevant to the key lines of enquiry described in the appendix to this report, and the extent to which these were known and understood by those involved with the 2011 and the subsequent 2014 investigation.  All of the services were highly reliant on the detail and quality of information that had been recorded in their systems given many of the people who were involved in contact, decisions or events even as recently as 2014 have moved on.   4. Most of the agencies have archiving policies that set a limit on how long information can be retained; for example the NHS retains a child’s health record until the 25th birthday (or 26 if they are 17 when an episode of treatment ends). This means for example that information regarding any contact in regard to school nursing or Children in Care health assessments for the oldest of the children have been destroyed in compliance with the policy. There is therefore for example, limited information in regard to the circumstances of emergency hospital attendances as a 15 and 16 year old with self-harming injuries in 1995 and 1996. This is the time when subsequent disclosures in 2014 described sexual abuse by the perpetrator.   5. As will become very clear through reading this report, children like Grace, Lisa and Carey face many barriers and inhibitions to reporting sexual abuse. Two of the girls had been sexually abused by other men and the third had witnessed significant physical and sexual violence committed against her mother who was a high risk MARAC1 victim of domestic violence and abuse. All three girls were subjected to intimidation by the perpetrator and were frightened by him. The perpetrator presented himself as a respectable and trusted adult and this, combined with the needs and vulnerabilities the girls had for example in regard to learning difficulties, had the cumulative effect of isolating them from potential sources of help.   6. Child sexual abuse often does not get disclosed at all. When children (or as adults) begin to disclose what has happened, it often does not occur as one complete, consistent and coherent account. This reflects the profound and long lasting damage that is done to children who may also not have the emotional and verbal language to express what has happened or is happening to them.                                                               1 Multi-agency risk assessment conference CONFIDENTIAL   Page 4 of 42   7. In 2011, when Grace as an adult made disclosures about being abused by the perpetrator, there was a partial mind-set that treated the information as reflecting ‘inappropriate behaviour’ involving adults. The police were not involved in an investigation in 2011 on the basis that there was no criminal act, leaving it to the local authority to determine what action to take2. The foster carers were temporarily suspended from having children placed with them but had resumed accepting placements after it had been concluded that the allegations had not been substantiated.  8. A second investigation in 2014, this time led jointly by the police and the local authority’s children’s social work services, responded to further similar allegations made by 13 year old Lisa and 15 year old Carey. Grace was contacted as part of that 2014 investigation and subsequently made a statement to the police about the sexual abuse that she had suffered between January 1995 and December 1995 from the perpetrator.  It was this second investigation that led to the subsequent prosecution and conviction of the perpetrator.   9. It is particularly concerning that any child could be sexually abused by a person entrusted and approved to provide care for them and it represents a gross sexual exploitation of a child. Many children needing the care of foster carers already have very adverse childhoods that have involved abuse and neglect. This is reflected in the respective histories of the three girls in this review.   10. The concern felt for the three children in this case is magnified by the fact that the investigation in 2011 did not stop the perpetrator’s abuse at that stage. This review provides the information and analysis about what factors contributed to that occurring. The organisations and people who work to protect children and young people want to learn any lessons from this case to help ensure that individuals who represent risk can be found out and stopped. This is the reason and motivation for conducting this review.   11. The perpetrator was in a position of trust which created the imbalance of power for him to be able to coerce, manipulate and deceive the three girls when they were under 18 into sexual activity. This meets the first part of the national definition of child sexual exploitation3. The exploitative nature of the offence, together with the impact of undermining the girls’ sense of trust and confidence in other people in positions of trust allowed his crimes to remain undetected for many years. There is no evidence that the perpetrator was part of any network of perpetrators involved in child sexual abuse or child sexual exploitation.   1.1 General context  12. In the spirit of establishing an appropriate context for the review, it is relevant to point out that several important developments have taken place since 2011 that influence how for example child sexual abuse and exploitation is now dealt with and understood.                                                             2 According to social care records the behaviour had involved attempted touching by the perpetrator; the police do not have this information recorded. It is accepted that the allegations should have been investigated by both services.  3 Child sexual exploitation is a form of child sexual abuse where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. CONFIDENTIAL   Page 5 of 42    13. In 2011 national guidance was more limited. In general, children vulnerable to sexual exploitation often fell outside the scope of specialist services and teams who were more focussed on interfamilial abuse.  Prosecutions were often seen as problematic because witnesses were viewed as potentially vulnerable to being presented as unreliable and susceptible to cross examination by lawyers defending the accused perpetrator. This was part of the contributing background to how Grace’s initial disclosures were processed in 2011; if there was a poor prospect of achieving a prosecution there was less imperative to conducting an investigation. This reflects an old style mind-set that is nationally being challenged through the development of new approaches to how investigations are undertaken.  14. The investigations in Oxfordshire, Rochdale and Rotherham since 2012 along with other reports have contributed to a far clearer public understanding in the UK about the extent and nature of child sexual abuse and child sexual exploitation (CSE). The Independent Inquiry into Child Sexual Abuse was set up because of the serious concerns that some organisations including individual local authorities have failed and were continuing to fail to protect children from sexual abuse and child sexual exploitation.    15. In 2011, the Child Exploitation and Online Protection Centre (CEOP) published a thematic assessment analysing 2,083 victims of child sexual exploitation4. In that report, which was focussed on localised grooming networks following a series of high profile prosecutions in various towns and cities across the UK, a number of findings were reported. Children subjected to CSE were frequently going missing from home or care, were disengaged from their schools and education, exhibiting a range of behaviour and were often victims of bullying. The victims feared violence from their abuser if they failed to comply or made reports to the police or social workers. This reflects some of the experience that the three girls reported who were sexually abused by the perpetrator who did not commit his sexual abuse as part of a network. The report highlighted that offenders frequently exacerbated vulnerabilities such as disengagement from families and detachment from services.   16. In November 2012 the Children’s Commissioner for England published the interim report of inquiry into child sexual exploitation5 which followed the publication in July 2012 of their report concerning the particular vulnerability of children in public care.   17. As a result of the various reports and inquiries, the barriers that face any child, and in particular children who have additional vulnerabilities in disclosing sexual abuse should be becoming much better understood along with the importance of professionals having the training, knowledge and motivation to proactively look out for any signs or symptoms that may indicate a child is being abused.   18. For example children’s behaviour and interaction and their emotional and physical presentation are some of the ways in which trusted and competent adults can be alerted and therefore be curious about what might be happening to a child. This is why it is important for children’s social workers to have the time and aptitude to spend time with children, to develop relationships of trust and for people such as primary health care professionals and teachers                                                            4 Out of Mind, Out of Sight Breaking down the barriers to understanding child sexual exploitation CEOP thematic assessment June 2011. 5 Berelowitz, S. et al (2012) Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Gangs and Groups London: Office of the Children’s Commissioner. CONFIDENTIAL   Page 6 of 42   to have the capacity to identify potential warning signs about abuse. Research is providing a growing body of information to help identify potential sexual exploitation. Self-harm, eating disorders, substance abuse, going missing are the potential manifestations that a professional with appropriate levels of curiosity and time to invite discussion can try to follow up.   19. The purpose of this preamble is to remind ourselves that the people who were processing information in 2011 will have been working within different guidance and understanding and this no doubt influenced the mind-set that they brought to their task of processing information. The review attempts to distinguish between things that could and should have been dealt with better at the time irrespective of this different context of knowledge and understanding. Put at its plainest, it is about helping people to do the basic things well enough in regard to keeping children safe.   20. In the words of Carey, one of the three children subject of this review, asking children if they are all right and giving them time to talk is one of those basic things.   21. Disclosure rather than detection is the most reliable route to identifying perpetrators of child sexual abuse and exploitation. An ‘invitation to tell’ for young people and making them feel cared about and building trust is highlighted in research key messages described later in the report.    1.2 Grace, Lisa and Carey’s contribution to the review 22. Grace, Lisa and Carey were informed of the review following the initial planning meeting. In view of their ages, particular attention was given to seeking their consent to access relevant information from the various agencies relating to their care as well as consulting them about the scope of areas of enquiry for the review. This was done through providing information verbally and in a written format to them.   23. They were encouraged to meet with the independent reviewer who is the author of this report. Grace and Carey initially agreed to meet in late February 2018 although those meetings were postponed at their request due to their respective illness.  At the time of preparing the draft report Grace still felt unable to meet the reviewer but has been kept informed about the review.   24. The independent reviewer met Lisa in early March 2018 who was supported by her social worker and current foster carer.   25. Lisa was placed with the perpetrator and his wife when she became looked after. There were no introductory meetings. Lisa stated that she was never happy in this placement although nobody realised this at the time. She thinks they should have been able to see that she was not happy and thinks that they could have been more curious and inquiring about her feelings at the time. The perpetrator used threats made to Lisa against her family to prevent her from disclosing what was happening. Lisa had a social worker who she could talk to and also had an independent visitor and advocate. Lisa also had two teachers that she felt able to talk to; it was one of the teachers that Lisa eventually told about the sexual abuse. Lisa described how the CONFIDENTIAL   Page 7 of 42   sexual abuse and its effect on her had all been going over and over in her mind and built up to a point when she needed to talk to a trusted adult and after that happened this led to action being taken promptly.   26. Lisa was unable to describe what made the difference between the various adults who she came into contact with from the different services; she described having a good relationship with all of them although did say that much of the contact with the social worker for example was at the foster carer’s home with little opportunity for talking away from the foster carers. Lisa stated that nobody asked her whether she was happy at the foster carer’s and feels that would have made a big difference.   27. Lisa could not remember being asked to provide information for a LAC review which she described as being ‘rubbish’ and ‘boring’. It has not been possible to find any of the consultation forms that are used to record the views, wishes and feelings of children for Lisa or for Carey. Lisa talked about the number of people who could come to the meetings and for example being asked to organise drinks for everybody could mean that when she came back into the room it was difficult to understand and pick up what people were discussing. She had limited recollection of ever being asked to provide comments into foster carer reviews; the occasion when it happened the carer gave her the form and Lisa gave the form back to the same carer and this therefore limited any opportunity for independence.   28. Lisa, at the prompting of her social worker, described how she had provided a Power Point for a meeting and how this had felt much more creative and useful for Lisa. We talked about how Lisa tends to understand pictures and what people say rather than reading information and how this is important when thinking about how to seek the views and involvement of young people such as Lisa6.   29. Carey agreed to a short telephone discussion with the independent reviewer rather than have a face-to-face meeting. Carey said that her sexual abuse had gone on for about four months and it was only after a chance conversation with Lisa that revealed that another girl was also being abused by the perpetrator. Up until that point Carey had felt unable to speak to anybody. She confirmed that her social worker visited at least fortnightly and she had a good relationship with the social worker. She also had a good relationship with a school staff member (thought to be the learning mentor).  30. The reasons that Carey felt unable to speak to anybody was a fear of not being believed and that she would be left in a worse position as far as the perpetrator was concerned. The perpetrator had a grandchild at the school and he would regularly be at the school.  31.  When Carey was able to disclose what was happening, the social worker responded quickly and took appropriate and effective action.                                                             6 The wishes and feelings form used by the CAPS service uses a picture format as does the All About Me form. CONFIDENTIAL   Page 8 of 42    32. Carey said that waiting for court was hard and also having to give evidence which she did by video link.   33. As regards lessons to be learnt Carey said that seeing children regularly, talking to them and asking them if they are ‘OK’ is important. Carey wanted to know if there was some way that carers could be more thoroughly checked.  CONFIDENTIAL   Page 9 of 42   2 Narrative summary of key information  34. The perpetrator and his wife were approved foster carers from 1988 until their de-registration in December 2014. They had 38 children placed with them; 28 were placed prior to 2011.   35. Grace was in placement between 1988 and 1997. Grace was eight years old when she was initially placed. She continued to have contact with the perpetrator and his wife after she left the placement. Lisa was in placement for about 12 months between 2013 and 2014. Carey was in a foster placement with a relative of the perpetrator who was also an approved foster carer from late 2011 until the spring of 2014.  Grace  36. In early October 2011, Grace then an adult, during a visit to the GP discussed being abused when she was in foster care. The GP recorded that they ‘discussed problems’ although nothing more specific was recorded and there is no evidence that Grace was advised to raise a complaint or for the GP practice to make a report about allegations under the LADO protocols7.   37. In early December 2011 Grace made her first specific disclosure about the perpetrator during a discussion with a social worker. This information was reported to the LADO who in turn reported the information to the police. The LADO also reported that Grace was concerned about ‘repercussions’ from the perpetrator. The LADO was uncertain if Grace wanted to pursue a complaint or not. Whether Grace wanted to make a complaint or not would not prevent an investigation taking place both in regard to the allegations that Grace was making and in regard to the fact that the perpetrator was an approved foster carer with his wife. The information was passed to the specialist police adult safeguarding unit.   38. Two strategy meetings chaired by the LADO in December 2011 discussed the allegations. The police did not attend either of these meetings (13th and 21st December 2011). The second meeting concluded that the allegations ‘had been explored’ and that the perpetrator was not a risk to children. There was no investigation undertaken by the police who recorded that this related to inappropriate behaviour and there were no offences to investigate. The police recorded that CSC would conduct a single agency investigation to establish what ‘concerns that the perpetrator may present’. The meeting concluded that there was no evidence of the perpetrator behaving inappropriately. The foster carers were reinstated and their fostering limit was raised from two to three children. An apology was provided to the perpetrator.                                                             7 The national requirement for local authorities to appoint a designated officer (LADO) to manage allegations against adults who work with children was introduced in Working Together (2006) and in Safeguarding Children and Safer Recruitment in Education (2006), Managing Allegations Department for Children, School and Families (2009). CONFIDENTIAL   Page 10 of 42   39. It was just over two weeks later that Grace consulted the same GP she had spoken to in October 2011. Grace made further disclosures about sexual abuse whilst in foster care (the foster carer was not named; there is no record of a name being sought or given) and Grace told the GP that she had informed children’s social care services. The GP offered counselling which was declined by Grace. As on the previous occasion there was no other follow up or check with children’s social care services to establish if they were aware of the disclosures being made by Grace. The GP was not aware of the LADO’s investigation and did not consult the LADO. The importance of using the LADO is highlighted as a central learning point for the review and as will become clear later in the report there were other professionals on other occasions who could and should have made contact with the LADO.   40. In March 2012 a social work assessment referred to Grace making disclosures about her abuse from the perpetrator. During a discussion in late 2013 with an independent psychologist, Grace made disclosures that she had been abused between 14 and 17 years of age. This information was not discussed with any other professional or service but was included in a psychological report that was subsequently completed for court proceedings that are not related to the circumstances of this review. The local authority had a copy of that report at the time. It would be expected practice that the local authority’s legal representative at the time would have reviewed the report. No action was taken either by the psychologist in terms of making a referral to the LADO or by any of the children’s social care services or by anybody in the legal service who had access to the psychologist’s report.   41. The report was not scanned into the children’s social care services electronic record system until January 2017 and therefore would not have been accessed as part of any routine checks or inquiries that might have been made after this date.   42. Grace was contacted by the specialist police officer investigating disclosures by Lisa and Carey in March 2014. Initially Grace was reluctant to have any contact but eventually agreed to provide a statement although cancelled several meetings before the statement was taken.  This should not be read as criticism of Grace; making any sort of disclosure at any stage would have caused profound emotional and psychological distress and the fact that she made previous disclosures that had resulted in her account not resulting in more effective action compounded by an apology being given to the perpetrator in 2011 makes Grace’s reticence very understandable.   Lisa  43. Lisa was placed with the perpetrator and his wife in 2013 and remained there until she was removed in 2014 after her disclosure of abuse by the perpetrator. An independent visitor and a children’s advocate were to be appointed but there was a delay in being able to match Lisa with an independent visitor. The independent visitor was introduced to Lisa in February 2014.  CONFIDENTIAL   Page 11 of 42   44. In March 2014 Lisa had made a disclosure to her learning mentor that the perpetrator had sexually assaulted her.  It was recorded that Lisa had been in constant fear of what the perpetrator and his wife might do. Lisa was also worried about what the perpetrator might do after any criminal trial; Lisa was designated as a vulnerable witness and had the support of the intermediary who had been involved from the initial assessment.   Carey   45. Carey was looked after by the local authority from 2011 but was not placed with the perpetrator. Carey was aged 15 when she was interviewed following Lisa’s disclosures. Initially Carey was unaware of the reason why she was meeting the detective and she was accompanied by her social worker. The detective asked Carey if there was anything she needed to tell them about the perpetrator. Carey initially said ‘No’ but when she was told that Lisa had said she thought she would want to speak to the police, Carey got upset and said there was something she needed to say.   46. Carey had never told anyone about this and the first time she disclosed was to the detective and to the social worker during the video recorded interview. Carey said that this was because the perpetrator had told her if she said anything he would be stopped from fostering and he would be sent to jail.  47. It was following these allegations by Lisa and Carey, the police sought contact with Grace having reviewed the information she had reported in 2011.   48. The two children in placement with the perpetrator and his wife were removed in March 2014 and a LADO meeting was held on the 21st March 20148. The LADO was a different officer from 2011. There were four strategy meetings between April and August 2014 to share information and to co-ordinate the investigations during which disclosures about the perpetrator’s abuse were made.                                                              8 Local authority designated officer (LADO) describes the individual or team of individuals who have responsibility for receiving and co-ordinating action in response to allegations made against individuals in positions of trust. This includes carers as well as officers employed by the local authority. The role and function is described in national guidance contained in Working Together to safeguard children and relates to the duties under section 11 of the Children Act 2004 for organisations to safeguard and promote the welfare of children.  CONFIDENTIAL   Page 12 of 42   3 The learning and analysis from this review   3.1 Summary of research 49. Learning from this review relates to perpetrator behaviour, disclosure and the impact of sexual abuse on children and improving systems and arrangements for the protection of children from sexual abuse and exploitation.  50. Of the adults who disclose childhood sexual abuse, surveys consistently show that between 46 and 59 per cent of those adults abused as children had never disclosed it in their childhood. Given that it remains a fact that it is only a minority of adults who ever disclose their experience of sexual abuse in their childhood, the proportion of children who never tell anybody at any stage about sexual abuse is many times larger. An adult disclosing childhood sexual abuse is therefore very significant information that has implications for the health and well-being of the adult making the disclosure of being a child victim of sexual abuse and represents a vital opportunity to help identify and deal with a perpetrator especially if there is any indication that they are in a position of trust such as in this case.   51. The nature of sexual abuse means that it is largely a silent and witness free crime and rarely leaves visible physical signs although the emotional and psychological trauma is consistently harmful and has serious and life changing consequence; it is a crime that is actively hidden by the perpetrators who persuade and coerce their victims of the abuse to keep it ‘their secret’ and can manipulate their victims into feeling they have responsibility for what happens.    52. It is how and why sexual abusers such as the perpetrator seek to hide within the systems where children already face multiple adversities and are the children least likely to either disclose that abuse is happening to them or are more likely to be disbelieved or discredited if and when they do say anything. Grace learnt that nobody believed her in 2011 and Lisa and Carey both said they feared not being taken seriously. The perpetrator selected child victims who were particularly vulnerable and were unlikely to be believed if they ever did make disclosures about abuse that was happening to them.   53. The research evidence set out in The Spiral of Abuse9 in relation to sex offenders provides a conceptual framework to understand the gradual process by which perpetrators of child sexual abuse offend.  The spiral describes how perpetrators, when confronted, will deny, rationalise, and minimise their actions, so that the normal moral inhibition that prevents people from acting on their arousal to children is overcome.  Fantasising about sexual contact with children can further reinforce their arousal and their cognitive-distortion through a type of behavioural conditioning.                                                               9 Sullivan J; The Spiral of Sexual Abuse’ 2002 CONFIDENTIAL   Page 13 of 42   54. The next stage is realising the fantasy by preparing or “grooming” a child by, for example, giving treats or special attention but also by intimidation.  This process can also include building up, for other people such as social workers, an image or reputation of the child as an attention seeker or troublemaker, who is subsequently less likely to be believed should the child allege abuse.  It is notable that the Virtual School describe how one of the girls was reported to be presenting ‘challenges’ in their placement although there was no similar presentation at school. The gains which perpetrators experience from abuse will vary from sexual excitement and satisfaction to enjoying a sense of power and control that can extend to deceiving various professionals.   55. The term “cognitive distortion” is commonly used to describe the type of rationalisation which allows someone to go beyond barriers set by guilt or fear in this type of situation.  Thus the spiral of abuse continues.  56. Sullivan also describes in other work that is quoted later, how sex offenders use manipulation techniques on both children and the practitioners that they may come into contact with. This was evident in this case.   57. In most instances, the only people who know about the abuse are the child and the abuser, and this situation may continue for a prolonged period as it did in this case.  The research evidence shows that only a minority of children who are abused can tell a protective adult and it is for this reason that there is a general consensus and growing evidence that child sexual abuse is a widely under reported crime.    58. The reasons for this are numerous but include; intimidation generated by blackmail or threats, fear of being disbelieved and guilt or dread of official intervention.  Drawing children into secrets, colluding with them about what stories to tell and the excuses to make, can force a child to assume some responsibility and culpability for the sexual relationship.   59. Sexual abuse of children remains one of the most complex areas of work for any of the professionals who have responsibility for identifying, responding and investigating allegations or suspicions that a child is being sexually abused.   60. Anger, aggressive and hostile attitude and significant behaviour problems are the potential indicators of abuse although can go unrecognised when for example education and health professionals are being consulted about children’s difficulties. The challenge for all the professionals is being able to distinguish for example between the anguish and distress that may reflect earlier abuse a child has suffered prior to becoming looked after and being in a position to understand that abuse could be a current issue in regard to the care being provided for example by a foster carer or other trusted adult. As Munro10 comments the ‘Behavioural evidence [of sexual abuse] also tends to be indeterminate…many victims show no behavioural signs at the                                                            10 Munro, E (2008) Effective Child Protection (2nd Edition). Sage Publishing, London pp 83-89. CONFIDENTIAL   Page 14 of 42   time of abuse…behavioural signs reveal the possibility of abuse…most however are non-specific and can be seen in any child under stress’.  61. Care and expertise is needed to achieve a balance between not seeing child sexual abuse in every aspect of ‘difficult’ behaviour but equally having arrangements in place that can identify, discuss and hypothesise about possible underlying reasons for children’s distress and behavioural turmoil.  62. It is a fact that children face very significant barriers in disclosing their abuse; the majority only disclose their childhood sexual abuse when they have become adults and either feel safe enough to disclose or they are for example becoming overwhelmed by the emotional and psychological consequences on them and for their children. This reflects the circumstances that Grace faced in 2011. One can only imagine the acute stress and distress that she must have felt when talking with the GP and the psychologist about her childhood experiences.   63. Non-disclosure and silence about childhood sexual abuse is therefore unsurprisingly far more common than disclosure or detection during childhood or at the time that the abuse is actually taking place. Drawing on his clinical experience, Summit (1983)11, for example, argued that while children who have experienced sexual abuse may tell others about it gradually or incrementally, many children remain silent about it, deny that it actually happened, or produce a series of disclosures of abuse followed by recantations. Summit’s observations were an important development, because he raised questions about relying solely on children’s statements in forensic investigations such as occurred in 2011 in this case; if children do not readily disclose abuse, then convictions for abuse are more difficult to obtain and as in this case if the person accused is a trusted adult the impetus for investigation is swiftly diluted and lost. In this case it contributed ultimately to the foster carer receiving an apology and thereby conferring increased power and protection from further disclosures.   64. Summit’s model termed child sexual abuse accommodation syndrome describes five components: (a) secrecy; (b) helplessness; (c) entrapment and accommodation; (d) delayed, conflicted, and unconvincing disclosures; and (e) retraction of disclosure. Summit argued that children who have been sexually abused may respond with self-blame and self-doubt. They may fear the perpetrator and the possible consequences of disclosure. All three girls described such fear and consequences. Hence, in order to survive sexual abuse by a trusted person, children make accommodating efforts to accept the abuse and to keep the abuse secret. Furthermore, according to Summit, when children do reveal their abuse, disclosure will be incremental over time, a process that often includes outright denials and recantations of prior disclosures, and then reinstatements of the abuse. It is important to keep in mind that there are two separate aspects of this model, each with its own components. The first stipulates the psychological consequences of abuse (fear, blame, and accommodation). The second                                                            11 Summit, R. (1983) The child sexual abuse accommodation syndrome. Child Abuse and Neglect (7): 177-193. CONFIDENTIAL   Page 15 of 42   aspect stipulates the consequences that these psychological states have on behaviour (secrecy, denial, and recantation).  65. On the basis of this understanding of sexual abuse disclosure, new strategies for interviewing children were developed with the aim of enabling them to disclose abuse more easily. There is now a substantial body of literature on forensic interviewing, and an emphasis on the importance of having specially trained interviewers in police and social work services available to undertake this work with a good enough understanding about helping children disclose information and being sufficiently well informed about current guidelines for interviewing within criminal proceedings for example. The evidence given to the review is that those people overseeing the original allegations in 2011 did not have this level of knowledge and insight or at least did not apply it sufficiently well to be effective.   66. Disclosure of child sexual abuse takes different forms as occurred in this case. Children can disclose information directly. These apparently clear disclosures will in themselves represent considerable complexity for the specialist police and social work staff who have responsibility for investigating the child’s statements and developing their understanding with the child of what has happened to them.   67. Individual factors that influence an individual making a disclosure have been identified in a review of the literature by Featherstone and Evans (2004)12 regarding the barriers that must be overcome by parents/carers, professionals and support agencies if children are to feel safe enough to disclose abuse. Children report feeling that there is no-one to talk to who will listen and can be trusted; that they will not be believed or taken seriously; and that nothing will change if they tell someone. In this particular case for example one of the children made a complaint about a passport not being organised and which was not resolved in a timely fashion; that would have left a residual feeling of nothing happening even when a formal complaint was made. They also report feeling embarrassed; reluctant to burden others; fearful of getting themselves or someone else into trouble; fearful about a loss of control over the information that is shared and how that information will be acted upon by adults; and that there is a stigma of involvement with formal agencies. They also have limited knowledge of available services and what those services can do to help.  68. Child sexual abuse can and is committed against children by both men and women. It is not confined to any particular social or economic group. The work of specialist assessment and treatment services has revealed the complex belief and value systems that abusers develop. Revealing the activity relies heavily on a victim, as a child or in adulthood more likely, disclosing that they are or have been abused. The abusers will not disclose information; they will seek to conceal their behaviour and will seek to divert or undermine detection of their behaviour.                                                              12 Featherstone, B.and Evans, H. (2004) Children experiencing maltreatment: who do they turn to? London, NSPCC. CONFIDENTIAL   Page 16 of 42   3.2 Factors that inhibit children from disclosing sexual abuse  69. The factors that influence whether a child discloses sexual abuse include;  a) Their relationship with the perpetrator, the age at which the abuse began; the use of physical coercion; the type, severity and extent of the child sexual abuse. Other factors also include whether the child has any form of disability or learning difficulty that can influence their understanding of what has happened to them. Factors such as ethnicity or religion can also be a factor; the children understand that the child sexual abuse is wrong but face additional barriers in feeling able to tell someone what has happened to them. Gender is also a factor; for boys in particular, disclosing child sexual abuse can be seen as a display of weakness or emotional vulnerability and this can be especially pronounced within a dominant subculture of masculinity and how young men in particular believe they should behave;   b) Some research suggests that long-term abuse by a parent, relative or similar trusted adult such as a foster carer that starts at a very young age for the child is the least likely to be disclosed;  c) Children who are able to disclose will frequently talk to a friend or to a sibling; for children who are looked after away from their family and their siblings may face additional problems in finding a trusted person to disclose information. Of all family members to whom children disclose child sexual abuse, mothers are the most likely person they speak to; again for children who are looked after may face additional barriers in feeling able to talk with a parent and especially if the abuse has involved a partner.   d) Historically, some professionals have believed that false accounts are frequent; although there have been cases including some brought before courts where doubt has emerged about the veracity of disclosures, these are not part of a common pattern; research has provided no systematic evidence that false allegations are common. Some of the proceedings that have been problematic have revealed shortfalls in how children’s statements and evidence was listened to and recorded.  e) Research also indicates that children do not seek help from agencies and professionals because they do not know that the services exist.   70. Research also provides compelling evidence about the variety of reasons for children not making a disclosure about their sexual abuse. These include;  CONFIDENTIAL   Page 17 of 42   a) Barriers in asking for help. These are most frequently children being able to identify a trusted adult who can help; having confidence in that person to be able to offer help; a person who has the time and motivation to help; the adult that one of the children used worked at the school;   b) Children frequently feel they will not be believed or taken seriously; this was a significant issue for at least one of the children who made disclosures;   c) Children worry about confidentiality and they fear losing control of what will happen as a result of disclosing information. This has implications for how professionals such as police and social workers in particular plan and handle their formal enquiries.   71. Children who need to be looked after are particularly vulnerable to sexual abuse due to the adverse circumstances many will already have experienced including poor attachment and neglect and represent additional opportunity to a perpetrator who is able to pass the vetting and assessment process for becoming a foster carer.   3.3 Impact of poor attachment and neglect  72. Attachment describes an emotional bond to another person. Psychologist John Bowlby as the first attachment theorist, described attachment as a "lasting psychological connectedness between human beings13". Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life. According to Bowlby, attachment also serves to keep the infant close to the mother, thus improving the child's chances of survival. Understanding the significance of that missing link for children who become looked after forms part of the insight into why they become even more vulnerable to an individual giving them attention.   73. Since Bowlby’s early work, further research and literature has developed to help develop an understanding about children’s needs, parenting behaviour and the impact of poor attachment for children’s subsequent development.   74. Attachment theory provides a framework to understand that attachment is characterised by different behaviour that are referred to as secure attachment, ambivalent attachment and avoidant attachment.   75. Many children14, who become looked after, and especially at an older age, will be children with an avoidant attachment and tend to avoid parents or caregivers. When                                                            13 Attachment and Loss: Bowlby J. (1969). 14 This statement is open to some challenge; the quality of assessing a child’s attachment varies and depends on the particular knowledge and experience of people such as social workers undertaking appropriate assessments CONFIDENTIAL   Page 18 of 42   offered a choice, these children will show no preference between a caregiver and a complete stranger and this represents additional risk from predatory adults. Research has suggested that this attachment style might be a result of abusive or neglectful caregivers. Children who are punished for relying on a caregiver will learn to avoid seeking help in the future and leads in turn to making them even more isolated from potential help.  76. The combination of sexual abuse and neglect combined with difficulties in attachment represent a great obstacle for being able to seek help.  3.4 Summary of learning from the agency reviews of practice 77. Key messages identified by the review include:  a) Given the number of children that the perpetrator had placed over the years, there can be no confidence that he has not abused other children who have not yet been able to disclose what happened to them; the steps taken to contact other children is described in the final chapter; b) The placement of children with foster carers is an act of trust; it requires rigorous and continual monitoring and supervision at all parts of the system for the carers and for the professionals involved in supporting the carers and the children and the cultivation of open and varied communication opportunities with children; in this case it was  the relationship with a learning mentor that was critical to the abuse being disclosed; c) Mishandled or ineffective investigation of child sexual abuse is especially damaging for the victims and leaves them in greater jeopardy; it helps give additional power to the perpetrator and makes it less likely that other children will disclose information; d) Presentation of perpetrators as a pillar of the community and hiding in plain sight; the perpetrator was an active member of a church and therefore assumed to have the appropriate ethics and values required and was a longstanding foster carer who was able to use his standing in a relatively small community to create the veneer of respectability; perpetrators thrive on a sense of power and control and he was aware of the power his role and reputation gave him in comparison to the girls whom he abused and in manipulating various professionals; the girls he abused had all suffered great adversity before being placed with him and he made clear to them that he was far more likely to be believed in the event of any allegations being made by any of the girls; this was demonstrated in 2011 when Grace made her allegations which resulted in apologies being extracted for the perpetrator;                                                             with other professionals. The prevalence of neglect in these and other children who become looked after has led the overview author to assert that many children who become looked after will present with avoidant attachment or ambivalent attachment. It is notable in this case that more than one of the children had strongly protective feelings of duty to their mothers rather than feeling they could rely on care and protection. CONFIDENTIAL   Page 19 of 42   e) Interviewing a suspected perpetrator needs a different mind-set and set of skills that is informed and supported by a research aware interview strategy; predatory abusers will have developed and mastered a repertoire of approaches for keeping victims quiet and professionals distracted and at a distance;  f) Foster carers who have well-established and long relationships with people such as social workers and teaching staff will undermine a child’s confidence in talking with anybody about anything as sensitive as sexual abuse (or other maltreatment that is not visible) by that foster carer or other ‘trusted adult’; g) Victims are selected or are more susceptible to a perpetrator because of particular vulnerabilities; the three children all had a need for acceptance and adult contact; they had various difficulties in learning and cognitive abilities; had already suffered abuse and were susceptible to threats to keep them silent about the abuse inflicted by the perpetrator;  h) Children and young people living in care who have had to overcome adverse early childhood experiences or neglect can be left unable to form trusting relationships15; they have great difficulty using other people’s help; they have difficulties in developing alliances with helpful people and this can place them at a disadvantage16; low self-esteem associated with experience of abusive relationships and low educational participation can exacerbate this; this needs to be addressed as part of ongoing routine care planning; i) Evidence from major inquiries and reviews across the UK have shown that the extent of child sexual abuse and exploitation has been poorly understood until relatively recently; children need time and the support of people who can help them disclose information; this includes being sensitive to clues and indicators in the child’s behaviour and health as well as showing proper curiosity and interest in listening and understanding when children or adults begin taking about abuse; it highly probable that there will be further learning to emerge for example from the Independent Inquiry into Child Sexual Abuse; j) Social workers who do not have the workload capacity or aptitude to  spend time with children in developing trust based relationships are unlikely to understand the needs of a vulnerable child well enough and are even less likely to be the recipient of accurate information about the true views, wishes and feelings that children have; this includes children being able to alert trusted adults such as social workers to risk and significant harm; children need professionals who have time to spend with them outside formal settings or care placement; this has implications for example in how workloads are assessed and prioritised; children will only disclose abuse to people they trust and can be confident will act effectively; this requires having the time, motivation and skills to build those relationships; k) Great caution needs to be applied to relying too much on systems such as consultation forms for statutory reviews as a means for getting a good enough insight into children’s needs, views and wishes;                                                            15 Stein, M. and Wade, J. (1986) Leaving Care. Oxford: Blackwell 16 Downes, C. (1992) Separation Revisited. Aldershot: Ashgate CONFIDENTIAL   Page 20 of 42   l) Providing good and child focussed care for vulnerable children requires access to effective supervision and support; this applies to a home based carer (who is not a family and friends carer17) as much as  to professionals working in a different setting; good supervision should be challenging and provoke reflection; an inability to use supervision and reflection or to heed advice in regard to development should be a cause for further inquiry and scrutiny; foster carers have to be open to training development opportunities and to recognise the value and importance of participating in support activities;  m) Lower level concerns about the quality of care were insufficiently collated and used to inform the ongoing supervision of the foster carers; the views of children placed with the foster cars or from their social workers were not recorded as part of the annual review n) Effective chronological records are essential for identifying patterns in regard to the behaviour of children as well as carers; persistent lapses in good care practice should not be treated as one off incidents;  o) The role of LADO has a significant role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or are in need of services and in regard to considering whether disciplinary action is indicated; their role should be ongoing until all processes including a conviction have been completed; part of that role is actively promoting opportunity for other victims to come forward; p) For the LADO to be effective requires all relevant professionals and organisations to be aware of the purpose and role of the LADO and to ensure that consultation and information sharing is well understood; people in positions of trust should expect to maintain appropriate standards of private and personal conduct; arrest or other evidence of inappropriate behaviour such as dishonesty or violence is relevant to share with the LADO; q) All professionals have a responsibility to support and cooperate with all processes relating to the protection of children and effective management of perpetrators; this includes ensuring effective participation in criminal and prosecution arrangements; there were long delays in some social work staff making themselves available to make statements to the police as part of the criminal proceedings; r) Contact for all three children with important professionals such as social workers did not provide enough time to develop relationships or take place away from the influence or interference by the carers; s) All professionals have a duty and responsibility to raise concerns either about a child they believe could be at risk of significant harm or a person who poses a risk of harm to children (or vulnerable adults); the GP, an independent psychologist, a solicitor and social work supervisor all missed evidence at different times given by Grace regarding sexual abuse that could have been instrumental in helping to identify the perpetrator’s sexual abuse prior to 2014;  t) All professionals in direct contact with children need a basic awareness of child sexual abuse and an understanding of how a child’s trauma can be exhibited through their behaviour for example; children who present with difficult and                                                            17 Adults who become carers by virtue of being a friend or a relative of a child.  CONFIDENTIAL   Page 21 of 42   confrontational behaviour may be exhibiting the effects of traumatic experiences that include abuse; children who have been sexually abused and have attachment disorders are highly unlikely to disclose their abuse and be highly susceptible to abuse.  3.5 Good practice identified through the review  78. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance.   79. Examples of good practice identified by the review include;  a) The recognition in 2014 that Grace, Lisa and Carey were vulnerable witnesses and the effort made to use special measures and support particularly in preparation and participation in the criminal proceedings;  b) The planning and conduct of the enquiries and investigation in 2014 displayed a much clearer understanding and empathy about the needs of Grace, Lisa and Carey in for example how interviews were scheduled; c) The effort and persistence in making contact with Grace in 2014 and apparently having better understanding about how little confidence and trust Grace could have and the deployment of a specialist police officer with specialist training; Grace was also offered support through a specialist sexual abuse support service in 2014 which she declined.  3.6 The views, wishes and feelings of the children and responding to their experiences and presentation of behaviour  80. Giving children the opportunity to speak freely and to have the confidence that they will be listened to, is an important part of promoting safer cultures and systems of care and to make it less likely that an abuser can hide their criminal behaviour.  However good the vetting and recruitment procedure for becoming a foster carer, perpetrators can and do hide their true motivation and behaviour for becoming approved and trusted to care for children.    81. Any family based care is by the very nature of the arrangement a far more private experience than for example living in a residential setting. A great deal of the care giving will be done out of sight and will be done on the basis of trust that the carer is ethically motivated and able to understand and have insight about the needs of a child. Care systems that promote the safety of children will be pro-active about checking routinely on whether that trust is well placed or not.   CONFIDENTIAL   Page 22 of 42   82. Children who have been neglected who crave basic attention and care giving or have experienced sexual abuse and have damaged perceptions about what constitutes healthy relationships and care will be vulnerable to predatory or exploitative attention.   83. More than one of the agency reports acknowledge that seeking the views of children as part of routine practice was not a widespread or strong part of local arrangements until relatively recently. The CCG agency report for example comments that there was no evidence that the views, wishes and feelings of any of the children were routinely sought during consultations with primary health care staff. The point is made that as far as Grace is concerned, general safeguarding and primary health care practice in regard to listening to children was far less developed than would be expected now.   84. Lisa said that she had never been happy in the placement and she felt that people should have been able to pick up on this; Lisa says that nobody ever asked about her feelings in regard to the placement. Improvement was recognised as being required and the implementation of practice models have promoted a clearer emphasis on bringing the child’s voice into routine professional practice across agencies.  85. The respective learning difficulties of the individual girls was not generally well recorded particularly in respect of measures that could help promote their voice being heard as part of routine practice and it certainly was not adequately considered when the first disclosures were made in 2011; the preoccupation at the time was in regard to evidential issues if ever put before a court. The police routinely record information that might have an impact on the ability of an individual providing information although were not involved in the 2011 inquiries.   86.  When Grace first disclosed being sexually abused by the perpetrator in 2011 there was little recorded evidence about how her views wishes and feelings were considered over and above her saying she did not want to make a formal complaint to the police. This reflects old style investigatory mind-sets that cannot understand the circumstances of the victim, the various barriers and inhibitors to victims feeling able to cooperate in investigations and the level of control and coercion that is a powerful dynamic between a perpetrator and a victim.   87. The facts of Grace’s earlier experience of sexual abuse, the awareness that she was particularly vulnerable and the history of difficulties she had through adolescence and early adulthood were all factors that deserved closer exploration and understanding in terms of implications for how the disclosure was handled and is acknowledged as areas of learning in the respective agency reports.   88. The fact that the allegations concerned a currently approved foster carer who had cared for many children over several years gave additional gravity. The early decision that there were no grounds to investigate whether a crime had been committed or not was premature and demonstrated a lack of basic curiosity about the potential implications for other children already placed over several years. It certainly suggests CONFIDENTIAL   Page 23 of 42   that the individuals involved in the discussions and decisions at the time did not have a good enough understanding that childhood sexual abuse was more likely to be revealed in adulthood or an understanding about the way in which disclosures are made as described for example by Summit and discussed at the start of this chapter.   89. Disclosures about child sexual abuse often occur incrementally and inconsistently over time. The investigation strategy could have been better informed with consideration as to which agencies and individuals should be contacted as part of the inquiries.  Disclosures cannot be relied upon as providing sufficient evidence and therefore thought is required about how to triangulate evidence as much as possible from different sources of information and evidence. If contact had been made for example with the GP practice, it is highly likely that the information about Grace consulting the GP less than two months previously during which she talked about being abused in foster care would have been disclosed. The CCG agency report acknowledges that the GP practice should have considered using the LADO procedures in October 2011 and also draws out the lack of detail that was apparently sought and certainly recorded at the time.   90. The Advocacy service that was available to Lisa and to Carey was not in place when Grace was a looked after child. The service is an explicit and independent service designed to ensure that the views, wishes and feelings of a child are promoted particularly during formal processes such as child protection conferences, LAC reviews or changes in placement arrangements. It was not this service that heard Lisa’s first disclosure about sexual abuse; it was a learning mentor. Children (and adults) will choose the person they feel they can talk to. Grace had initially gone to the GP. Unlike Grace’s experience with the GP, the learning mentor ensured that the information was followed up with children’s social care services and with the LADO.   91. The Advocacy service acknowledges that there was a long delay between the decisions to allocate an independent visitor for Lisa in May 2013 until the first introductory visit in February 2014. The reason for the nine month delay is attributed to staff changes, a shortfall in volunteer visitors, although there had also been delay in processing the service referral forms as well. Giving children access to adults who have the time and aptitude to form relationships and to encourage children to talk and communicate (such as play and art for example) is one of the foundations of promoting and hearing the child’s voice.   92. There was a far more robust and empathetic approach to seeking information from Lisa and Carey as well as from Grace in 2014. There is good evidence that there was much clearer focus on the respective needs of Lisa and Carey when their initial disclosures were made in 2014. The fact that Lisa had moved placement and the impact that could have upon her was considered when scheduling interviews to ensure that she was settling into her new placement and support an effective collection of evidence. The fact that the children were fearful of repercussions and CONFIDENTIAL   Page 24 of 42   their need for support as the investigation continued led to the use of the specialist intermediary.   93. It is not surprising that Grace had difficulty in initially agreeing to speak with any investigating officers in 2014. It is good practice that specialist officers made such concerted effort to speak with Grace and she was also given support through the Witness Care Officers. These officers kept very regular contact with Grace and it is believed that this helped in having Grace’s attendance at court.  94. Although children’s behaviour can be a manifestation of abuse it can be problematic for professionals to determine or understand what the behaviour represents; as Munro observes, behaviour can be ‘indeterminate’. In general there was an absence of sufficient curiosity about the respective experiences and presentation of Grace, Lisa and Carey.    95. With the benefit of hindsight, some of the recorded information about behaviour presented by the girls whilst in placement could have been symptomatic of being sexually abused. For example, between February 1995 and November 1996 there were eight overdoses which were generally alcohol and paracetamol. There is no record of these being discussed by the GP practice. Although the expectation now would be for this to have occurred it was not the same expectation in 1990’s. The GP practice was also aware that the mental health service were involved and might have felt they had little to add at that stage. Similarly there was far less developed focus generally on the specific circumstances and needs of children who were looked after. The issue of self-harm was far less recognised by any of the services than it is today. Other evidence such as poor eating and of going missing from home was not the subject of any significant enquiry or reflection at the time of the incidents.  3.7 Effectiveness of the statutory mechanisms in overseeing and influencing the quality of care provided for the children in placement.  96. The CSC agency report described a number of shortcomings in regard to how the respective system of safeguards was applied.   a) Visits were made by social workers to the children, although the majority took place in the foster carer’s home and probably with the foster carers present; in the case of Carey, there is only evidence that 12 of the 17 statutory visits being completed; none of the children were visited more frequently than the legal minimum requirement;  b) Although the records of the LAC reviews confirmed that consultation forms were used by Lisa and Carey, no copies are retained on file; there were copies of the wishes and feelings consultation forms used by the Advocacy service on that service’s files; c) A report from the respective child’s social worker was not always available for reviews concerning the children in placement or for the annual review of the CONFIDENTIAL   Page 25 of 42   foster carers; this suggests systemic issues rather than just reflecting individual practice; d) There are gaps in information from education and health services; e) Only Carey was offered direct support to access support from the Advocacy service although Lisa also used the service although there was a long delay in processing a referral and then matching an independent visitor; f) There was limited evidence about advocacy and complaints procedures being promoted with the young people; the system for complaints was originally established with the implementation of the Children Act 1989 and associated guidance; g) The occasions when children’s social workers raised issues about the care practice of the foster carers this did not result in formal supervisory requirements; likewise during the 2011 investigation of Grace’s disclosures included reference to shortcomings in practice although no formal and enhanced supervision requirements were considered or implemented but rather provision of an apology to the carer; h) The fostering panel and the chair of the panel were not informed and consulted as part of the LADO and children’s services 2011 investigation; changes have already been made to ensuring that any allegations and complaints are reported to the fostering panel.   97. Social workers need the time and the motivation to spend time with children away from their placement to get to know the child, to promote trust and to give the child opportunity to talk about their views, wishes and feelings. The CSC agency report highlights that in April 2014 the looked after children social work team was reduced by seven whole time equivalent social work posts.   98. Although the statutory reviews provide opportunities for children to record their views there is no record of evidence in regard to any of the children for example in regard to any of the consultation forms. Similarly, there is no evidence that they were given appropriate information and support to use complaints processes. There was delay in appointing an independent visitor. Lisa and Carey were given access to an advocate; Lisa provided placement feedback when she left the placement with the perpetrator; she described not feeling part of the family, did not feel listened to and did not see her social worker enough. There is no formal mechanism for ensuring that when such information is forthcoming it then leads to effective follow up action.   99. The agency report from CSC found that although there were no formal allegations or complaints made prior to 2011 there were issues that had been identified. This had included the foster carers’ response to challenging behaviour, offensive and discriminatory attitudes and language and standards of some care. The fact that none of the children felt able to speak out at the time or that anybody was able to have any indication of their daily lived experience with foster carers has to be a significant area of learning from the review.  CONFIDENTIAL   Page 26 of 42   100. The agency review confirms that although there was evidence of annual reviews of the foster carers in accordance with regulation and agency standards, the quality of recording and rigour was inconsistent. The personal development plans were not comprehensive and the pattern of relatively lower level concerns and shortfalls were not identified and followed up. For example, the carers were not participating in training and this was probably contributing to their inappropriate response at times to children with enhanced levels of emotional need. The agency report highlights that there were occasions when there were problems in having the appropriate capacity for training and development; such shortages help create the latent conditions where carers who are motivated to keep their training and development updated will take up any available opportunities.   101. The predictors for the maltreatment (not child sexual abuse) of children living in family foster care were sought by a research study to identify the characteristics of riskier foster homes18. Of four characteristics that presented increased risk were homes about which case‐workers had reservations; the other three factors were homes that had younger foster mothers, homes in which children shared bedrooms with other family members and homes that were restricted for placement of certain children.   102. The perpetrator and his wife were supervised by longstanding fostering social workers. This consistency and long term involvement would often be seen as a strength although it may have contributed to professional staff becoming too familiar and less able to identify the foster carers’ shortcomings. The established relationship that the perpetrator had with social workers and at the school would have been a significant factor in any child feeling they would not be believed. The agency report describes a ‘start again’ syndrome where isolated events or incidents of practice were not collated and viewed within the context of longer term attitudes and behaviour.   103. The agency report acknowledges that when Grace made her allegations in 2011, and the history of care practice issues, there would have been cause to elevate the level of oversight of the carers.    104. The information about Grace’s allegations or the apparent shortcomings in care practice were not apparently reported to and discussed by the agency fostering panel. It is not apparent that a formal review of the carers was undertaken before the decision was made to increase their fostering limit. The role of the fostering panel is to be available to provide advice and recommendations given the range of experience and knowledge that a panel should have amongst its membership. The panel are now routinely informed when an allegation or complaint is raised in regard to a foster carer.                                                              18 Zuravin. S,  Mary Benedict, Somerfield. Child Maltreatment in Family Foster Care, Am J Orthopsychiatry; 63(4):589-96 October 1993.  CONFIDENTIAL   Page 27 of 42   105. The police and CSC were the only two agencies made aware of the allegations by Grace in 2011. The police involvement in the 2011 investigation is unclear. The police had no record of a strategy meeting taking place and although the LADO meeting in December 2011 records that a detective constable visited Grace there is no corresponding record on the police system. There is no recorded evidence that anybody from the police safeguarding service spoke with Grace. There is no evidence about what account was given to the exploitative nature of the abuse being disclosed by Grace or of the perpetrator having access to children as a trusted adult. The police had no record of any outcome from the CSC investigation. CSC concluded that the perpetrator was’ not a not a risk to children’ and there was ‘no evidence that he had acted inappropriately’. There is little recorded evidence about how the investigation was undertaken and the factors considered in reaching the conclusion in 2011.   106. The disclosures that Grace made to a psychologist in 2012 appear to refer to incidents of abuse between 14 and 17 years of age. These allegations were not entered into the CSC system until January 2017 and do not appear to have been investigated at any stage. There is no record of the psychologist having used the LADO or MASH referral systems. The disclosure should have been recorded and processed as a LADO referral by the psychologist. The information contained in the report should have been recognised as a LADO issue with implications for the protection of other children. The report will have been read by several people including the social worker, the social worker’s supervisor, and the solicitors and CAFCASS officer. The information was not shared with the fostering service.   107. In 2014 it was the police and CSC jointly who were primarily involved in conducting investigations. Information was sought and shared with other services in regard to collating evidence and co-ordinating safeguarding arrangements. The investigation was more robust and a more complex investigation. There was joint investigation between the two services involving specialist interviewers. There was explicit consideration about the vulnerability and additional needs of the victims. This included using the Code of Practice for Victims of Crime to guide support arrangements when the decision was made to prosecute the perpetrator.   108. The LADO convened strategy meetings ended before the criminal proceedings had been completed. A significant learning point to come from this review is emphasising that the LADO role should continue until all related processes have been completed. For example, the police had difficulty in arranging for some social work staff to be available to provide statements as part of the criminal process. The LADO could have helped facilitate that more effectively. There were ongoing support needs for the three victims of the perpetrator’s abuse during and after the criminal proceedings. It remains the case that it is more likely rather than less likely that there are other victims of the perpetrator’s sexual abuse who have not yet disclosed information.   109. The LADO is a critical part of the system for ensuring that individuals who have positions of trust are subject of appropriate monitoring. Evidence of abuse is only likely to emerge incrementally. In December 1995 the perpetrator had been arrested CONFIDENTIAL   Page 28 of 42   in relation to a complaint of GBH. Although the CPS decided that no charge would be processed through court, the allegation of violence and the suggestion of coercion in the report of the incident was relevant to the perpetrator’s role as a foster carer. The information was not shared at the time of the offence or during the 2011 or 2014 LADO strategy discussions. The police have given assurance that such offences would now be reported. Currently, the Common Law Police Disclosure (CLPD)19 provides for the police being able to disclose known information regarding an individual in order to enable a third party such as a LADO to consider risk mitigation in respect of an employment or voluntary role believed to be undertaken by the individual. This common law power enables the police to share personal sensitive information with a third party where there is a “pressing social need”. A pressing social need encompasses safeguarding or protecting from harm an individual, a group of individuals or ‘society at large’. The CLPD provisions endorsed by the chief constables in March 2014 did not become operational advice until March 2015 following the withdrawal of the Home Office’s previous guidance.   110. A CLPD is not reliant on a conviction or a charge.  When a person is released from custody, either after arrest or having attended as a voluntary attendee for a violent, sexual or drug related offence the Information Management Team are automatically notified of these offences electronically. This team will then undertake a review of the offence and determine if a CLPD should be made.  111. Other local organisational changes occurred after 2011 that contributed to improved co-ordination. The MASH brings together the local authority, education, health and police in the same location with virtual links to other services as necessary. Referrals, including LADO notifications, are discussed by a multi-agency group which feed into strategy discussion or meetings when enquiries are to be undertaken under s47.                                                              19 Common Law Police Disclosures (CLPD) – Provisions to supersede the Notifiable Occupations Scheme (NOS), National Police Chiefs’ Council March 2015 CONFIDENTIAL   Page 29 of 42   4 Conclusions and recommendations  112. Regrettably, the perpetrator is not the first foster carer to be convicted of sexually abusing looked after children placed by a local authority. The sexual abuse of children (including child sexual exploitation) is a highly complex issue; more seems to be known about what does not work well in safeguarding rather than what helps people and organisations to be more effective in safeguarding children.   113. The objectives of this learning review are;  a) Prevention; stopping child sexual abuse happening and particularly in a regulated and supervised care arrangement such as a foster care placement; b) Improving the protection for children and young people who are placed with carers through better identification, disclosure, reporting and response to information.  4.1 Promoting prevention and awareness 114. There is learning that applies to all children and young people for keeping them safer from sexual abuse. Research from North America indicates that preventative education delivered in schools can help increase the knowledge and awareness of all children and help to change culture, attitudes and environments in which child sexual abuse can take place. Age and developmentally appropriate pre-school and school-based education programmes on child sexual abuse can be effective at teaching children and young people to recognise inappropriate behaviour and to improve their knowledge of self-protection20.   115. The PSHE Association provides a helpful checklist of 11 points for effective implementation of PSHE which could be used to inform the implementation of sex and relationship prevention education21. Schools can also provide a safe space for sexual abuse disclosure to take place22, taking into account the systemic and organisational                                                            20 Baker, C. K., Gleason, K., Naai, R., Mitchell, J., and Trecker, C. (2013) Increasing knowledge of sexual abuse: A study with elementary school children in Hawaii. Research on Social Work Practice, 23(2), pp.167-178.  Pulido, M. L., Dauber, S., Tully, B. A., Hamilton, P., Smith, M. J., and Freeman, K. (2015). Knowledge gains following a child sexual abuse prevention program among urban students: A cluster-randomized evaluation. American Journal of Public Health, 105(7), pp. 1344-1350. Walsh, K., Zwi, K., Woolfenden, S., and Shlonsky, A. (2015) School-based education programmes for the prevention of child sexual abuse. The Cochrane database of systematic reviews, 4, Article No: CD004380.  Zwi, K. J., Woolfenden, S. R., Wheeler, D. M., O'Brien, T. A., Tait, P., and Williams, K. W. (2007) School-based education programmes for the prevention of child sexual abuse. Cochrane Database of Systematic Reviews, 3, 21 PSHE Association (2016) Key Principles of Effective Prevention Education. London:  CEOP/ThinkUKnow/PSHE Association. Available at: https://www.pshe-association.org.uk/system/files/PSHE%20Association%20report%20to%20CEOP%20April%202016%20FINAL.pdf [acessed on 09/07/18]  22 Office of the Children’s Commissioner (2015) Protecting Children from Harm, London:   Office of the Children’s Commissioner.  Available from:  https://www.cscb-new.co.uk/wp-content/uploads/2015/12/Child-sexual-abuse-protecting-children-from-harm-Nov-2015.pdf [Acessed 09/07/18] CONFIDENTIAL   Page 30 of 42   factors that make disclosure difficult (and already mentioned) as well as the research into children’s experiences of trying to tell and not being heard23 (Cossar et al, 2013).    116. Perpetrators of child sexual abuse (and sexual exploitation) are able to commit their abuse in secret and often without detection because children and young people do not disclose what is happening to them. It is a minority of people who ever disclose child sexual abuse; a greater number of those who do disclose are adults when they make the disclosure.   117. Children who are placed away from their families face additional vulnerability. Giving children regular and independent access to people outside of their care placement and independent from their carers is essential. This does not mean relying on specific arrangements such as independent visitors; children choose who they confide in and it is about having the various professionals sufficiently knowledgeable about the child’s circumstances and what to do if they are given the sort of partial and incomplete information that a disclosure may represent; this includes education and health practitioners who have routine contact with children (and with adults who may disclose childhood abuse).   118. Compliance with statutory standards as to the frequency of visits to a child in placement is merely achieving the minimum standards and does not in itself provide any information about the utility and quality of the contact with the child. Information and reflection about the manner in which children communicate, the people they choose to communicate with should be a starting point to measuring the effectiveness of contact with a child in placement and of routinely reviewing the quality of care arrangements. A clear and appropriate record of contact that provides evidence and information about the child’s views, wishes and feelings should be a benchmark standard.  119. Supporting and encouraging a broad community of professionals to improve and develop their awareness, knowledge and understanding about child sexual abuse is essential. This begins with achieving a broader understanding that child sexual abuse is widespread and under reported, that silence and non-disclosure in childhood is very common, that children face many barriers in talking about it at all and that when disclosures do occur they can be subject to retraction and inconsistency and be incomplete.   120. Adults such as Grace who disclose childhood abuse are providing an opportunity to identify perpetrators and to protect children they may have contact with; the abuse is never ‘historical’ and it is highly likely that there will be other victims of the perpetrator to be identified. The disclosure can be prompted by a crisis such as                                                            23 Office of the Children’s Commissioner (2013) It takes a lot to build trust, London:   Office of the Children’s Commissioner.  Available from https://www.uea.ac.uk/documents/3437903/0/OCC+Recognition+and+Telling+report.pdf/923aec11-0221-4d54-8c77-f83189e9e02d [accessed on 09/07/18]  CONFIDENTIAL   Page 31 of 42   appears to have been the trigger for Grace in adulthood beginning to speak about what had happened to her over several years in her childhood.   121. It is essential to provide support to the victim who is very likely to have been living with the emotional and psychological damage that is manifested for example in substance abuse, poor mental and physical health. These are the type of factors that investigators and prosecutors may say indicate unreliability as potential witnesses in a court for example.   122. The sentencing of the perpetrator following his conviction was widely reported in the media at the time of his conviction and sentencing; no further victims came forward following that media coverage.   123. In May 2017, the Police Serious Case Review Co-ordinator researched Police local systems and completed Serious Incident Information Gathering Reports for 27 children who had been formerly fostered by the perpetrator and his wife. This was to identify if other children who had been placed with the perpetrator and his wife wished to make a complaint and if they would need including in the scope of this review. This information report was submitted to the SCR subcommittee for consideration as part of the commissioning of this review.  124. There are special measures available at court for vulnerable victims and witnesses. Child witnesses under the age of 18 will automatically be eligible for special measures by virtue of section 16 of the Youth Justice and Criminal Evidence Act 1999. A vulnerable or intimidated witness will be eligible for special measures under sections 16 to 33 of the YJCEA 1999.  In the case of Grace, Lisa and Carey, they were identified as vulnerable by the police and special measures were applied for and granted by the court. The special measures included an intermediary for Lisa to assist with cross examination at court, the use of screens for Lisa and Carey preferred the use of a video link to give her evidence. Grace indicated that she would prefer to give evidence with the use of screens. Pre- court visits were also arranged for Grace, Lisa and Carey and subsequently were undertaken with Lisa and Carey accompanied by the intermediary.   125. An independent sexual violence advisor service was launched in 2015 and the Sexual Assault Referral Centre (SARC) was also launched in 2015 and would be offered.  4.2 The LADO  126. Widely promoting the purpose and role of the LADO is important and goes wider than the work of carers and professionals working directly with the local authority and encompasses for example volunteer organisations and activities; clear understanding by health professionals, teachers and learning mentors, criminal justice and legal practitioners as well as more widely across the community. In dealing with sexual abuse, the LADO can play a vital role in collating intelligence that on its own has little CONFIDENTIAL   Page 32 of 42   significance but can begin a process of joining up different elements of evidence and concern.   127. The LADO needs to be a role undertaken by somebody who has sufficient awareness, understanding and knowledge about sexual abuse and exploitation and maintains and develops that expertise through refresher training and research updates with peers.   128. The LADO will often have to challenge people and organisations who may be reporting information about an individual who has an established reputation or status that is valued or well regarded. Recognising the potential for human bias and cognitive influence in how information is processed about that individual is an essential part of the LADO function. Ensuring there is clear differentiation and definition of roles in regard to the investigation of information and how support is provided to the respective parties. Professionals who feel their role is to provide support to a carer for example is unlikely to have the level of sceptical and challenging curiosity to contribute effectively to an investigation that is suitably robust and thorough.   129. Social workers and police officers who do not have sufficient understanding about child sexual abuse are unlikely to have the necessary mind-set, knowledge and skills to conduct the type of inquiries and investigation that is required.   130. The Police have committed to investing in training of Safeguarding Staff. Multiple Specialist Child Abuse Investigators Development Programme (SCAIDP) courses have been held in 2018. Capacity on the SCAIDP courses has been increased from 8 student places to 12 student places. Following attendance on the SCAIDP course, each student is provided with a tutorial development plan and is required to complete and submit a portfolio to satisfy the criteria of the course. In order to be fully accredited as a specialist investigator, students must also attend and complete the Initial Crime Investigators Development Programme (ICIDP). The training to become a specialist abuse investigator is intensive and rigorous.  131. The Police have specially trained officers (STO’s) who are responsible for the first response for sexual offences. These officers are both male and female and every attempt is made to ensure that the victim is offered a choice of gender of officer who attends. STO’s receive extensive training in line with College of Policing standards and are given the opportunity for refresher training on a regular basis.  132. The LADO has a responsibility for ensuring that a sufficiently informed and clear strategy is developed for responding to information and ensuring that agencies are not solely relying on a victim’s disclosure for example.   133. The LADO has a role until all processes are completed. This includes facilitating and supporting the respective agencies in ensuring that support and protection is being given to the victim, that attention is given to identifying victims who have not come forward and the strategies required to deal with this and to ensure that the police and CPS are appropriately supported in any prosecution of the perpetrator.  CONFIDENTIAL   Page 33 of 42    134. The LADO investigation in 2011 did not identify the risk that the perpetrator represented to girls placed in his care and was compounded by the fact that it resulted in the carers being given an apology and having their fostering limit increased. This would have had powerful implications for any child who had concerns about the perpetrator wanting to raise them.  135. The level of collective response in 2011 relied on the statements by Grace and the interview of the perpetrator and his wife by social workers. The decision by the police that there was no crime to be investigated was both premature and removed an important input by specialist police officers to be instrumental in conducting an interview with the perpetrator under caution.   4.3 Supervision of foster carers  136. The supervision of foster carers needs to be robust. Where relationships have developed over several years between carers and social workers and other professionals, children who have concerns or are being abused will feel even more that they are unlikely to be believed or taken seriously.   137. Ensuring that children are asked for their views, wishes and feelings independent of their carer; ensuring that their social workers are required to provide information for the foster carer review; maintaining a chronology of concerns or issues raised in regard to the carer; assessing the carers attitudes to training and personal development; the extent to which they can demonstrate appropriate empathy and understanding about the behaviour and needs of children.     4.4    Recommendations   I. The LSCB should ensure that an apology and an appropriate account of the lessons learnt is provided to each of the three ‘children’. The LSCB should also ensure that arrangements for ongoing support and counselling are being facilitated by the relevant organisations.   II. The LSCB partners should satisfy themselves that all practicable steps have been taken to identify and to make contact with any other children who were in placement with the perpetrator to ensure that those children are aware that the perpetrator has been prosecuted and to give opportunity for any further information to be provided and to offer advice, help and support as may be appropriate.   III. The LSCB should consider what information it receives about the delivery of PSHE in local schools and to consider if there is further scope to promote better awareness for children and young people about relationship education and of sexual abuse.  CONFIDENTIAL   Page 34 of 42   IV. The LSCB should support the LADO to promote improved awareness, knowledge and understanding about the role and function of the LADO with relevant local organisations, including local medical and legal stakeholder organisations. This should include written guidance about the role of the LADO.  V. The chief officers of all of the member organisations of the LSCB should ensure that there is appropriate written guidance for staff to cooperate with any criminal investigations relating to safeguarding children (and vulnerable adults) including the giving of statements and other evidence and information to the relevant investigating and prosecuting agencies.  VI. The LSCB should encourage the chief officers of partner organisations that commission independent specialist or expert services in relation to children in need or at risk of harm, to ensure that there is written guidance provided to those professionals as part of their contract outlining the circumstances and their responsibilities for reporting any relevant concerns to the LADO that may emerge during the course of their work.  VII. The LSCB should consider whether the review indicates any further development of training and professional development in regard to child sexual abuse; in particular in relation to the recognition and response to child sexual abuse.   VIII. The LSCB should consider if they should have any further information that arrangements for contact and visits with children who are looked after are providing sufficient quality and regularity and that there are effective arrangements for evaluating this in the relevant services.  IX. The Common Law Police Disclosure (CLPD) should be included in any updated local child and adult safeguarding protocols to ensure clarity of understanding about the purpose of such information being shared by the police.  X. The LADO, in consultation with children’s social care services, should formally review whether any agency has any grounds to consider making a referral to any of the relevant professional bodies regarding the processing of information contained in the professionals report in 2013.   XI. The independent chair of the fostering panel should be provided with a copy of the review and be invited to make a formal response to the LSCB regarding any further development in regard to the panel’s role in proving oversight and advice and the robustness of supervision, support and review of foster carers.   4.5 Issues for national policy 138. Professional bodies and regulatory authorities have a role in promoting improved awareness about child sexual abuse and exploitation and the responsibilities of professionals in regard to the protection of victims and the prevention of crime. Education, health, and social care as well people working in civil and criminal law need CONFIDENTIAL   Page 35 of 42   to know and understand the circumstances under which the LADO must be consulted and informed of information that indicates a person in a position of trust is a perpetrator of sexual abuse. The national panel may wish to consider whether professional bodies such as for example The Law Society or the Medical Royal Colleges have a role in promulgating learning at a national level.  139. National guidance issued by the National Police Chiefs’ Council provides for the police being able to disclose known information regarding an individual in order to enable a third party such as a LADO to consider risk mitigation in respect of an employment or voluntary role believed to be undertaken by the individual. This common law power enables the police to share personal sensitive information with a third party where there is a “pressing social need”. A pressing social need encompasses safeguarding or protecting from harm an individual, a group of individuals or ‘society at large’. A CLPD is not reliant on a conviction or a charge. There is no corresponding guidance to other organisations who may be in receipt of, or party to such information.      CONFIDENTIAL   Page 36 of 42   5 The methodology of the review 1. This SCR used the principles and requirements set out in the government national guidance (Working Together to Safeguard Children 2015).   a) Recognises the complex circumstances in which professionals work together to safeguard children; b) Seeks to understand who did what and the underlying reasons that led individuals and organisations to act as they did; c) Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than relying on hindsight;  d) Is transparent about the way information is collected and analysed; e) Makes use of relevant research and case evidence to inform the findings;  f) Specifically considers all relevant equality issues related to ethnicity, religion, disability and diversity;  g) Is able to develop a multi-agency action plan in light of the findings.    2. A review panel was convened of senior and specialist agency representatives to oversee the conduct of the review and agreed case specific terms of reference.  3. The purpose of this review is to identify in particular:  a) The extent to which the views, wishes and feelings of the three children were sought, considered and acted upon in regard to any concerns explicitly disclosed or represented in their behaviour or other presentation such as self-harm; b) The extent to which agencies could have identified concerns about the care or abuse of children in the care of the perpetrator prior to 2014 and the subsequent conviction of the perpetrator; c) The quality and rigour of professionals’ response at single and multi –agency level; this includes how any significant information, observations or incidents were dealt with through contact, assessment and action planning; d) The extent to which the relevant legal frameworks were applied for reviewing of the care arrangements for the children and the quality of the foster carers in meeting the needs of the children, the processing of any concerns or complaints, and the invocation of multi-agency child safeguarding procedures including LADO; e) The level of understanding about any particular factors in regard to the vulnerability of the children and includes any disability or learning difficulty, cognitive understanding and/or legacy of maltreatment prior to placement with the perpetrator; CONFIDENTIAL   Page 37 of 42   f) The quality of advice, support and supervision for professionals and the general oversight of arrangements for vulnerable children looked after on behalf of the local authority; g) Identify any issues in regard to the capacity or resourcing of services. 4. The approach to this review reflects a duty of candour. Any young person looked after by the local authority has the right to expect that the care provided to them will be appropriate to their needs and will protect them from abuse.   5. The review takes account of the reality of arrangements for complex multi-agency working involving organisations over several years, some of which no longer exist or their responsibilities had been transferred as result of changes to organisational, legal or commissioning arrangements. It considers the extent to which relevant legislation and guidance was applied with the aim of understanding why the systems for safeguarding children placed with the perpetrator did not operate effectively enough particularly in 2011.   6. As far as has been possible given the circumstances of the review, the aim has been to understand why those involved with the children and foster carers, or who received information about the children and foster carers, took the action or made the decisions they did at that time in regard to any evidence or indicators of concern or abuse.    7. The agencies known to have had involvement with the children were asked to produce an agency report addressing the key lines of enquiry described in paragraph 21. Through a collaborative learning process the review identifies evidence of strengths and good practice, and supports the development of an action plan to address the learning arising from the review.  8. The LSCB commissioned Peter Maddocks as an independent person to lead the review and to provide this report. He does not and has not worked for any of the organisations who are party to the review, and does not hold and never has held elected office in the district. Similarly he is not related in regard to personal or professional matters to any person working for or responsible for the provision of services.    9. The fact that the review is examining events that occurred over several years means that many of the people who were involved at the time of critical events or decision making were no longer available to participate in any aspect of the review. This meant that the SCR has been reliant on collating evidence and information from agency records without the benefit of being able to include practitioners in developing the analysis and understanding about how for example information was understood and processed at the time.   CONFIDENTIAL   Page 38 of 42    5.1 The key lines of enquiry 10. Agencies were asked to provide a critical evaluation of their services and practice against each of the following:  a) How did your agency seek evidence and information about the views, wishes and feelings of the children and to what extent was it appropriately considered in any enquiries, assessment, consultation, decision making and action. Can you identify any barriers or obstacles that may have hindered good enough understanding about any evidence or information from any of the children?  b) Did relevant staff demonstrate sufficient professional curiosity and maintain an appropriate focus on the child in responding to the experiences and presentation of the children? Comment on the level of understanding about any particular factors in regard to the vulnerability of the children and includes any disability or learning difficulty, cognitive understanding and/or legacy of maltreatment prior to placement with the perpetrator that inhibited disclosure of abuse. c) What involvement was there from your agency in ensuring any of the statutory mechanisms (Foster Carer Reviews, LAC reviews, Pathway Planning, promoting access to the complaints process) were effective in overseeing and influencing the quality of care provided for the children in placement? Can you identify any learning? d) What involvement was there from your agency in the conduct of the investigation in 2011 or in 2014? Was the involvement by your agency as effective as it should have been? What learning can you identify to ensure that investigations are thorough and robust? e) Can you identify any examples of where the care or response by the foster carers required challenging or further enquiry? What action was taken or not taken and can you identify any learning for the review? f) Can you identify any learning about the relationships professionals develop with long term established foster carers and their ability to retain a child-focus and to challenge poor care? g) Did your agency ever have cause to use the child protection mechanisms relating to the reporting and responding to concerns about quality of care and allegations of abuse from the children by the foster carer; were they appropriately utilised and robust in their application? What learning can you identify? h) Can you identify any opportunities that were missed to challenge and to intervene earlier to reduce risks to the children from abuse or inappropriate care? What learning can you identify? CONFIDENTIAL   Page 39 of 42   i) Was inter and intra-agency communication and information sharing by or involving your agency sufficient and appropriate, and are there any gaps evident and can you identify any learning? j) Can you identify any issues in regard to the capacity of your service resulting from your review of the three cases?  k) Even in the most difficult of circumstances there can be examples of good practice. Can you identify any in your own service or with any other organisation? l) Comment on any changes that have already been made that make it less likely that the perpetrator would be able to remain undetected or any changes that you believe are still required to improve the detection and protection of children from similar poor care and abuse    CONFIDENTIAL   Page 40 of 42   6 Summary of the relevant legal and regulatory arrangements  1.  A system of statutory checks and ongoing oversight arrangements of the child’s care and progress are intended to ensure that care is not just safe but that it nurtures the overall development of the child. The arrangements that are now in place in 2018 for the approval, monitoring and care of children are more rigorous and extensive than when the perpetrator was first approved in 1988.   6.1 Supervision, support and review of foster carers  2. Foster carers have a central role in providing the family based care that is so critical for providing security, stability and a strong sense of identity to children who have often suffered great adversity in their lives. The foster carer is one of the people who will spend the most time with a child and the nature of the role means that much of that contact is done within the privacy of the carer’s home and out of sight of any professional.   3. Once a foster carer is approved they will be agreeing to provide care in line with national and local standards and will have a social worker who is responsible for supervising and supporting them in their role as foster carers. The expectations of that supervision role are spelt out in standard 21 of the Fostering Services; National Minimum Standards in England. This includes;   a) Each approved foster carer is supervised by a named, appropriately qualified social worker who has meetings with the foster carer, including at least one unannounced visit a year.  Meetings have a clear purpose and provide the opportunity to supervise the foster carer’s work, ensure the foster carer is meeting the child’s needs, taking into account the child’s wishes and feelings, and offer support and a framework to assess the carer’s performance and develop their competencies and skills. The frequency of meetings for short break foster carers should be proportionate to the amount of care provided.  Foster carers’ files include records of supervisory meetings. (21.8)  b) There is a good system of communication between the fostering service social workers and the child’s social worker.  The fostering service social workers understand the role of the child’s social worker and work effectively with them. (21.12)  4. As part of the routine support and supervision, the foster carer is subject to reviews that are described in regulations and statutory guidance the latest version of which is regulation 28 of the Fostering Services Regulations 2011 as being at least once a year. These regulations were in force at the time of the 2011 allegations made by Grace. In conducting the annual review the fostering service must seek and take into account the views of the foster carer, the child placed with the foster carer and the placing authority (the child’s social worker). The review has to determine if the foster carer continues to be suitable to provide care and the terms of the approval.   5. The later sections of the report describe how aspects of the review and monitoring of the perpetrator and his wife were not sufficiently robust.   CONFIDENTIAL   Page 41 of 42    6.2 Role of independent people  6. There are separate regulations governing the placement of the child which include arrangements for statutory contact with the child in placement by the social worker, holding statutory reviews and for this to overseen by an independent reviewing officer (IRO). Since 2004 all local authorities have been required to appoint Independent Reviewing Officers (IROs) to protect the interest of children throughout the care planning process. The requirement to appoint IROs arose from concerns that looked after children could 'drift', with care plans that either did not meet their needs or were not implemented. Even where care plans had been agreed by a court, they had no ongoing role in ensuring that the local authority put them into practice. Given these concerns, it was decided that every looked after child should have an IRO: an adult with oversight of their care plan and empowered to act on their behalf in challenging the local authority. Although IROs were to be appointed by the local authority, they must be independent from the immediate line management of the case. In April 2011, revised government regulations and statutory guidance about care planning came into force, which (amongst other things) strengthened the IRO's role.  7. The Children Act 1989 (sec 23ZB) requires a local authority to appoint an independent visitor when either the criteria are met or the local authority consider it is in the child’s interest to have an independent visitor.   8. The two main criteria are that it appears that communication between the child and a parent or any person who is not a parent but has parental responsibility for the child has been infrequent; or the child has not been visited (or has not lived with) a parent or any person who is not the child’s parent but who has parental responsibility for the child, during the preceding 12 months.  9. The guidance is explicit that the independent visitor does not provide skilled advocacy in complex matters and draws attention to using specialist schemes operated locally.24.   10. An additional set of statutory arrangements created by the Children Act 1989 and The Children Act 1989 Representations Procedure (England) Regulations 2006 brought in arrangements for children (and other people) to raise complaints or representations about the care of children. The system allows for independent investigation at stage two.                                                             24 The National Standards for the Provision of Children’s Advocacy Services, issued as section 7 guidance in November 2002, set out standards for the commissioning and delivery of advocacy services. The standards provide a framework for the planning, development and review of advocacy practice at all levels. In implementing this guidance, local authorities with social services responsibilities should ensure the standards are followed. Further guidance was issued through The Advocacy Services and Representations Procedure (Children) (Amendment) Regulations 2004 with a focus on children having access to advocacy support as part of the complaints and representation arrangements for looked after children. .  CONFIDENTIAL   Page 42 of 42   11. Children who are looked after and of school age are expected to receive additional support to promote their achievement and participation at school. Because of the passage of time there was little recorded information in regard to Grace; a fire in 2007 had destroyed historical records.  Carey and Lisa were both supported at school  with a personal education plan (PEP) and education health care plan (EHCP).    6.3 The local authority designated officer (LADO)  12. The role of the local authority designated officer (LADO) was introduced in 2006 and is set out in Working Together to Safeguard Children (2018) and is governed by the local authorities’ duties under section 11 of the Children Act 2004 and LSCB inter-agency policy and procedures. This guidance outlines procedures for managing allegations against people who work with children who are paid, unpaid, volunteers, casual, agency or anyone self-employed. The LADO must be contacted in respect of any person who has behaved in a way that has harmed or may have harmed a child, possibly committed an offence against or related to a child, or behaved towards a child that indicates that they may pose a risk of harm to children. The LADO has a role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or are in need of services and in regard to considering whether disciplinary action is indicated.   13. Overarching all of these arrangements are the various Acts, regulations along with statutory guidance described in Working Together to Safeguard Children for raising concerns about a child at risk of harm and for the sharing of information, planning and conduct of enquiries and assessment under section 47 of the Children Act 1989.  