Sexual abuse of two sisters aged 14-years-old and 13-years-old by their father over a period of six years. Both children were placed with a foster family, and a police investigation was initiated. Learning focuses on: home education of children; working effectively to identify and address sexual abuse and exploitation; understanding adult sexual offending behaviour and evaluating the risks of likely and future harm; supporting children to seek help from professionals; children communicating that something is wrong through their behaviour; interviews with children which do not follow guidance are likely to undermine effective safeguarding, decision-making in the family courts and criminal processes; recognising and addressing the impact of domestic abuse; safeguarding children from being physically harmed, characterised as "physical chastisement or physical punishment"; delivering culturally competent practice; the importance of a structured approach to children's experience of parental neglect over time. Recommendations include: make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews that relate to home educated children; scrutinise how partner agencies are equipping their staff to understand and support children's help seeking behaviour; issue a child centred position statement about the appropriateness of physical chastisement and provide guidance about what safeguarding responses are required; understand and scrutinise how supervision arrangements promote professional curiosity, are child centred, and address fixed thinking across partner agencies.
      
    Serious Case Review No: 2021/C9189  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.      1    NSPCC on Behalf of an unnamed Safeguarding Children’s Partnership  Child Safeguarding Practice Review Hatty and Jen Family J Jane Wiffin July 2021           This review is dedicated to the bravery and courage of Hatty and Jen who experienced significant harm but found a way to tell adults what was happening to them. This is not an easy thing for those who are being abused and harmed at home.       2   CONTENTS  Pages  1. Introduction   4-6 Why this Child Practice Safeguarding Review (CSPR)1 is being undertaken Process of the review Family involvement  2.  Narrative chronology of professional involvement and family background 6-12 3.  Analysis, findings, and recommendations  13-15  15-20  20-21  21-23 24-25 26-27 27-28 Finding 1: Home education of children Finding 2: Working effectively to identify and address sexual abuse and exploitation Finding 3: Recognising and addressing the impact of domestic abuse Finding 4: Safeguarding children from being physically harmed, characterised as “physical chastisement or physical punishment” Finding 5: Delivering culturally competent practice Finding 6: Working to address the long-term neglect of children Finding 7: Recognising and addressing fixed professional thinking       1 In England, child safeguarding practice reviews (previously known as serious case reviews) should be considered for serious child safeguarding cases where abuse or neglect of a child is known or suspected. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf pg. 84    3  1. Introduction Why this Child Safeguarding Practice Review (CSPR) is being undertaken. 1.1 This independently led Child Safeguarding Practice Review is about Hatty (aged 14) and Jen (aged 13) who reported being sexually abused by their father over a period of six years. Immediate safeguarding action was taken; they were placed with a foster family and a police investigation commenced, which is ongoing.  1.2 The local Safeguarding Children Partnership2 in area 1 (SCP) undertook a Rapid Review of the contact agencies had with Hatty and Jen and concluded that their circumstances met the criteria for a serious child safeguarding incident as set out in Working Together 20183 and that a local CSPR would be commissioned. The Safeguarding Children Partnership Learning Group noted that Jen was being home educated and that this was one of two incidents where children were being home educated and where there were concerns about sexual abuse and neglect where children were being home educated. This raised questions and concerns about the potential invisibility of home educated children, possibly leaving them without support or adults to talk to outside the home when they have worries or concerns and/or are experiencing abuse.  1.3 With a thematic focus the review examined elective home education and how agencies can more effectively safeguard this group of children. The review also considered the involvement of multi-agency partners with this family over time. It is important to note that multi agency involvement with this family commenced when mother was pregnant with Hatty, some 15 years ago. While the historic nature of some of this involvement means that practice has since changed significantly, particularly in relation to safeguarding children who are the victims of sexual exploitation, where contemporary research suggests that an issue remains relevant to the national safeguarding landscape this learning has been included.  Process of the review 1.4 The methodology adopted for this CSPR was a hybrid systems approach with a focus on evaluating the practice response to the children, identifying improvements needed locally and nationally to safeguard and promote the welfare of children, and to consider whether there is a need for policy and practice change in any identified area. This approach is consistent with the purpose of CSPRs as outlined in Working Together 2018.   2 The Children and Social Work Act 2017 introduced the requirement that local safeguarding children boards be replaced with new local safeguarding children partnerships led by three safeguarding partners – the Local Authority, Clinical Commissioning Group and Police; this is called the Safeguarding Children Partnership. 3 Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf Chapter 4, pg. 81    4  1.5 All key agencies were asked to provide a chronology of their involvement with Hatty and Jen and their family over the period from 2010 to the disclosure of sexual abuse in 2020. The family spent some time in local authority area 2 (LA2) and they have provided a chronology. Interviews were conducted with the professionals who had recent contact with Hatty, Jen and their father. These professionals provided useful insights and reflections on the family circumstances and the lives of the girls. Staff from the school that Hatty and Jen had previously attended knew them well and felt deeply about their wellbeing. Finding out they have been abused and harmed was difficult for them.  1.6 The CSPR was overseen by a panel of agency representatives (CSPR panel) who met regularly and who contributed to the analysis of the available information, helped to consider practice themes, and provided appropriate robust and sensitive challenge. The CSPR was chaired efficiently and compassionately by the SCP Chair of the Learning and Thematic Review Group, managed very efficiently by the Partnership Board Manager, and administered effectively. I would like to thank everyone for their hard work and commitment at what has been a challenging time, with all the restrictions and increased demands caused by the Covid-19 pandemic. The independent reviewer is Jane Wiffin, who is independent of all agencies, and she is responsible for writing this overview report. Family involvement  1.7 The review considered the best way to include Hatty and Jen in this review. They have both experienced a lot of change and have had to tell many adults about their lives. They wish to settle into their new settled circumstances. Their views will be represented by those that know them well and in the context of the criminal proceedings.  1.8 Father is a potential subject of criminal proceedings and so it has not been appropriate to seek his views.  1.9 The independent reviewer spoke to mother at length. This has been a difficult time for her. She had not had contact with Hatty and Jen for many years. This is in the context of historical coercion and control by the father towards mother; she believed that he would be a good father with support from his extended family. She was shocked to hear about the allegations of abuse made by Hatty and Jen. Her reflections are in tune with some of the findings of this review. She reported being too young to understand that she was being sexually exploited by father She was a young parent who coped well initially. She completed an apprenticeship when the girls were little and got a good job. She said that father’s violence, coercion, and control undermined her and caused deep depression. She felt professionals did not    5  see this, hear her voice, or recognise her position. She feels a deep sense of responsibility for Hatty and Jen and what has happened.  2. Chronology of professional involvement with Hatty, Jen and their family Historical Information Jen and Hatty are dual heritage: Black British and British Asian. They have a large extended paternal family, with whom they had regular contact. They had limited contact with their mother from when their early years until very recently and they had no contact with their extended maternal family.  2.1  Hatty and Jen’s mother came into local authority care aged 13 and once in care she lost contact with her family.  2.2  During father’s contact with professionals and services there was little exploration of his family and their circumstances. He told the professionals that he had a complex and difficult relationship with his mother and had been physically abused as a child by his parents, he said he witnessed domestic violence and that he was violent to his mother in his teenage years. During the recent legal proceedings because of the allegations made by Hatty and Jen, many members of the female extended family shared a history of sexual abuse, domestic abuse, and physical abuse in childhood.  2.3 Throughout the written records for Hatty and Jen there are few descriptions about how father met mother. It is known that he was 20 and she was 14 and she was a child who was in the care of the local authority. This was determined as equating to sexual abuse and was reported to the police by her social worker. Father was cautioned for the offence of sexual activity with a child under 16 and placed on the sex offenders register for two years. When compared to today’s standards of practice, in relation to children who are sexually exploited, the actions taken by CS and police may seem to be standard practice. In reality, at this time, this practice was far from universal. As evidenced in the various enquiries4 and serious case reviews5 that have subsequently happened, children like mother who were being sexually exploited were seen as making ‘lifestyle choices’ to enter into these ‘relationships’. Therefore it is important to note that the actions taken by CS and police at this time was good practice. However, the importance of this case history needed to be kept in mind when providing services to the children and when making decisions about their care, but this issue of father’s sexual abuse of mother became lost overtime.  4 Such as: Independent Inquiry into Child Sexual Exploitation in Rotherham 1997 - 2013 Alexis Jay OBE 5 Such as: Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F Oxford Safeguarding Children Board 2015    6  2.4 Mother was pregnant and aged nearly 16 when Hatty was born, Jen when she was 17. Mother lived with a foster family, but quickly moved to independent accommodation. Father lived some of the time with them.  Chronology of professional involvement  2.5 This is a high-level summary of the historical involvement of Hatty, Jen and their family with professionals over a 10-year period. It does not include all contacts or meetings. Although these are historical events, they are important in understanding Hatty and Jen’s early lives and the cumulative impact on their teenage years. There will be little commentary on events, but important themes will be highlighted and discussed in the analysis and findings section.  Living in Local Authority 1: a 12-month period Hatty aged 4, Jen 3. 2.6 When Hatty and Jen were 4 and 3, mother called the police because father had violently assaulted her; she reported this has not been the first incident. Father was arrested, charged, and sentenced to a one-year probation order and required to attend an integrated domestic abuse programme (IDAP6). An initial assessment7 was completed at this time by LA1 and this concluded that mother provided good care to Hatty, and Jen and a warm and caring relationship was observed between mother and the girls. Father left mother’s flat at this time, but over the next six months would move in and out when he had no other accommodation. This caused concern to the leaving care worker who supported mother.  2.7 Some months later father reported to the police that he had found Hatty and Jen at home alone at 8am; the door to the flat was locked and mother had been away all night. When the police arrived, there were concerns about the state of the flat and indications of neglect. Mother was arrested for child neglect, but this charge was not pursued. The girls were placed with foster carers for the next seven months and made subject to child protection plans for neglect8. Mother reported that she had been suffering from depression; father said he had been the main carer for the girls and mother did not dispute this, despite father not living permanently with them. It was agreed that parenting assessments would need to be completed.  2.8 The parenting assessment9 described mother as having a warm, loving, and caring relationship with the girls and that father’s parenting style was harsh,  6 IDAP is a nationally accredited community-based groupwork programme designed to reduce reoffending by adult male domestic violence offenders. 7 An Initial Assessment was a brief assessment of each child referred to children’s services to determine whether the child was a Child in Need of protection of additional services and the nature of any services required. This has been subsequently replaced with the single assessment process. 8 A child protection plan is drawn up at the initial child protection conference. It says what support and monitoring will be put in place when a child is at risk of significant harm because they have suffered, or are likely to suffer physical abuse, emotional abuse, sexual abuse, or neglect. 9 An assessment of parent's ability and capacity to provide good enough care for their child. The assessment will usually look at the parent's personal history, views, and attitudes towards parenting, understanding of child    7  critical and he did not engage with the girls. Mother expressed uncertainty in her ability to parent and commit to the girls; she had been inconsistent in her attendance in contact. Father expressed a strong desire to parent the girls. The parenting assessment concluded that father should have full care of Hatty and Jen, with the support of the extended family with whom they would live. Mother was to have regular supervised contact with Hatty and Jen.  2.9 Initially contact arrangements were that mother and father would see Hatty and Jen together, but mother reported domestic abuse by father to the police and father reported mother assaulted him and it was agreed that contact would be held separately.  Move to Local Authority 2: an 11-month period Hatty aged 6, Jen 4. 2.10 Father and the two girls moved to live with the extended family in a new area (LA2). The family history was shared, an assessment completed and a child in need plan put in place. This was to support father in his parenting role and to encourage mother to maintain contact. There were regular child in need meetings10, home visits and Hatty and Jen were routinely seen on their own. Mother was not part of these plans, and there were inconsistencies in contact arrangements which remained unexplored.  2.11 A referral was made to CAMHS by Hatty and Jen’s GP because they were anxious and unsettled at school. This referral provided few details, except that the girls had been abandoned by their mother with whom they now had intermittent contact and they were described as upset, anxious and unsettled by this. Family therapy with father and the girls was agreed and would be ongoing for the next few years.  2.12 Father reported concerns about his mental wellbeing to his GP and he was referred to the local psychiatric community mental health team11. He was seen by a psychiatrist and reported a troubled childhood, long-standing depressed mood and feeling overwhelmed by his current family responsibilities. He was prescribed anti-depressants and the plan was support through psychotherapy. Father did not attend subsequent appointments because he said he was feeling better and said he no longer needed support. He had no further contact with adult mental health services.  2.13 There was serious conflict between father and extended family members which threatened the stability of the arrangements for Hatty and Jen. These were  development and a child's needs, the resourcefulness of the parent to seek help and support, and who forms their support network. This will then form the basis of a report with a recommendation to the court in care proceedings or a local authority decision about who should care long-term for the child and what support a parent would require caring for their child. 10 These meetings are convened regularly, bringing together the multi-agency network.  11 Community mental health teams (CMHTs) support people with mental health problems living in the community, and their carers. The team may include a community psychiatric nurse (CPN), a psychologist, an occupational therapist, a counsellor, and a community support worker, as well as a social worker. Often a member of the team will be appointed as a care coordinator, to keep in regular contact and help plan care.    8  resolved, but there were ongoing family tensions, conflicts and violence which impacted on Hatty and Jen’s wellbeing. One of these was Jen telling school that father had hit her. This was investigated by their social worker; father denied that this had happened, and Jen withdrew her allegation. The conclusion was that this was likely physical chastisement and the child in need plan continued.  2.14   Father was accused of a significant physical assault by a female member of his family, which involved the police. Father was asked to leave, and he and the girls were homeless.  Move back to LA1 and support through an early help plan: a period of 9 months Hatty aged 6, Jen 5. 2.15 The family were provided with temporary accommodation in LA1. LA2 continued to provide support to the family; the children were seen regularly and reported to be happy and settled and father was described as more confident in his parenting. CAMHS continued to play an important role in supporting the family.  2.16 Father was discussed at a multi-agency risk assessment conference (MARAC)12 because of the recent assault on a female family member. The conclusion was that father posed a high risk of future domestic abuse. LA2 ceased their work with Hatty and Jen at this time and LA1 put in place an early help plan focused on parenting support. Family therapy and individual support continued at CAMHS. The CAMHS team tried to include mother in the work by suggesting individual sessions with the family therapist, but mother was not able to engage with this.  2.17 Father sought to have the contact order13 in place for mother revoked. A section 7 report14 was commissioned and undertaken by a student social worker (LA1 SSW1). This report highlighted the recent family history and the views of Hatty, Jen, father, mother, and the extended family. Jen and Hatty talked positively about their life with father. Jen reported concern that father sometimes slapped them and Hatty referred to arguments which she did not like. They both reported missing their mother and the role that father played in deciding when they would  12A MARAC is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs), probation and other specialists from the statutory and voluntary sectors. After sharing all relevant information they have about a victim, the representatives discuss options for increasing the safety of the victim and turn these into a coordinated action plan. The primary focus of the MARAC is to safeguard the adult victim. The MARAC will also make links with other fora to safeguard children and manage the behaviour of the perpetrator. 13 A contact order specifies how often the parent who does not live with the child should see the child or children and the terms of that contact. 14 A Section 7 report is ordered by the Court when they want information about a child’s welfare, what is best for the child and sometimes where there are certain risk factors or concerns raised in relation to a child, parent or other relative. A social worker will provide an independent assessment of a situation and will report these findings to the Court. The Court usually stipulates what they want the worker to focus on in their report.    9  see her. Father reported that mother had been unreliable in attending contact; mother reported this was because was father was controlling and had prevented contact.  2.18 The private law proceedings15 discharged the contact order in place for mother and concluded that the parents needed to agree contact arrangements between them. Father proposed that the contact arrangements remain the same, with mother seeing the girls one evening a week and having telephone calls. Mother now had a full-time job, and she was providing financial support to father for Hatty and Jen.  2.19 Father was convicted of harassment of mother and received a two-year restraining order16 with father not to have any contact with mother under any circumstances. There was now no professionals oversight to consider what this meant for contact arrangements. Continued support from CAMHS: a period of two years Hatty aged 7, Jen 6. 2.20 For the next two years Hatty and Jen lived with Father in temporary accommodation in LA1 and they continued to be supported by CAMHS and their school. There were regular family therapy sessions and CAMHS started an assessment of Hatty and Jen for child psychotherapy17. The stated aim of the psychotherapy was to support the girls regarding their feelings of abandonment by mother, her unreliability and absence. The girls were regular attenders of the sessions with the psychotherapist which were recorded in terms of their play. Early on Hatty and Jen played out situations that indicated their distress and this is discussed further in the analysis section. After two years the contact with CAMHS service came to an end. A referral by a family member to the NSPCC: a period of 6 weeks Hatty aged 9, Jen 8. 2.21 Almost immediately after the CAMHS support ended an extended family member made a referral to the NSPCC. This included concerns about neglect, father’s aggression, a lack of emotional care for the girls and that father was preventing contact with mother. LA1 started a single assessment18; father  15 Private law means a court case that is just between family members, such as parents or other relatives – and which does not involve a Local Authority or other state agency. 16 Restraining orders are court orders issued by a judge at the end of criminal proceedings to prevent someone from causing harm to someone else, in situations involving domestic violence, harassment, stalking or sexual assault. Restraining orders put restrictions on the offender, for the purpose of refraining them from causing further trouble to the victim. 17 The local CAMHS service described child psychotherapy as helping children and young people to make sense of sad, angry, painful, or confusing feelings and thoughts. Its focus is to improve relationships at home and on behaviour, as children become less preoccupied or better able to concentrate. Most children can then make better use of opportunities at school. Child psychotherapists are trained to help children understand feelings that are not possible to speak out loud. They do this through play, drawing and talking about events and experiences.  18 When children and young people are referred into children's social care for assessment and meet the threshold, they are allocated to a qualified social worker to undertake a single assessment which should identify their needs and risks and understand the impact of any parental behaviour on them as an individual.     10  refused consent for the school the girls attended to be contacted on the basis that he had a good relationship with them, and they would already have shared concerns if they had any. The assessment noted that the flat was in a poor state of repair, without basic amenities. The sleeping arrangements seemed chaotic. Father reported this was all due to financial constraints. Hatty and Jen said they were unhappy about the living arrangements, and they missed their mother. Mother said that father was not enabling her to see Hatty and Jen. The conclusion of the assessment was that the referral concerns had not been substantiated and no further action was considered necessary. The issue of distinguishing genuine economic hardship from poor emotional care and neglect is discussed in the analysis section.  School support: a period of 4 years  2.22 For the next 4 years the family had no further contact with any specialist services. The primary school the girls attended were unaware of any historic concerns about sexual abuse, domestic abuse, violence, fractured family relationships or possible issues of neglect. Over the following years they had some concerns about Hatty and Jen. These included them being hungry at school, being unkempt at times and they were often unable to get hold of father to discuss concerns with him. Advice was sought from the multi-agency safeguarding hub (MASH19) about a lack of supervision for Jen after school. The school felt that all these concerns were poverty related, and they believed that father was at times struggling as a single parent. Concerns were always discussed with him, and practical support provided.  2.23 When Jen was in her last term of primary school, her learning mentor became aware that she did not have a secondary school place. Contact was made with father who said that Jen had not received an offer from her preferred school, and he planned to home educate her until a place there became available. The learning mentor liaised with all appropriate agencies regarding this, including expressing her view that home education was not right for Jen because of the amount of support school currently provided which would be absent going forward. The junior school thought carefully about Jen and her social and emotional needs; they organised for Jen to help with after-school homework club and art club to ensure that she had contact outside of the home and to support her emotional wellbeing.  2.24 The Elective Home education (EHE) service contacted father to organise a meeting and a home visit was agreed. At this visit the EHE teacher was satisfied with the learning materials provided for Jen. There were no concerns about their accommodation which was assessed as suitable for home education. Jen  19 Multi-agency safeguarding hubs (MASH) are a hub of key agencies (which can include children's services, police, health, education, probation, and youth offending) which are co-located or have an agreed protocol in place to promote better information-sharing, decision-making and communication in relation to concerns about children. The aim is that referrals are responded to in a coordinated, appropriate, and timely way.    11  said that she liked being home educated and that she could take her time without lots of other children around. The EHE teacher noted that Jen seemed very anxious, was struggling to contain her emotions and she cried at one point. Father was seen to respond appropriately to reassure her, and he said that Jen put a lot of pressure on herself to succeed.  2.25 The EHE teacher contacted the learning mentor at the junior school to talk this over and to ask if there had been any child protection concerns. The learning mentor said that she did not think this home education was the right plan for Jen, but there had not been any safeguarding concerns. She decided that no further action was necessary at this time and said she would visit Jen again in 6 months to check on progress. This home visit got moved twice by father and was planned for 9 months later and never took place because the allegations of sexual abuse had been made.  2.26 Hatty told professionals that her father had been sexually abusing them for many years and when interviewed Jen also reported a long history of sexual abuse. Father was arrested and Hatty and Jen were placed with a foster family. A joint police/children’s services child protection inquiry started, and an Achieving Best Evidence interview was conducted. At the conclusion of the Finding of Fact hearing later in 2020 the presiding judge was critical of the initial police/children’s services interviews with Hatty and Jen and the subsequent ABE interview. This meant that the ABE interview has had to be undertaken again. Criminal proceedings are ongoing.        12  3. Analysis and findings 3.1 The purpose of a local Child Safeguarding Practice Review is to look at the circumstances of children who have been harmed and to consider whether there are lessons to be learned about how agencies work, both individually and collectively, to safeguard and promote the welfare of children and to consider any necessary changes to practice or processes as a result. This CSPR was initiated because of the serious allegations made by Hatty and Jen about being sexually abused by their father; this was in the context of Jen being home educated. This is one of two reviews within this child safeguarding partnership where children who are home educated have made disclosures of sexual abuse. This raises important questions about the extent to which the current home education guidance ensures the safety and wellbeing of these children. This is underlined by the number of recent serious case reviews where home education is a factor where children have been harmed and abused. This was the review’s starting point, but in seeking to understand Hatty and Jen’s circumstances, it has emerged that here were several historical concerns. These are outlined below; although they are historical, they are part of Hatty, Jen and mother’s story and are important to consider in the context of the harm they experienced. Finding 1: Home education of children 3.2 At the point of Jen’s transfer from junior to secondary education, father decided that she would be home educated; he gave his rationale as waiting for a place at her preferred school. Jen’s junior school was concerned that this was not the right decision for Jen because of the amount of support they were providing to her. They were unaware of the family history, and although they worried about father’s ability to cope and his struggles financially, they did not have any safeguarding concerns. Jen’s school could see no way in which they could object to this; in England parents have the right to educate their children at home, but they encouraged father to register Jen as home educated to ensure some oversight of her needs and circumstances. In addition, they organised for her to come regularly into school. This was effective practice; there is no requirement for parents to register children as home educated, and this can increase their invisibility and isolation. 3.3 Once Jen was registered as home educated, Father agreed to meet the home education teacher and agreed ultimately to a home visit. The primary purpose of a home visit in these circumstances is to ensure that a child is being provided with an appropriate education. Section 7 of the Education Act 1996 makes clear the importance of children of compulsory school age receiving efficient full-time education that is suitable to their age, ability, and aptitude, and addresses any special educational needs. The home education teacher was satisfied with the evidence provided but was aware that Jen seemed stressed and a little    13  distressed. She judged that father responded in an appropriate way and checked with Jen’s school that there were no current safeguarding concerns. She did not feel that there were safeguarding concerns to be addressed. The home education teacher could have sought information from the MASH team, which would have provided her with background information.  3.3 Sections 10 and 11 of the Children Act 200420 give local authorities duties for safeguarding and promoting the wellbeing and welfare of children in their areas. This includes children educated at home. Section 175 of the Education Act 200221 requires authorities to plan for ensuring that their education functions are exercised with a view to safeguarding and promoting children’s welfare. Therefore, the general duties of local authorities in relation to safeguarding are the same for all children, however they are educated. In some circumstances elective home education may make it more possible for parents to prevent the independent oversight by professionals of children who are being harmed and neglected.  3.4 There have been several serious case reviews nationally22, 23, 24 & 25 that have highlighted home education as a factor in the abuse and neglect of children, although not necessarily a causal one. The main consistent finding of these many reviews is the invisibility of home educated children and their lack of contact with agencies who could monitor their safety and wellbeing. Most of these reviews suggest that parents actively prevented this contact. This is an important issue. There is considerable research which suggests that children find it difficult to tell anyone when they have been abused, particularly when they have been sexually abused. When they do tell, they usually choose a friend, a friend’s parent or family, someone trusted in their own family, a teacher, school mentor, school nurse or extra-curricular activity provider. For home educated children, there may be fewer opportunities for these contacts and therefore fewer opportunities to seek help about abuse.  3.5 The home education teacher had insufficient evidence to believe that Jen’s circumstances met the threshold for safeguarding action. Recent changes to the home education service means that there is easier access to the MASH and background information; the home education service now has routine safeguarding consultation sessions and they can bring children about whom they have concerns or worries to a regular meeting for discussion. These are all important steps; however, it remains of concern that there are children with vulnerabilities, but which does not immediately meet the threshold for safeguarding action, who by virtue of their home educated status do not have access to school nurses or those who could evaluate their ongoing emotional and social wellbeing.   20 https://www.legislation.gov.uk/ukpga/2004/31/contents  21 https://www.legislation.gov.uk/ukpga/2002/32/contents  22 https://bbcdevwebfiles.blob.core.windows.net/webfiles/Files/case-reviews-home-education.pdf  23 http://www.northamptonshirescb.org.uk/scr/childab  24 https://www.cumbria.gov.uk/eLibrary/Content/Internet/537/6683/6687/17123/426059438.pdf  25 https://www.oscb.org.uk/practitioners-volunteers/serious-case-reviews/     14  Recommendations: 1. The local home education policy should be refreshed to explicitly focus on child-centred practices and taking account of the findings of the two recent local CSPRs, the 2019 national guidance and the interplay between elective home education and children missing from education.  2. The Local Safeguarding Children Partnership to make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and CSPRs that relate to home educated children.  Finding 2: Working effectively to identify and address sexual abuse and exploitation. 3.6 The sexual abuse and sexual exploitation of children and young people is a serious issue which has significant negative emotional and developmental consequences which can last throughout childhood and into adulthood. Prevalence studies for England and Wales suggest that some 15% of girls and 5% of boys experience some form of sexual abuse before the age of 1626. However, sexual abuse is a hidden crime and many of those who experience it do not report their experiences for several years, if at all. In fact, it seems that only around 1 in 8 cases of child sexual abuse reach the attention of statutory services, which means far more children are being sexually abused than agencies are currently identifying or safeguarding27.   3.7 There is considerable evidence that children subject to sexual abuse are not identified by professionals, that there is an over-reliance on children telling professionals what is happening to them, and when they do tell, their testimonies are often considered unreliable, and they do not stand up to scrutiny in comparison to denials by adults. There are many known barriers to children telling someone that they have been sexually abused including fear, shame, embarrassment, coercion, family cultural pride and lack of recognition that what is happening is abuse. The Children’s Commissioner and a recent thematic Joint Targeted Area Inspection28 have expressed concern about how effectively the safeguarding system meets the needs of this group of children. So, although some of what this review highlights are historic in nature, there are likely to be ongoing concerns about the complexities of addressing sexual abuse.    26 https://www.csacentre.org.uk/csa-centre-prod/assets/File/CSA%20Scale%20and%20Nature%20infographics%202nd%20edition.pdf  27 Children’s Commissioner report, 2015 https://www.childrenscommissioner.gov.uk/report/protecting-children-from-harm/  28 https://www.gov.uk/government/publications/the-multi-agency-response-to-child-sexual-abuse-in-the-family-environment     15  Understanding adult sexual offending behaviour and evaluating the risks of likely and future harm  3.8 The first significant issue emerging from a review of Hatty, and Jen’s circumstances is the issue of father’s early sexual abuse of mother. This happened 16 years ago, and the passage of time means that there is little information about the circumstances in which father met mother, but it was when she was 14 and in the care of the local authority. At the age of 15 she was pregnant with Hatty. Father was an adult who had sexually offended against a child which should have alerted professionals to consider him a possible future sexual risk to children. Mother was a child/young person in the care of the state and as the corporate parent; the police were alerted by mother’s support worker to these concerns, and this led to action. Concerns about father’s sexual offending behaviour, potential grooming behaviour and likely coercion and control got lost. Over time the information about father’s sexual offending became vague and unclear. Father often misrepresented the age gap when he and mother met, and as time went on his sexual abuse of mother was not a known factor of concern or was euphemistically referred to.   3.9 It is striking that so many members of father’s family were themselves sexually abused in childhood. Father’s sister tried to tell her mother (MGM), but reported not being listened to. Maternal Grandmother reported that the sexual abuse she experienced had a profound impact on her life and she was not able to tell anyone about it. The learning here is that all professionals need to be alert to the possibility of child sexual abuse, be prepared to give children the opportunity and support necessary to talk about it and make sense of behaviour as communication. 3.10 This history of sexually offending against a child should always be taken seriously. In 2004 the Bichard inquiry reported that the sexual behaviour of Ian Huntley with children had not been taken seriously enough and professionals had been too ready to accept that these were equal and consenting relationships. This report focused on the importance of understanding adult males who prey on and groom young girls to sexually abuse and exploit them; this led to a clear framework for analysing underage sexual activity which was contained in the accompanying good practice guidance to Working Together 2006. There have been similar concerns emerging from the many inquiries across the country regarding child sexual exploitation, particularly those who are care experienced (in the care of the state) and the role of the corporate parent. There have been some very significant changes in statutory guidance, procedures, safeguarding practice and societal attitudes regarding the sexual exploitation of children but it remains important to continue to  reflect in the context of contemporary practice whether professionals are currently equipped to assess the grooming behaviour of adults who are likely to/have sexually    16  abused a child to make an appropriate risk assessment and consider the implications for future harm rather than accept notions of a perceived relationship and consent.  Father sexually abused mother: the lack of analysis of his offending behaviour and that the sexually abuse got lost in professional records, meant that no one considered that father might pose a sexual predatory risk to other children, including Hatty and Jen.  Supporting children to seek help from professionals. 3.11 It is a core ambition of the safeguarding system that children and young people feel able to talk to family, friends, and professionals about any concerns they have. This concept of help-seeking behaviour is important. Help-seeking behaviour is a core part of child development, where babies and children learn over time how to seek help, get validated for that help seeking behaviour and learn who can be trusted. It is an essential skill. It is a developmental task which takes place over time and is supported by the response of parents/adults. This starts in babyhood when a baby cries and someone responds. Children who are abused, neglected or who receive inconsistent care over time are likely to have underdeveloped help-seeking behaviour or are actively discouraged or prevented from seeking help through threats, intimidation, or suggestions of impact on family. It is essential that professionals respond to children’s help-seeking behaviour generally, but specifically in the context of children raising concerns about safeguarding matters. The research evidence suggests that children will “test out” the response of professionals before making more serious allegations of harm. It is essential that in a child-centred system children’s concerns are listened to and responded to.  3.12 At the beginning of 2012 Jen told someone at school that she had been “beaten” by her father and this had been witnessed by a member of the family. Jen told the SW she had made the story up; the social worker noted that both girls seemed nervous, but there was insufficient reflection regarding whether the girls had been asked/intimidated into withdrawing the allegation and the conclusion of these enquiries implied that she had made up the story for attention.  3.13 The focus should have been on the fact that Jen was asking for help and the meaning of this explored further. Children want validation for their concerns and the message that harming children is wrong; they want to know what action will be taken, they want their need for help acknowledged and reinforced and there to be some repair of the harm experienced. This will enable them to develop help-seeking strategies in the future because they have been heard; the message is that telling people that something is wrong is the right thing to do and will lead to some action. It is critical that professionals respond proactively and with curiosity to children when they seek help, exploring and analysing the meaning for the child and the implications for their wellbeing. If their worries are    17  not acknowledged and their concerns not explored and understood, then they are less likely to seek help from professionals again.  Behaviour as communication  3.14 Whilst the case events referred to in this section happened almost 10 years ago contemporary research suggests that children often think they have communicated that something is wrong for them or that they are being sexually abused through their behaviour; they hope professionals will notice, pick up on clues in their behaviour, and act. CAMHS recognised that much of Hatty, and Jen’s play and behaviour indicated distress. This was recorded and analysed in the context of their past abandonment by their mother, without any reflections on their current circumstances of living with father who had mental health difficulties and who was known to be violent to others. The girls’ behaviour observed during therapeutic sessions needed more exploration and connection to the known incidents of domestic abuse perpetrated by father. CAMHS had concerns about father’s behaviour and demeanour which were also recorded, this behaviour was concerning but not sufficiently analysed in the context of parenting and the need to provide consistent emotional care to Hatty and Jen. It is possible that the risks posed to the children were obscured from view in the context of the positive engagement and the therapeutic alliance that had been achieved.  3.15 The children’s preoccupation about toileting issues was not analysed, and it is meaning therefore not understood. If CAMHS had known that father had sexually abused mother, they might have understood Hatty and Jen’s behaviour differently. CAMHS should have received information about the history, and they should have sought more information about the past. Instead, they relied too heavily on what father said the issues were, which meant continued focus on mother and her behaviour, rather than on father and his behaviour. Investigating allegations of child sexual abuse 3.16 Once a child has alleged that they are being sexually abused there are clear procedures for the joint police/children’s services response and approach. A strategy meeting/discussion will ensure that there is multi-agency planning for an appropriate and child-centred response which enables the child to outline their allegations in their own way using their own words, without being prompted or questioned unduly. It is important that children do not have to repeat their allegations on too many occasions and that both initial interviews and likely follow-up visually recorded/Achieving Best Evidence (ABE) interviews are conducted by experienced professionals who have undergone appropriate training. The guidance for the conduct of initial interviews is clear and includes a strong emphasis on planning and preparation; the purpose of the initial questioning of the child is to get a brief account of the allegations and a more detailed account should not be pursued at this stage. The interviewers should    18  ask open ended questions, rather than forced choice, leading or multiple-choice questions, and the answers should be recorded accurately using the child’s words.  3.17 This interview is to establish the need for a visual recorded/Achieving Best Evidence interview as part of a police investigation. The ABE was intended to be delivered by both police and social work staff but can be led by either discipline. The ABE guidance is clear that issues such as language, ethnicity, disability, previous experience of services will influence this decision. It is critical that the ABE interview is conducted by experienced and trained interviewers of children, who are aware of the four phases outlined in the ABE guidance and who understand the importance of enabling the child to outline their allegation in a free narrative approach, using open ended questions. 3.18  The initial interview of Hatty and Jen by the police officer and social worker was not sufficiently planned, was too interrogative in nature, and too many detailed questions were asked. The subsequent ABE was not planned, used leading questions and the words used by the girls interpreted and recorded differently from what they said. This has caused the need for Hatty and Jen to have to undertake new ABE interviews as part of the ongoing criminal proceedings, causing them unnecessary stress. Poorly conducted interviews with children which do not follow the guidance are likely to undermine effective safeguarding, decision-making in the family courts and criminal processes, thus undermining children’s safety.  3.19 There have been several national court judgements highlighting that initial interviews go into too much detail and are interrogative in nature. This was the case here and implies a need for training and clarity of the purpose and process of these early interviews where child sexual abuse is a concern. There have also been several judgements29 30 31 32 about the conduct of Achieving Best Evidence Interviewers, where a failure to follow the interviewing guidelines means that courts are unable to rely on this as evidence.  3.20 This review has highlighted the importance of training, including skills in communicating with children, the process of the ABE and the style and approach needed. An audit has been completed by the police considering this case into how relevant guidance is being implemented regarding achieving best interest interviews (ABE). This has reported no issues, but given the national concerns about ABE interviewing, and the evidence from this review about the need for effective multi-agency practice in this area to ensure that children do  29 https://www.familylaw.co.uk/news_and_comment/evidence-of-sexual-abuse-in-children-proceedings-pt-2  30 https://www.familylawweek.co.uk/site.aspx?i=ed208530  31 https://www.familylawweek.co.uk/site.aspx?i=ed219146  32 Re W, Re F [2015] EWCA Civ 1300, Re E (A Child) [2016] EWCA Civ 473, Re Y and F (Children) Sexual Abuse Allegations) [2019] EWCA Civ 206 and in the judgments of MacDonald J in AS v TH and Others [2016] EWHC 532 (Fam) and Re P (Sexual Abuse: Finding of Fact Hearing) [2019] EWFC 27    19  not have to be re-interviewed and further traumatised, the child safeguarding partnership needs to consider what further action is necessary. Recommendations  Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 3. The Local Safeguarding Children Partnership to scrutinize how partner agencies are equipping their staff to understand and support children demonstrating help seeking behaviour. 4. The Local Safeguarding Children Partnership to consider what multi-agency action may be needed locally to demonstrate consistent compliance with the ABE guidance.  Finding 3: Recognising and addressing the impact of domestic abuse  3.21 There were many allegations over the years of father being domestically abusive to mother, to his sister and his mother. Each incident was responded to appropriately by the police and where possible, action taken. These incidents were not part of the analysis of the family’s circumstances. It is striking the extent to which father’s own view that the domestic abuse incidents were just disputes was accepted and the domestic abuse perpetrated by him was minimised. It was not factored into plans around contact between Hatty, Jen and mother, and not factored into an understanding of mother being inconsistent in seeing Hatty and Jen. Father’s self-report of her unreliability was accepted at face value. This needed to be more carefully analysed in the context of coercion and control arising from both the domestic and sexual abuse of mother by father.  3.22 Mother’s voice is absent from much of the specialist work that took place between 2010 and 2014 which included the Section 7 report when the history of DV was not mentioned despite mother’s report that father prevented her from seeing Hatty and Jen, and Hatty talking about father deciding when mother could see them. The conclusion of the assessment was supportive of father’s right to make decisions regarding the needs of Hatty and Jen. Again, father’s reports of mother as unreliable were accepted and not contextualised alongside coercion and control.  3.23 Hatty and Jen were present when several of the domestic abuse incidents perpetrated by father took place. There is little evidence that the impact on them was discussed or analysed beyond asking them if they were OK. CAMHS did discuss the potential impact of domestic abuse on Hatty and Jen, and they asked father to consider their needs. The recordings at the time show that CAMHS used language such as “physical altercation” which minimised the violent actions of father. CAMHS sought to understand mother’s role in the    20  family but did not consider the impact of domestic abuse and violence or its likely impact on her being able to be part of Hatty and Jen’s life.  3.24 There were indications within the psychotherapy sessions that Hatty and Jen were acting out some of the incidents of father’s domestic abuse that they had witnessed. In one session they played out a situation using teddy bears talking to the police, saying “there are bad people in the office”, the therapist being taken away by the police and the girls barricading themselves in the therapy room with the therapists. Hatty and Jen were noted to be very distressed. Yet there was no analysis of this behaviour, and the likely link to witnessing domestic abuse. The analysis remained fixed on the distress caused by mother’s absence and abandonment (see Finding 6 for an analysis of the evidence of fixed thinking on professional practice during the years 2010 to 2014). 3.25 These case events took place some years ago and there is no doubt that the safeguarding response to domestic abuse has changed considerably in the past 10 years. However, this is part of Hatty, and Jen’s life story and domestic abuse remains a widespread and serious issue33 which has a significantly negative impact on large number of children, their parents, and extended families34. It is therefore essential that there are systems and processes in place to address domestic abuse effectively and there evidence to suggest that these things are in place in the local area. 3.26 Nationally, research has shown that this is a complex area of practice. The Ofsted Joint Targeted Area Inspections of Domestic abuse (2016)35 highlighted the need for continued improvements in practice regarding the key issues that were emerging in this case: assessment, support for children, support to survivors and challenging a blaming approach, holding perpetrators responsible for their behaviour and the harm they cause, alongside taking domestic abuse seriously and ensuring it is not minimised or replaced by euphemistic language.  Recommendations: This issue of how domestic abuse is addressed is an historic concern. It is still a serious issue but there have been changes in the recognition of its seriousness, its impact on those who are survivors, their parenting, and the direct impact on children. Therefore, this review makes no multi-agency  33 ONS (2016), March 2015 Crime Survey for England and Wales (CSEW) 34 Cleaver, H et al (2011) Children’s Needs – Parenting Capacity. London: The Stationary Office https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf  35 HM Inspectorate of Probation, CQC, HMICFRS, Ofsted (2017): The multi-agency response to children living with domestic abuse. Reference no: 170036    21  recommendations; individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. Finding 4: Safeguarding children from being physically harmed, characterised as “physical chastisement or physical punishment”. “Quite simply, it (physical punishment) doesn’t work and it’s wrong. It doesn’t teach children why their behaviour was wrong or what they should do instead, and it tells them that it is OK to use physical force and aggression against other people”36. 3.27 There has been significant debate in England about whether it is legitimate for parents/carers/family members to use physical punishment in the context of disciplining their children; this is generally described as “reasonable physical chastisement”. This debate has focussed on the fact that “reasonable physical chastisement” is legal, that family history and culture influence this method of discipline and a belief that “physical chastisement” or physical punishment is used in the best interests of the child. There are several difficulties with this assertion. Children view physical punishment as the most severe type of discipline and report that it hurts both physically and emotionally37. Some describe feeling scared, sad, and unloved, and say that it negatively affected their relationship with their parents38, 39.  3.28 There is strong research evidence that physical punishment is bad for children and compromises their developmental outcomes into adulthood. It is associated with increased childhood aggression and antisocial behaviour. Physical punishment affects children’s emotional and mental health including depressive symptoms and anxiety. There is also evidence for a link between childhood physical punishment and adult aggression, antisocial behaviour, adult mental illness, and adult substance abuse. Research shows that the relationship between physical punishment and problem behaviour is reciprocal: physical punishment exacerbates existing problem behaviour, leading to a vicious circle of cascading conflict. Parents who use physical punishment in response to perceived problem behaviour are likely to make that behaviour worse. Physical punishment carries a worrying and serious risk of escalation into injurious abuse and maltreatment. The evidence supports the notion that  36 https://www.pat.nhs.uk/Default.aspx.LocID-022new0dm.RefLocID-022006001002.Lang-EN.htm  37 Sherbert Research. (2007). A study into children’s views on physical discipline and punishment. DCSF and COI. 38 Dobbs, T. A., Smith, A. B., & Taylor, N. J. (2006). "No, We Don't Get a Say, Children Just Suffer the Consequences": Children Talk about Family Discipline. International Journal of Children’s Rights, 14(2), 137. 39 Milne, E. (2009). “I don’t get sad, only when my mum smacks me”. Young Children give advice about family discipline. Children are Unbeatable. Retrieved from:  http://www.childrenareunbeatable.org.uk/assets/pdfs/I%20dont%20get%20sad%20-%20report.pdf          22  physical punishment and physical abuse are part of a continuum of violence, differing only by severity or degree40.  3.29 Jen spoke to professionals about being physically hit by father; there was little professional exploration of why she raised this as an issue and its meaning to her. An assumption appears to have been made that father, as a parent, used physical punishment in Jen and Hatty’s best interest to address perceived behaviour concerns. What emerges from a review of the whole of the family history is that physical abuse and domestic abuse was a significant feature of the extended family life. Father and his siblings reported being physically abused and they witnessed the domestic abuse of their mother. Father said that he believed that the severity of the physical punishment he experienced caused him to be violent to his own mother, and this violence was so severe that he had to leave the family home at age 14. Father was domestically abusive to mother and his sister. Hatty and Jen lived in an environment where physical violence to adults and children was deemed acceptable.  3.30 Physically punishing children does not work as a strategy to address perceived behaviour difficulties and there is evidence that using violence to teach children promotes violent behaviour as a means of problem solving in childhood and adulthood. This information needs to be shared with parents and advice given about alternative approaches to discipline.  3.31 There should also be no automatic assumption made that a parent is using physical punishment as a response to a child’s behaviour or that it is part of the cultural context of the family. Each incident must be assessed and analysed from a child-centred perspective. Some physical punishment by parents is a loss of control, which can escalate to greater levels of violence, some is caused by a parent’s use of violence to control and humiliate, and some by their negative feelings towards the child.  3.32 Although this issue was a historical concern for Hatty and Jen, there remain ongoing debates about the rights of adults and the legality of physical punishment within contemporary safeguarding practice. The current London Child Protection procedures suggest that adults hitting a child without leaving a mark is acceptable practice which requires no professional action. The danger of this approach is that each incident may be treated in isolation, the cumulative harm not recognised and the meaning for the child and their attachment relationships not understood. Although the law suggests it is acceptable to physically punish children, safeguarding partnerships should have a child-centred view about its appropriateness and provide advice and guidance, and challenge where necessary.   40 Bunting L, Webb MA, Healy J (2008): The ‘smacking debate’ in Northern Ireland – messages from research. Northern Ireland Commissioner for Children and Young People.    23  “Research papers commonly conclude that ‘more research is necessary’. However, when the existing evidence is as strong as it is in the case of physical punishment and given that physical punishment is a clear human rights violation, there seems to be little value in calling for more research on its effects. To borrow Gershoff’s words: ‘We know enough now to stop hitting our children’”41. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 5. The Local Safeguarding Children Partnership to issue a child centred position statement about the appropriateness of physical chastisement and provide guidance about what safeguarding responses are required. Finding 5: Delivering culturally competent practice 3.33 This review has deliberately anonymised Hatty and Jen’s cultural heritage because of concerns that this would make their circumstances recognisable. They are of dual heritage and are non-white. There was little information about father or mother’s cultural context beyond descriptions of their ethnicity. There was an absence of information regarding what was important to father and his mother from a cultural perspective and no information regarding whether they were asked about their experiences of racism in the community or when in contact with services.  3.34 There was also no information about mother’s cultural heritage, and the impact of this part of Hatty and Jen’s cultural identity being absent because they were not living with her. The cultural identity needs of Hatty, and Jen were discussed in several of the assessments completed but ultimately no action was planned or taken. 3.35 Legislation42, guidance43 and research44 highlight the importance of identifying a child and their family’s cultural context and heritage, as well as their experiences of racism and discrimination alongside family strategies to address this.  “Every Assessment should reflect the unique characteristics of the child within their family and community context. The Children Act 1989 promotes the view that all children and their parents should be considered as individuals and that  41 https://www.cypcs.org.uk/ufiles/Equally-Protected.pdf  42 Children Act 1989 www.legislation.gov.uk/ukpga/1989/41/contents  43 DOH (2000) Framework for the assessment of children in need and their families http://webarchive.nationalarchives.gov.uk/20130404002518/https://www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf  44 Thoburn, J et al (2004) Child Welfare Services for Minority Ethnic Families: The Research Reviewed: Jessica Kingsley press    24  family structures, culture, religion, ethnic origin should be respected”, Working Together 201545 3.36 This focus on cultural competence grew out of historic concerns regarding the professional safeguarding response to children and their families from Black and minoritized groups which was “colour-blind”46, meaning it often lacked a recognition of culture, personal47 and institutional racism48. This led to some children disproportionally coming into the care of the state and other children not being effectively safeguarded49.  3.37 There remain national concerns regarding many professionals’ ability to work proactively in a culturally competent way. The Hamza Khan SCR50 reflected that “the cultural and religious complexity of the family was not enquired into. This is surprising given the local diversity of culture, religion and language”. Brandon and colleagues have found in the biennial reviews of SCRs51 that issues of culture and ethnicity were a common theme, which was not adequately explored in safeguarding practice.  3.38 Cultural competence is the ability and confidence of all professionals to explore and ask questions about the cultural context and practices of the different children and families that they work with. This includes understanding and addressing racism and discrimination and recognising that cultural identity will be treated with understanding and respect. 3.39 It does not mean that professionals can fall back on simplistic notions of culture to avoid making difficult decisions about when and whether to intervene with families or to allow stereotypes and discriminatory attitudes to influence practice.  3.40 Culturally competent workers recognise every individual as unique and equally worthwhile. Assessments, plans, and interventions need to include a discussion of health beliefs, process of immigration, attitudes to professionals and attitude to family relationships. Alongside this it is important to explore a family’s experience of racism and discrimination and consider its impact on family life,  45 DfE (2015) Working Together to Safeguard Children: London https://www.gov.uk/government/publications/working-together-to-safeguard-children--2  46 Phillips, M. (2002) Issues of ethnicity and culture. In: Wilson, K., James, A. (eds) The Child Protection Handbook (2nd edn). Edinburgh/London: Ballière Tindall 47 Prejudice, discrimination, or antagonism directed against someone of a different race based on the belief that one’s own race is superior: Oxford University Dictionary 48 [Institutional racism is] the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping which disadvantage minority ethnic people. (Macpherson, 1999b: 6.34) 49 Thoburn, j et al (2004) Child Welfare Services for Minority Ethnic Families: The Research Reviewed: Jessica Kingsley Press 50 http://bradfordscb.org.uk/?page_id=158  51https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf     25  access to services and opportunities. The culturagram tool52 can be a helpful tool in exploring these issues. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 6. The Local Safeguarding Children Partnership to develop a multi-agency position statement about expectations for culturally competent practice and provide support to improve agencies’ practice. Finding 6: Working to address the long-term neglect of children.  3.41 The neglect of children’s needs by those responsible for their care and nurturing of their emotional wellbeing is a serious issue which has significantly negative developmental consequences for children in the short-term and has the potential to limit their adult lives in the longer term. It has become clear over time that early neglect needs addressing and taking seriously. This is an area where practice has changed and developed, locally and nationally, over the last 10 years.  3.42 The issue of neglect is a key aspect of Hatty and Jen’s life story. They were born to a young mother who was herself still a child and who was in the care of the state because of abuse and neglect. She was subject to domestic abuse from father who had sexually abused her. These events happened several years ago, and it is beyond the remit of this review to explore the support she was offered at this time, but it is clear she was under pressure and early action was necessary to support her; there were early concerns about mother’s neglect, rather than father’s influence. The influence of father and the harm he caused was an enduring feature of the neglect and trauma suffered by the children. One of the critical issues in these situations is to understand why neglect is happening, the cause, and to use this as the basis for intervention. Contemporary research suggests that young parenting, experience of abuse and neglect, domestic abuse and lack of social networks have a big part to play. These were the factors in mother’s life. As stated, understanding and responding to neglect has changed considerably over recent years. However, recent SCRs and contemporary research continue to identify that this remains an issue that still requires national attention. Therefore, for the purposes of national learning, the experiences of Hatty and Jen are important to bring to light.  3.43 Father took on full time care of Hatty and Jen ad there were ongoing concerns about how he was coping. These concerns were addressed, but neglect of the  52 Cultural Competency Toolkit: Health and Social Care https://www.hackney.gov.uk/Assets/Documents/Cultural-competencies-toolkit.pdf     26  girl’s needs was never highlighted, despite evidence of emotional neglect and physical abuse. An extended family member made a referral regarding physical and emotional neglect. This outlined Hatty and Jen as unhappy and asking for help. The home circumstances were in a poor state. Hatty and Jen expressed concern about the circumstances they were living in. Father reported that this was a poverty related issue, and this explanation was accepted. The issue of emotional neglect was not addressed, and the historic concerns of abuse and violence not factored into an analysis. The school the girls attended were unaware that this assessment was being undertaken. There is a balance to be struck between a parent’s rights to privacy and a child’s right to have the whole of their circumstances understood. The school saw Hatty and Jen every day and had taken on a supportive role. They needed to know about these concerns, so they could keep an eye on the wellbeing of the girls and offer support to father. 3.44 From this point onwards Hatty and Jen were known only to the schools they attended. There were ongoing concerns about what is described as “low level” neglect and a sense of poverty and isolation for a single parent. They felt that Hatty and Jen were progressing academically and socially. The school provided compensatory care to address things like them being hungry and the continued poor state of the home. Whilst the school discussed with MASH the specific issue of a lack of supervision for Jen after school, their niggling concerns needed to be shared with MASH in order to receive support in conceptualising this as a case of neglect and consider what more may be needed to improve Hatty and Jen’s lived experiences.  3.45 One of the core defining features of neglect is its pervasiveness, persistence, and cumulative harm. Hatty and Jen experienced a level of neglectful caregiving across the span of their whole lives. The impact of this is unclear. This review has highlighted the importance of a structured approach to children’s experience of parental neglect over time, with a focus on understanding cumulative impact for children, causal factors, interventions that lead to significant change and the likelihood that neglect can lead to other forms of abuse occurring.  Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. There has been significant work locally to address child and adolescent neglect and in recognition of this one recommendation is made.  7. Where there are concerns about possible neglect, designated safeguarding leads in schools to routinely seek consultation with MASH and share all information in full.     27   Finding 7: Recognising and addressing fixed professional thinking   One of the most common, problematic tendencies in human cognition … is a professional failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.53  3.47 There is a substantial body of research evidence that has clearly identified the unconscious tendency for early evidence bias in human decision-making; that is, an initial summing up of a situation strongly influences the analysis of subsequent or new information leading to fixed thinking and faulty conclusions. Serious Case Reviews have repeatedly found that professionals were either unwilling or slow to revise their judgements in the face of new or contradictory evidence and that this selective interpretation of information, only using that which confirmed their preferred view about a particular case, became a “pervasive belief” which influenced the professional response. These pervasive beliefs were found to remain, even where there was considerable evidence of lack of progress or lack of success in the interventions and services offered. As Munro notes, “the single most important factor in minimising errors in safeguarding practice is for professionals to be enabled to admit that they might be wrong.” 3.48 There is considerable evidence that across the period when Hatty and Jen were known to specialist services there were pervasive views held about mother, that she had abandoned her children, was not committed to having a relationship with them, and was not interested in engaging with services. Across agencies this was seen to be the cause of the anxiety and distress that Hatty and Jen experienced. This belief cast a long shadow, meant the children did not see their mother for many years and did not have the opportunity to have a relationship with her. Concerns about father’s domestic abuse, physical punishment of the children, erratic behaviour and mental health difficulties were known, but not seen as the central issue having an impact on Hatty and Jen.  3.49 The pattern of seeing mother as the problem pervaded, stoked by father and in some small part the extended family yet there was evidence to the contrary which was disregarded.  3.50 Ultimately, mother lost contact with Hatty and Jen for many years. The absence of any specialist input meant that there was no reflection on why and what could be done about this. Father reported to Hatty and Jen that their mother did not want to see them. There was no voice that could provide the alternative view,  53 Fish, Munro and Bairstow (2009), Learning together to safeguarding children. Pg. 9     28  that mother did not feel safe to see Hatty and Jen because it would bring her back into contact with father and his controlling and coercive behaviour.  3.51 Professionals must be willing, encouraged and supported to challenge, and where necessary revise, their views throughout the period of any intervention. To achieve this, practitioners and their managers should routinely play their own ‘devil’s advocate’ in considering alternative actions, explanations, or hypotheses. Supervision should provide a safe but challenging space to oversee and review cases with the help of a fresh, experienced, pair of eyes and to systematically guard against either rigid adherence to a particular view. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 8. The Local Safeguarding Children Partnership needs to understand and scrutinize how current supervisory arrangements promote professional curiosity, are child centred, and thereby address fixed thinking across partner agencies.   