Sexual and physical abuse of Child F and her younger brother, Child G, by their stepfather over several years; the family lived in Preston and Wigan. Child F made multiple disclosures to different professionals which were subsequently retracted. Their mother was sexually abused as a child and had consecutive relationships with 4 men who posed a risk to herself and her children; the stepfather was previously implicated in causing serious injuries to a 6-month-old child. Child G had a genetic medical condition which his mother struggled to cope with; Child F visited health professionals several times with head and back injuries and urinary tract infections. Both children were subjects of child protection plans. Following allegations of abuse by Child F in 2013, the stepfather was arrested; the investigation was closed because she was not deemed a credible witness. She was removed from home during the investigation and informally fostered afterwards. Child G had denied previous allegations, but disclosed abuse in February 2014. He and their younger siblings were taken into care. Key findings include: limited understanding of how and why victims of abuse disclose and withdraw allegations; the mother's parenting capacity was not formally assessed and no long term support plan was put in place; the voices of Child F and Child G were ignored or disbelieved on some occasions. Uses elements of the Social Care Institute for Excellence (SCIE) systems model to make recommendations, including: family history and genealogy should be used to identify and assess patterns of risk; the police should review evidence gathering practices in cases where a child has alleged abuse.
      
 Title:  Child F and Child G: serious case review. LSCB: Wigan Safeguarding Children Board Author: Clare Hyde Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Child F and Child G SERIOUS CASE REVIEW AUTHOR: CLARE HYDE DATE: WEDNESDAY 10TH AUGUST 2016 COMMISSIONED BY: WIGAN SAFEGUARDING CHILDREN BOARD      1  Contents INTRODUCTION ....................................................................................................................................... 3 METHODOLOGY ...................................................................................................................................... 4 Independence ......................................................................................................................................... 7 Serious Case Review Panel ...................................................................................................................... 7 Confidentiality ......................................................................................................................................... 8 Family involvement ................................................................................................................................. 9 Staff involvement .................................................................................................................................... 9 Dissemination of learning ....................................................................................................................... 9 Race, Religion, Language and Culture ..................................................................................................... 9 BACKGROUND INFORMATION .............................................................................................................. 10 Family Background ................................................................................................................................ 10 ANALYSIS AND RECOMMENDATIONS ................................................................................................... 22 Sharing of information appropriately between partner agencies ........................................................ 23 The partnerships collective understanding of how and why victims of abuse disclose and withdraw allegations. ............................................................................................................................................ 26 Partnership planning around the Acquiring Best Evidence (ABE) interviews. ...................................... 29 The quality of partnership working and decision making at Strategy Meetings and Section 47 Enquiries ............................................................................................................................................... 30 The sharing / obtaining of historical information to inform current practice and service provision. .. 33 The process of transfer from another local authority and the appropriate reviewing of current protection plans. ................................................................................................................................... 34 Summary ............................................................................................................................................... 36 Recommendations ................................................................................................................................ 39 Multi Agency Recommendations .......................................................................................................... 39 Single Agency Recommendations ......................................................................................................... 40 Greater Manchester Police ................................................................................................................... 40 Children’s Social Care ............................................................................................................................ 41 Education .............................................................................................................................................. 41 Conclusion ............................................................................................................................................. 41 What has changed since this Serious Case Review began? .................................................................. 42 References ............................................................................................................................................ 43      2          3  INTRODUCTION  1.1 This Serious Case Review was conducted under the statutory guidance of Working Together to Safeguard Children 2015 which states (page 79) that a serious case review should take place “for every case where abuse or neglect is known or suspected and…a child is seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child”.  1.2 In this case Child F (who is now aged 18) told different professionals that she had been subject to many years of sexual and physical abuse by her stepfather (FS123). The first time that Child F told professionals that she was being physically abused by FS123 was in June 2004 when she was 6 years old. Child F retracted this allegation.  1.3 Child F made 2 further allegations of physical abuse against FS123 both of which she retracted.  1.4 In August 2011 Child F made an allegation of sexual abuse against FS123 which she retracted.  1.5 Child F made 2 further allegations of sexual abuse the third taking place in July 2013.   1.6 Child F lived with her mother MCFG, her stepfather FS123, her brother Child G and her half siblings S1, S2 and S3.  1.7 Following the allegation in July 2013 FS123 was removed from the family home whilst investigations were undertaken.   1.8 FS123 returned to the family home after five months. Child F remained in the informal foster care of a neighbour.  1.9 Two months after FS123 returned to the family home Child G who was then aged 14, told the police and social services that he had also been the victim of sexual and physical abuse perpetrated by FS123 (although during the investigation into Child F’s allegation he had denied this).     4  1.10 Child G described how the abuse continued after FS123 was allowed back into the home.   1.11 At this point steps were taken to protect Child G and the three younger children at home by placing them in foster care and starting care proceedings.   1.12 A brief summary of Child F and G’s family history:  MCFG was 20 when Child F was born and 21 when Child G was born. The family lived in Preston, Lancashire.  MCFG and FCF&G separated in April 1998, reunited in October 1998 and finally separated in November 1998.  MCFG was a victim of domestic abuse in this relationship and one or both adults used drugs and alcohol.  In April 1999 a Health Visitor queried MCFG’s learning abilities and carried out enquiries with MCFG’s former school and made a referral to the learning disability service. A paediatrician caring for Child G also made a comment that questioned MCFG’s cognitive ability.  It was noted in June 1999 that MCFG had an eating disorder the behaviour of which was possibly being mimicked by Child F who was then aged 21 months.  In January 2000 MCFG began a relationship with man who had several aliases, mental health issues and a personality disorder. This relationship ended Feb 2000.  In February 2001 MCFG met and a married another man. He was on Police bail due to allegations of rape. This relationship broke down within 1 month of getting married.   MCFG met FS123 in 2002 and moved to live with him in Wigan in March 2003.  FS123 had previously been implicated (with other adults) in causing serious injuries to a 6 month old baby.   FS123 and MCFG had 3 children together (in 2004, 2008 and 2013)  METHODOLOGY  2.1 The government has indicated that it supports changes recommended by Professor Eileen Munro that serious case reviews should be conducted using systems based learning methodology and it was agreed that important learning could be gained by conducting a ‘whole system’ serious case review in order to conceptualise how services routinely operate and to identify what is working well or where there are problematic areas.   5  2.2 The WSCB Case Review Sub Group recognised that the review would need to be as robust and transparent as possible and should be identify the extent to which it would make a difference and improve Wigan’s multi-agency safeguarding response.   2.3 Consequently, the WSCB Serious Case Consideration Panel made a recommendation that WSCB should conduct a robust, transparent and participative serious case review with the emphasis upon professional involvement to address how agencies had worked together in this case, identify any learning, aggregate lessons from individual organisations and ensure that an improvement action plan was put in place.  2.4 The Serious Case Review was designed and led by Clare Hyde MBE, independent reviewer, from The Foundation for Families (a not for profit Community Interest Company). Ms. Hyde developed a review model that would enable participants to consider the events and circumstances, which led up to the point at which Child G made allegations against FS123.  2.5 The analysis in this report uses some elements of the framework developed by Social Care Institute for Excellence (SCIE) to present key learning within the context of local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive recommendations have limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from serious case reviews 2009 -2010, (Brandon, M et al), calls for a limiting of ‘self-perpetuating and proliferation’ of recommendations. Current thinking about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation rather than over complex action plans.  2.6 A Serious Case Review Panel was convened and was made up of senior and specialist representatives from agencies involved with the family in the time covered, to oversee the conduct and outcomes of the review. All panel members were independent of the family and casework. The role of the panel was to assist the lead reviewer in considering the evidence, formulating the recommendations and quality assuring this report.  2.7 Agencies involved with Child F and Child G were asked to provide a chronology and these were integrated into a combined chronology by the Wigan Safeguarding Children Board Business Support Team. The following agencies provided a chronology:    Child F and Child G’s High School  Bridgewater NHS  6   Gateway  GMP  Lancashire Council   NHS WBCCG   Social Care   W&L Homes   Westfield Children's Centre  WWL NHS   2.8 The author of this report considered the integrated chronology and designed and facilitated a learning event with the group of multi-agency professionals involved with Child F and Child G and their family to consider in detail the chronology of events and key practice episodes that underpinned those events.   2.9 It was agreed that the period of time covered by the SCR would be 18th September 1997 to 27th February 2014.  The review considered intervention up to July 2013 there is no information regarding the action taken in 2014, subsequent care proceedings and planning which was implemented for the Child F and Child G (and their siblings) including the care plans developed to meet their needs.    2.10 The WSCB Case Review Group suggested terms of reference that provided the key lines of enquiry for the SCR in addition to the terms of reference described in national guidance. The key lines of enquiry included in the terms of reference were: A. Sharing of information appropriately between partner agencies with particular reference to how the Police shared information with Social Care B. The collective understanding of frontline practitioners of how and why victims of abuse disclose and withdraw allegations. C. Partnership planning around Acquiring Best Evidence (ABE) interviews. D. The quality of partnership working and decision making at strategy meetings. E.  The sharing / obtaining of historical information to inform current practice and service provision. F. The process of transfer from another local authority and the appropriate reviewing of current protection plans.   2.11 The SCR aimed to provide an ‘whole system’ approach involving key front line practitioners (and their line managers) who worked with Child F and Child G and the adults of Child F and Child G’s family in a learning event.  In this way, Child F and Child G’s ‘story’ was to be central to the Learning event.   7   Independence 2.12 The lead reviewer was Clare Hyde MBE. Ms Hyde is founder and Director of The Foundation for Families, a not for profit community interest company established in 2010.  Ms Hyde was CEO of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde was a member of Baroness Corston’s review team which was commissioned by the Government following the deaths of several women in custody.  2.13 Ms Hyde is currently working with local safeguarding children boards and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi -agency response to children and young people at risk of sexual exploitation.  2.14 Ms Hyde also designed and facilitated the multi -agency learning review of child sexual exploitation in Rochdale in 2012. Ms Hyde is currently the Independent Chair / Lead Reviewer of several Serious Case Reviews and a Domestic Homicide Review and has designed and led several Learning Reviews on behalf of local safeguarding children and adults boards. Serious Case Review Panel 2.15 The Serious Case Review panel met on 4 occasions between October 2015 and July 2016. The overview report was ratified at the Wigan Safeguarding Children Board meeting on 18th July 2016.  2.16 The panel comprised of:   Service Manager Safeguarding and Partnerships                                                                        Wigan Safeguarding Children Board (WSCB) Business Manager                                                                                                                        Wigan Safeguarding Children Board (WSCB) Assistant Director Children and Families                                                                                     Wigan Council Social Care Enhanced Service Manager Targeted Services                                                                           Wigan Council Social Care Principle Manager Targeted Services                                                                                           8  Wigan Council Social Care  Enhanced Service Manager Integrated Services                                                                         Gateway Service Team Leader Borough Wide Vulnerable Team                                                                            Gateway Service Senior Practitioner Referral Team                                                                                                Gateway Service         Safeguarding Lead for Children, Young People, and Vulnerable Adult, Tenancy Service                                        Wigan and Leigh Homes (WALH)  Children’s Centre Co-ordinator                                                                                                     Sure Start Children’s Centre  Detective Inspector                                                                                                                       Greater Manchester Police  Assistant Director Safeguarding Children/Designated Nurse Safeguarding Children & Looked After Children            NHS Wigan Borough Clinical Commissioning Group (WBCCG)  Named Nurse for Safeguarding Children                                                                                     Bridgewater Community Healthcare NHS Foundation Trust Specialist Nurse for Safeguarding Children                                                                                 Bridgewater Community Healthcare NHS Foundation Trust Named Nurse for Safeguarding Children                                                                                     Wrightington, Wigan, and Leigh Hospitals Foundation Trust WWL Named Midwife for Safeguarding Children                                                                                   Wrightington, Wigan, and Leigh Hospitals Foundation Trust WWL Assistant Principal and Designated Person for Child Protection  High School                                    Confidentiality 2.17 Working Together to Safeguard Children 2015 clearly sets out a requirement for the publication in full of the overview report from Serious Case Reviews: “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and  9  good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.”1 Family involvement 2.18 The family were made aware that a Serious Case Review was taking place and Child F and Child G were invited to meet with the Lead Reviewer.   2.19 The Lead Reviewer met with Child G and Child G’s Social Worker on 11th May 2016 and with Child F on 30th June 2016. The SCR Panel Member from Greater Manchester Police joined this meeting for a period of time (at Child F’s request) as Child F wished to ask questions about the criminal proceedings.  Staff involvement 2.20 The staff who were involved with Child F and Child G and their family participated in a whole day Learning Event in order to:   Clarify the information contained in the combined chronology and to allow the lead reviewer to find out about Child F and Child G’s history and to develop hypotheses.  Consider the terms of reference and other key lines of enquiry and consider possible lessons.  Dissemination of learning 2.21 The learning from this review will be disseminated to the WSCB agencies via board and board sub group meetings in order to raise awareness and improve professional practice.   2.22 The WSCB will ensure that the learning from the report influences the planned multi-agency engagement and learning events such as the annual conference and locality briefings.   2.23 Specialist training around such areas as the impact of unresolved childhood trauma on the ability to parent and supporting young people who disclose and retract abuse will be commissioned. Race, Religion, Language and Culture 2.24 Child F and Child G are English White British. Religion is not considered to be a feature of their lives and they are described as working class.                                                                10  BACKGROUND INFORMATION 3.1 What we know about Child F and Child G and their family raises a large number of practice issues, both for individual agencies and for WSCB, particularly in relation to families with complex and/or multiple needs and risk factors.   3.2 The review attempted to identify how agencies and individual practitioners responded to the needs of Child F and Child G and their family between  18th September 1997 and 27th February 2014.  3.3 In order to do this agencies carried out reviews of their records and materials including:  Electronic records   Paper records and files   Patient or family held records   3.4 The time frame of the review covers a period of time when the family lived in both Preston and Wigan and agencies from both areas held historical information about the family which was highly relevant to the assessment of risk and need in this case.   Family Background  3.5  Child F was born in September 1997.  3.6  MCFG was 20 years old when Child F was born.  3.7 In October 1997 MCFG and their father (FCFG) asked that Child F was removed from their care. Child F was one month old at the time. It is unclear from the records available to this review what the reasons were for this e.g. was this a one off incident of a young mother and father not coping with a new-born baby.  3.8  Child F remained with her parents however and Child G was born 12 months later.  3.9  MCFG was then aged 21 and had two children aged under 13 months.  3.10 In 1997 a Health Visitor shared concerns with Preston Social Services (the family lived in Preston at the time) regarding many extended family members being sexually abused or abusers.   11  3.11 Also in 1997 MCFG accused their father (FCFG) of sexually molesting other children. 3.12 One or both MCFG and FCFG were reported to be using drugs and alcohol. MCFG was a victim of domestic abuse in this relationship. (The couple separated in April 1998 reuniting in October 1998 and separating again in November 1998). 3.13 In 1997 MCFG disclosed that she had been sexually abused as a child and raped as an adult. It is not clear from the records available to this review what happened as a result of this disclosure. 3.14 MCFG took an overdose in 1997 which she survived. 3.15 As early as 1997 Child F and Child G’s maternal grandmother (MGCFG) raised concerns with professionals that MCFG could not look after the children properly.  3.16 This concern focused in particular on the management of Child G’s serious medical condition (PKU)* which required regular monitoring by health professionals and also that a very strict diet was followed. (*Phenylketonuria (PKU) is a rare genetic condition that is present from birth). 3.17 MCFG missed a number of medical appointments in relation to Child G’s condition and this led to concerns being raised by health professionals and MGCFG. 3.18 In 2000 a Health Visitor in Preston tried to establish if MCFG had learning difficulties by liaising with MCFG’s previous High School Head Teacher. The Health Visitor and was informed that MCF&G did not have a “special needs” file but it was considered that she was under achieving and was reported to be “prone to fantasy”. The Health Visitor made a referral to the Learning Disabilities service for an assessment, but was informed that the referral was not appropriate as it did not meet with their referral criteria. (MCFG’s cognitive abilities were queried on subsequent occasions but it does not appear that she has undertaken an assessment) 3.19 There were a significant number of visits to A & E with Child F (7 visits between the age of 10 months and 4 years) for head and back injuries. On one occasion the account of how Child F had sustained her injuries was inconsistent.   3.20 During one visit to A & E (in 1999) concerns were again raised by MGCFG about MCFG’s ability to care for the children.  3.21 In January 2000 MCFG began a new relationship with a man who had several aliases, mental health issues and a personality disorder. He was being managed by the Probation Service at that time. Child F and Child G were then aged 2 and 1. This relationship ended in February 2000   12  3.22 Also in January 2000 MCFG took Child F for a health appointment and reported that she had dark and offensive smelling urine. The health practitioner advised MCFG to collect a urine sample so that it could be tested for infection. It appears from the records available to this review that MCFG did not take a urine sample to be tested. 3.23 During this period of time MCFG and the children moved several times.  3.24 On 15th February 2000 an Initial Child Protection Case Conference took place and Child F and Child G became subject of a Child Protection Plan under the category of neglect.   3.25 In March 2000 MGCFG reported to a Health Visitor that Child F had simulated the movement and sounds of sexual intercourse. MGCFG reported that she believed Child F had witnessed MCFG’s sexual activity with her partner.   3.26 In February 2001 MCFG met and a married another man. He was on Police bail due to allegations of rape. This relationship broke down within 1 month of getting married.  3.27 At some point in 2001 MCFG met FS123 who lived in Wigan.   3.28 FS123 was implicated (along with other adults) in causing serious injuries to a 6 month old child.  3.29 An Initial child Protection Case Conference took place on 12th February 2002 in Preston. Child G was made subject of a Child Protection Plan under the category of neglect due to concerns about his mother’s management of the PKU.  There were no other concerns raised during the CPCC and the focus was placed on the health needs.   3.30 This was Child G’s second period as the subject of a child protection plan.  3.31 Child F was not subject to a child protection plan at this time.  3.32 The family moved to Wigan to live with FS123 in 2003.  3.33 On 20th June 2003 a ‘transfer in child protection’ case conference was held in Wigan. Child G was already subject of a Child Protection Plan in Preston. A Social Worker and Health Visitor from Preston attended the conference. The outcome of transfer in conference was that both Child F and Child G became subjects of a Child Protection Plan under the category of at risk of physical abuse for both children and neglect in respect of Child G.    13  The risk of physical abuse was because of concerns that FS123 had been implicated in the non-accidental injury of a Child. It was agreed that FS123 should not have unsupervised contact with Child F and Child G.  3.34 At that point, Child F was 5 years old and Child G was 4 years old.  3.35 A risk assessment of FS123 was completed in September 2003 and he was assessed as ‘medium to low’ risk to the children and the Child Protection Core Group decided that the restrictions on FS123’s contact with Child F and Child G should end. It was noted at the Core Group meeting that Child F ‘did a lot of caring for Child G’ and a referral to a young carers service was discussed (it is not clear if this referral took place or what other outcome there was). Chid F had just reached 6 years of age at this point.  3.36 On 16th October 2003 a Child Protection Review Conference was held and Child F was deregistered but Child G remained on a Child Protection Plan under the category of neglect due to MCFG’s inability to meet his health needs.   3.37 Sibling 1 (S1) was born in January 2004.   3.38 The minutes of a Core Group meeting held on 15th June 2004 meeting in respect of Child G record that school reported concerns regarding a of physical assault on Child F who had attended school with a bruise and when asked said ‘I fell, my dad didn’t do it’.    3.39 Between June 2004 and October 2010 Child F made 3 allegations that FS123 physically assaulted her. She retracted her allegations on each occasion.  3.40 In July 2005 school staff witnessed a possible assault of Child G by FS123 and reported this to the police. Child G denied that this had been an assault.   3.41 On 9th September 2005 Child F, then aged 8, reported to the School Nurse that her back ached when she went to the toilet to pass urine and it “stung”. The School Nurse advised MCFG to take Child F to see her General Practitioner. It is not clear from the records available to this review if MCFG followed this advice.  3.42 On 22nd November 2005 despite the fact that MCFG was unable to manage Child G’s serious health condition a decision was made to de-register him and end the Child Protection arrangements. It was agreed to manage the case at a  14  ‘Child in Need’ level.  The decision to end the CP plan at CPCC review was made on a multi-agency basis with the benefit of an independent chair to provide challenge and scrutiny if required.  It was deemed that whilst there were identified needs Child G was no longer considered to be at risk of significant harm.  Upon review of the minutes of the CP conference dated November 2005 there is a record of continued concerns specifically regarding health issues however there is no record that any professional challenged the decision for the period of registration to end.    3.43 Between 2005 and 2013 the management of Child G’s PKU remained a serious concern and MCFG repeatedly failed to meet his dietary and other health needs and failed to ensure that he attended medical appointments.    3.44 In summary the period of time between the family moving to Wigan in 2003 and Child F’s first allegation of sexual assault in 2011 was characterised by continuing significant levels of concern about neglect in respect of Child G’s health needs and by a pattern of allegations followed by retractions of physical abuse of the children carried out by FS123.  3.45 One allegation of physical abuse was made by Child F in October 2010. Child F told staff at her school that bruises had been caused by FS123 hitting her. This triggered a safeguarding referral and a social worker visited Child F at school. Child F retracted her allegation but told the social worker that physical chastisement was used by FS123 at times.  Child F reported that this was only when she deserved it and that she needed to be hit as it was the only time she would listen.  Child F reported that her FS123 lightly tapped her hand or bottom. During the same conversation the social worker noted that Child F ‘discussed home life fondly and raised no concerns’. Child F was aged 13 at this point. The assessment was closed with no further action.     3.46 During this same period MCFG gave birth to S1, S2 and S3 and lost another child at 18/19 weeks gestation in July 2007.   3.47 In summary it is apparent that MCFG had herself experienced significant and traumatic life events and had 4 consecutive relationships with men who each posed a potential risk to herself and her children. In addition, before Child F and Child G made an allegation of sexual abuse, the following issues were known:  Persistent neglect of Child G’s health needs.  Inability to manage Child G’s strict dietary needs.  15   Concerns raised by MGCFG that MCFG could not look after the children.  Child F at the age of 6 was acting as a carer for Child G.  Three recorded incidents which could have been indicators of sexual abuse (simulating sex and symptoms of urinary tract infections).  Numerous A&E consultations for injuries to Child F; some of which were serious with, on one occasion an inconsistent account of what had happened.  Reports by Child F that FS123 hit or injured her which were later retracted however Child F did confirm that FS123 used physical chastisement.  Recorded concerns about MCFG and Child F and Child G having or developing eating disorders (MCFG was thought to have anorexic tendencies and Child F was observed with her fingers down her throat at a time when she was also losing weight. Child F was 21 months old at the time).  3.48 On 22nd August 2011 a friend of Child F told a taxi driver that Child F was being sexually abused by FS123. The taxi driver attended Wigan Police Station on the same day to report that a female juvenile passenger had disclosed to him that her friend, Child F, was being sexually abused by her father.  The police identified the friend and she was visited and informed the attending officer that Child F had disclosed that FS123 was regularly abusing her. She described how FS123 would get drunk and sexually touch her. He had tried to have sex with her but had never actually done it. She stated that if she told anyone he would ‘take her to a nasty place and he would hang her over the banister by her feet’.   3.49 The police officer spoke with Child F who initially denied saying anything but then admitted to telling her friend this story to ‘fit in’. At this point FS123 approached the officer and enquired why he was speaking with Child F. Child F became upset and the officer arrested FS123 on suspicion of sexual assault. At this time MCFG approached the officer and was aggressive towards Child F. As a result the officer invoked a Police Protection Order (PPO) under the Children’s Act 1989. FS123 was taken to Wigan Police Station. Two police officers spoke to Child F alone. She continued to deny that anything had happened to her and stated that she had made up the allegation to ‘fit in’ as everyone else seemed to have been abused.  3.50 One police officer spoke with MCFG who stated that the family of 6 were struggling as there are only 3 bedrooms therefore Child F had to share with her younger brother. She also stated that Child F had a personality disorder and was self-harming.  16  The officers also received information that Child F had previous made a false allegation about FS123 physically abusing her. 3.51 The officers decided that they would remove the PPO from Child F and FS123 was released from police custody without being interviewed. The officer submitted a ‘Vulnerable Persons 1-8’ write up on the Police log and made a number of suggestions for Social Services to support the family.  This information was not formally shared with social care at the time or in the strategy meetings held later.    17  3.52 At some point during 2012 (the exact date is not recorded) a note in Child F and Child G’s secondary school records states that students were calling Child F and G’s mother ‘disgusting’ and calling FS123 a paedophile following them hearing Child F stating that FS123 had raped her. Child F did not want FS123 to be informed or he would get angry and ‘start smashing plates’. Child G asked pastoral manager to speak to Child F ‘about the situation’. The note states that Child G is scared of FS123’s reaction when he gets home. It appears that Child F and Child G’s secondary school took no action other than to record this series of incidents and did not share this information with any other agency.   3.53 On 27th June 2013 a children’s charity contacted the police to inform them that an anonymous friend of Child F had called them to report that FS123 was sexually abusing her and this had been going on since the previous year. It was reported that he had taken her to the pub, bought her drinks and touched her inappropriately.  3.54 The anonymous caller had stated that MCFG was aware that the abuse was taking place. 3.55 At 10.20 pm two police officers attended Child F’s home and spoke to MCFG. She was informed that a report had been received in relation to Child F.  3.56 Child F was woken from her sleep and asked numerous questions, in the presence of MCFG. Child F denied confiding in anyone and that FS123 had not done anything.  3.57 MCFG believed that a female known to them was responsible for the rumours. She named this female as an ex-neighbour. MCFG reported that something similar was reported last year and that FS123 had been arrested. 3.58 At this time no crimes were confirmed and the police officers gave Child F contact details if she wanted to speak to them further. The police officers did not attempt to trace and speak to the ex-neighbour. 3.59 A Public Protection Incident (PPI) was created by the police but this was closed based on the information from the attending officer. A referral was made to Children’s Social Care by the police. 3.60 On 1st July 2013 Children’s Social Care were contacted by the police regarding information received from the children’s charity.  The police reported that they had visited the home following the report and had spoken to MCFG and Child F within the family home and that they had taken no further action was taken by them.  Upon receipt of the referral checks were undertaken and contact made with involved agencies.  No safeguarding concerns were raised by the involved professionals; therefore no further action was taken by Children’s Social Care.    18  3.61 On 12th July 2013 the Children’s Social Care Duty team contacted the pastoral manager at Child F’s school to share information about the police referral and advised that as Child F was denying this was true no further action was being taken. 3.62 On 20th July 2013 Child F telephoned the police from a neighbour’s house and reported that FS123 had physically and sexually abused her since the age of 7.  3.63 Child F disclosed that the sexual abuse occurred on a regular basis and that previously she had refused to confirm the abuse as she was scared.  3.64 FS123 was arrested on suspicion of child sex offences.  3.65 A police officer (PO1) from the PPIU conducted the investigation. Child F was video interviewed and confirmed the report of sexual abuse from the age of 13. She also disclosed physical abuse from the age of 7 which included a number of assaults. 3.66 Child F said that she had told MCFG about this on the evening of 19th July 2013 however MCFG told her that she was a liar and she was going to kick her out of the house.  3.67 Child F disclosed that she had been physically abused by FS123 and recalled that when she was 5-6 years old he pushed her head into a kitchen cupboard until MCFG told him to stop. She also referred to another incident where he dragged her downstairs pushing her to the floor and kicking her.  3.68 FS123 was arrested for sexual assault, attempted rape and section 47 Assault. He denied all offences. 3.69 The police contacted Children’s Social Care on 20th July 2013 and informed them of Child F’s allegations and of FS123’s arrest. 3.70 Child F remained at the home of the neighbour and some days later went to live with the neighbour’s mother under informal fostering arrangements.  3.71 On 24th July 2013 Children’s Social Care were contacted by the police with additional information in respect of the reported disclosure by Child F.  The information provided by the police highlighted that Child F had already attended an ABE Interview as part of police enquiries.  The information was passed to the allocated worker with a recommendation for a strategy meeting to be held. 3.72 On 25th July 2013 Children’s Social Care completed a Child and Family Assessment with a recommendation for a strategy meeting to be held on 1st August 2013.  19  3.73 At the strategy meeting held on 1st August 2013 Child F’s allegations were discussed in the context of the family’s history of involvement with children’s social care, two recorded incidents of possible assault by FS123 of Child F and Child G and FS123 possible involvement in the serious assault of a 6 month old baby.  3.74 The strategy discussion noted that it was possible that MCFG was aware of the physical abuse. When Child F told MCFG of the sexual abuse it is alleged that MCFG stated that FS123 was her “only form of happiness”. Child F then apparently retracted the statement. It was also reported at the meeting that the family’s local community were aware of the allegations. 3.75 It was agreed during a strategy meeting that the threshold for a child protection conference to be held was not met as FS123 had left the family home.  The meeting held was a multi-agency meeting; present at this meeting were representatives from social care, including a team manager and social worker, the investigating police officer, school nurse and health visitor.  There is no record of any disagreement regarding the outcomes and actions made in the strategy meeting. 3.76 On 27th August 2013 Section 47 Enquiries were completed.  These enquiries identified that the children were considered to have suffered significant harm however they were not thought to be at risk of continuing harm as FS123 had left the family home and his contact with the children was supervised.    3.77 On 15th September 2013 Child F completed a second video interview during which she alleged that FS123 had raped and sexually assaulted her.  3.78 Also on 15th September 2013 PO1 updated the PPI records with the following comments: “There are several issues with regards to this investigation and a history of Child F making allegations against FS123 and then retracting same. I am also aware after speaking with school that Child F has been accused of telling lies there over other incidents. They also confirm that Child F has been overheard by teachers telling classmates in school about the abuse; however she has denied doing this to me. Social services records have been obtained and show previous allegations made and comments made by Child F where she stated that she had lied.  In light of this I will discuss this investigation with my Sgt to ascertain if this case meets the threshold test and whether there is any merit in taking this to CPS”. 3.79 On 23d September 2013 FS123 was further arrested for offences of Rape and Sexual Assault by Penetration. He denied the offences stating that the only reason he believes that Child F would make up this allegation is because on the night of the report he stopped her from going out to babysit. FS123 stated that Child F has been telling people about his arrest. He was bailed until 8th November 2013.  20  3.80 Also on 23rd September 2013 a second strategy discussion took place and Child F’s further allegation of rape and sexual assault against FS123 were discussed. 3.81 On 2nd October 2013 PO1 updated Child F in relation to the arrest of FS123.  3.82 On the 02/11/2013 a Detective Inspector at the PPIU made a decision to finalise the investigation stating that it did not pass the threshold test. He updated the report with the following rationale: “I have reviewed the investigation. Whilst Child F does give a clear account there are certain evidential difficulties and witness issues. Whilst we are not stating that the offence did not occur this will be a case of one against the other. The difficulty is that Child F has not been consistent in her disclosures, and this has been happening from a very early age. We have accounts of Child F stating that her father (sic) had bitten her in 2007. She later stated that she did this to get him into trouble. There was a further incident in 2010, where again she accused him of assault, when we have school records and friends testimony to state that this occurred whilst falling in a park. MCFG does not believe any of the reports made by Child F. Furthermore there is information to suggest that Child F has historically been found to be telling friends that she is pregnant, or has cancer. She is also currently stating she is having pregnancy tests despite also stating she is not in a sexual relationship with anyone. Whilst abused children can display these behaviours, it does make it difficult from a credibility point of view to overcome these issues. In this case I do not believe that she would come across as a credible witness, that there is no independent evidence to suggest a sexual offence has occurred, that there have been no other sexual disclosures by his other children and the child is not believed by her own family. I do not believe this offers a realistic prospection of conviction and should be filed as such”. 3.83 On 3rd October 2013 a Child in Need meeting was held in respect of Child F, Child G and S1, S2 and S3. 3.84 On 4th October 2013 a Child and Family Assessment was completed and finalised by a Children’s Social Care manager.  The assessment made a recommendation for further social care intervention under a Child In Need plan.   3.85 Throughout September and October 2013, Child F and Child G’s secondary school sought information from Children’s Social Care and were included in some information sharing with the police and Children’s Social Care. A multi-agency strategy meeting was held in August 2013 when the school were on their summer break meaning school did not attend.  Further to this, the first CIN meeting was held in October 2013 – this was attended by the school. As well as the school, Social Care alongside MCF&G, F&G, and the PG123 of F&G’s siblings were in attendance. The pastoral manager from the secondary school also attended the Child In Need meeting in November 2013 and December 2013.    21  3.86  The school staff put a ‘management plan’ in place for Child F following her disclosures which attempted to support Child F (and manage Child F’s relationship with Child G, and other students one of whom was a relative of FS123). 3.87 On 5th November 2013 Child F was informed of the decision and the investigation was finalised. 3.88 On 6th November 2013 a Child in Need meeting was held. Child F and Child G attended the meeting. Allegations of sexual abuse to Child F were reported as “no further action, not enough evidence to proceed with a prosecution”. MCFG was reported to be upset that FS123 was not yet back at home.  3.89 During the meeting MCFG was very hostile towards Child F. It was documented that the Social Worker needed to intervene during the meeting and request that MCFG was respectful of Child F’s feelings. Child F continued to live with the neighbour’s family. Child G reported that he did not want any contact with Child F. At this point, FS123 had not returned to the family home. 3.90 On 11th November 2013 Child F was seen by a School Nurse who carried out a comprehensive health assessment. The School Nurse recorded that Child F stated that she was feeling well, but emotionally “up and down”, reported that she missed contact with younger siblings, and would like to have time with MCFG without either of them arguing or shouting. Child F stated that she had poor concentration due to a poor sleep pattern, having nightmares and disturbed sleep. Child F reported that she gets angry about what was happening and tends to say too much to too many people including friends which had caused problems in school for Child F and Child G. Child F stated that she wanted contact with FCFG The School Nurse reported that emotionally Child F was struggling, currently waiting for referral for one to one support, Child F was awaiting counselling through school, and a referral to child and adolescent mental health services had been made.  3.91 On 5th December 2013 a Child in Need meeting was held. It was recorded that work with the family had been completed and that in light of the positive progress made and the work completed with the children which had raised no concerns it was agreed that FS123 would return to the family home. Child F continued to reside in the care of other adults and there were no identified plans in respect of a return to the care of MCFG.     3.92 It was agreed that the case would be closed at Child in Need level and that a referral to the ‘Gateway Service’ would be made in respect of Child F only as she remained outside the family home. The Gateway Service provides support to children and young people 0-19 years and their family at level 2/3 of the threshold of need. There is a step up/down process in place from Gateway to Wigan Social Care teams to ensure a positive transition to and from Wigan specialist services.  22  3.93 On 25th February 2014 a contact was received via the Out Of Hours Social Care department.  The information was received from a professional reporting that Child F had informed them that her younger sibling Child G had made disclosures of sexual assault perpetrated by FS123.   3.94 On 26th February 2014 the police record states “This allegation was received from two sources; Firstly, a referral was made from Youth Leader. He said that Child F had attended the youth club and disclosed that Child G (15yrs) had be subject to sexual abuse by FS123 between 1.1.2004 and 26.2.2014”. 3.95 Police attended and spoke to Child F who said that Child G reported to her on 25th February 2014 that FS123 had been performing sexual acts on him. 3.96 On the 26th February 2014 Child G contacted the police directly and reported that he had been sexually abused by FS123. The report was made from a neighbours address.  3.97 A ‘Specially Trained Officer’ attended the address. Child G disclosed that he was victim of sexual abuse from the age of 6 involving touching and penetration. Child G disclosed that the last incident had occurred on 22nd February 2014 at his home address.  3.98 Child G told the police officer that everything that Child F had said in the past had been correct and that he had been lying. When asked why he didn’t disclose the abuse in the past Child G said it was because he was scared. Child G said that MCFG was not aware of any of the sexual abuse.  Child G was asked if FS123 had ever hurt S1, S2 or S3 to which he said he had not.  3.99 Child G disclosed that, over the years, he and Child F were sexually abused by FS123 at the same time. 3.100 FS123 was arrested on 26th February 2014. 3.101 A Public Protection Order was issued and Child G, S1, S2 and S3 became looked after by the Local Authority.  ANALYSIS AND RECOMMENDATIONS  4.1 This section sets out an analysis of key findings and associated recommendations that are designed to offer challenge and reflection for WSCB and partners.  4.2 The key lines of enquiry for the SCR were explored through the process of the Learning Event and considered together with the details submitted in individual agency chronologies:   23   Sharing of information appropriately between partner agencies   4.3 Information sharing between the police and social care in this case was poor.  4.4 Examples of poor information sharing between the police and social care include:  4.5 On 22nd August 2011 following the report by a taxi driver that a passenger had told him that Child F was being sexually abused by FS123 the police concluded their enquiries (FS123 was arrested but not interviewed) without contacting social care as part of their enquiries nor did they inform social care that this incident had taken place.  4.6 During this incident the attending police officers were told by MCFG that Child F self -harmed and had a personality disorder. They did not verify or share this information with any other agency.  4.7 On 27th June 2013 a police officer attended the family’s home in response to the anonymous phone call to the children’s charity. Although this incident led to a referral to Children’s Social Care the police officer did not contact Children’s Social Care to seek background information about the family or involve them in plans to speak to Child F in a neutral setting not in the presence of MFCG. This incident was not linked to the August 2011 incident.  4.8 The issue of the police sharing information before and after interviewing Child F and Child G is covered at paragraph 4.34 below.   24  4.9  Child F and Child G attended the same primary and secondary schools and school staff played a key role in a) being recipients of information and disclosures from Child F and Child G and b) attempting to manage and contain a very difficult tension between supporting Child F after her first allegation of sexual abuse against FS123 and Child F and Child G’s deteriorating relationship which was sometimes ‘played out’ in front of other pupils. Given the school’s crucial and difficult role they were not routinely invited to contribute to discussions or decision making and nor were they kept fully informed as events occurred. 4.10  The school however also knew at an unrecorded point during 2012 that Child F was telling her fellow pupils that FS123 had raped her and the school do not appear to have shared this information or acted upon it.   25  4.11 MCFG and FS123 were referred to a Children’s Centre shortly after the birth of S3 in April 2013. It was apparent from discussions during the Learning Event that the Children’s Centre did not have access to any information about the family’s history of contact with other agencies. Children’s Centres often play a crucial role in engaging with families who might not readily engage with other agencies and it is vital that they are party to historical information particularly when there have been safeguarding concerns. The issue of parental consent to access and share information is crucial in cases (such as this) where there is significant historical information.  4.12 There were several examples of good practice in information sharing for example between the Health Visitor in Preston and the Health Visiting Service in Wigan as MCFG and the children moved to Wigan. This transfer of care was well planned and would be seen both at the time and today as being best practice. 4.13 Another example of good practice in information sharing were the regular alerts and communications from Child G’s secondary care providers raising concern about the management of his health condition. 4.14 Participants in the Learning Event discussed information sharing at length and some participants observed that they were finding out some information for the first time during the Learning Event itself both from reading the integrated chronology and from discussions with other participants. It is probable that significant pieces of information had been shared appropriately in the past but the timescales of the review (19 years) would have impacted on who knew what from such a vast amount of information. 4.15 It was apparent that in some instances information was sought, gathered and shared but the information was not fully understood or contextualised. Examples include: 4.16 The police contacted Child F’s school following her allegation of sexual and physical abuse in July 2013 to ask for information about Child F. Specifically they asked if Child F told lies. The police officer who spoke to a member of staff from the school made the following note “There are several issues with regards to this investigation and a history of Child F making allegations against FS123 and then retracting same. I am also aware after speaking with school that Child F has been accused of telling lies there over other incidents. They also confirm that Child F has been overheard by teachers telling classmates in school about the abuse; however she has denied doing this to me. Social services records have been obtained and show previous allegations made and comments made by Child F where she stated that she had lied”.   26  4.17 This interpretation by the police officer of the school’s account that Child F sometimes told lies demonstrated a lack of understanding about the way in which children and young people disclose sexual and physical abuse and the pattern of denial and retraction which can follow such allegations.  4.18 Another example of information being shared but not being understood was the decision which was made by the CPS that the threshold was not met to proceed with criminal proceedings. This information was interpreted by some practitioners as confirmation that the abuse had not happened as some of the recipients of the information did not understand the different evidential thresholds.  This issue was discussed by participants in the Learning Event.  The partnerships collective understanding of how and why victims of abuse disclose and withdraw allegations.  4.19 Considerable focus was given to the pattern of disclosure by child victims of abuse during the course of the Learning Event.  The participants were given the opportunity to explore recent and more established research and to reflect on their own understanding of why children and young people disclose and retract and how this affected judgement and practice.  4.20 Child F in particular disclosed both physical and sexual abuse on several occasions and then retracted her allegations. This pattern of retraction must be seen in the context of the child or young person’s family setting and also in the context of what evidence through research tells us.  4.21 Child F’s family history was complex and both she and Child G had been the subject of Child Protection Plans under the categories of neglect and physical abuse. The person that allegations were made against was FS123 a man implicated in causing serious injuries to a 6 month old baby and the reason that Child F and Child G had been made subject of the child protection arrangements in respect of physical abuse.  4.22 Child F and Child G’s mother had 4 consecutive relationships with men that posed a potential significant risk to herself and her children.   4.23 This current and historical family context should have afforded Child F’s allegations far more credibility and Child F’s retractions and Child G’s denials far less credibility than were given in this case.  27    4.24 Instead, Child F gained a reputation for lying and attention seeking and this had an impact on how she was responded to and vitally left herself and Child G exposed to further harm.  4.25 Personal and professional judgement were prejudiced by a lack of understanding of Child F’s retractions and Child G’s denials which were taken at face value. This impacted upon how the S47 and criminal investigations were conducted.   4.26 The following research was shared with Learning Review participants:   4.27 In an influential article, Summit (1983) described the disclosure process as the "Child Sexual Abuse Accommodation Syndrome" (CSAAS). “The CSAAS consists of five stages: (1) secrecy; (2) helplessness: (3) entrapment and accommodation; (4) delayed, unconvincing disclosure; and (5) retraction. According to Summit children retract their statements as part of a process of dealing with sexual abuse victimization”. Summit, R. C. (1983).  The child sexual abuse accommodation syndrome.  Child Abuse and Neglect, 7, 177-193.      4.28 A separate study carried out by Sorenson and Snow in 1991 examined 117 cases and found most disclosures of abuse were accidental (74%) and many victims (22%) recanted their statements only to reaffirm them later (93% of recantations). 72% of initially denied abuse, and 78% were reluctant to discuss the abuse”. Sorenson, T., & Snow, B. (1991). How children tell: The process of disclosure in child sexual abuse. Child Welfare, 70(1), 3 15.  4.29 A more recent study carried out by the NSPCC with 60 young people who have been physically and / or sexually abused showed that several of the young people described being pressured by their families to retract, through subtle threats that it would adversely impact on the family or that the young person would end up in care. We believe that in Child F’s case MCFG pressurised Child F to retract and indeed her overwhelming response when Child F finally refused to retract was extreme anger towards her. No One Noticed No One Heard: A study of disclosure of Childhood Abuse NSPCC 2013  4.30 The NSPCC study participants also highlighted positive and negative accounts of interactions with teachers, police and social workers emphasised that they wanted to be noticed. Police and social care professionals who were involved  28  with families for other reasons were often perceived as interested only in the matter at hand and not in the wider experiences of the young person.  4.31 In this case it was apparent both from Learning Event participants and from agency’s chronologies that Child F’s retractions and Child G’s denials were not recognised or understood in the context of the children’s family history or as part of a pattern of disclosure.  4.32 It was also apparent that Child F’s stories of, for example, having cancer or of being pregnant were viewed as attention seeking and this was not explored with her in a sensitive and ‘alert’ manner.   4.33 Rather than being viewed as a sign that Child F was distressed and may well have been trying to draw attention to herself because she needed help these stories were dismissed whilst at the same time contributing to the judgement that Child F told lies.    29  Partnership planning around the Acquiring Best Evidence (ABE) interviews. 4.34 The way in which the ABE interviews of Child F and Child G were conducted did not meet expected standards of best practice which are detailed in the Ministry of Justice guidance ‘Acquiring Best Evidence in Criminal Proceedings’. 4.35 This guidance outlines partnership planning thus “For children who have had past or current involvement with that local Children’s Social Care authority, useful information may already have been provided from different professionals or may be obtained from other adults who know the child (e.g. parents, carers, teachers, educational psychologists, youth workers, occupational therapists), and it may be that other individuals are offered a more active role in the planning process.”  Ministry of Justice Achieving Best Evidence in Criminal Proceedings: Guidance on interviewing victims and witnesses, and guidance on using special measures 2013 4.36 Child F was ABE interviewed 3 times and Child G once and the police did not involve Children’s Social Care or any other agency in the planning for the interviews. In fact; Children’s Social Care only knew about the ABE interviews once they had taken place.  4.37 A joint protocol for information sharing in child abuse cases was published in 2013, whereby police and prosecutors are expected to share and seek appropriate information about vulnerable children with and from Social Services, schools and family courts in accordance with the protocol and a good practice model. There is no evidence that this protocol was used in this case. 4.38 A joint HMIC and HMCPSI inspection of how ABE interviews had been conducted in child sex abuse cases was published in 2014. The inspection concluded that there was poor compliance with the ABE Guidance and made several key recommendations some of which are pertinent to this case and are made as recommendations of this serious case review. 4.39 At the point of Child G’s disclosure Child F had already been interviewed twice and the officer in charge was aware of Child G’s disclosure of joint sexual abuse. An interview strategy should have been discussed with a ‘Tier 5’ interview advisor and consideration given to involve a child psychologist and a discussion with the CPS. 4.40 The quality of the ABE interviews which was compromised by the lack of planning led to the decision by the CPS that the threshold for criminal proceedings had not been met. This decision not to proceed with criminal proceedings compounded the belief of other agencies that Child F was not credible. This meant that the risk posed by FS123 to Child G and S1, S2 and S3 was not recognised.  30  4.41 The impact that this failure to strictly follow the ABE Guidance or refer to the protocol had upon Child F was that she was not treated by the police as a vulnerable child (and a potentially intimidated witness) but as an adult. This may well have re-victimised and traumatised Child F.  The quality of partnership working and decision making at Strategy Meetings and Section 47 Enquiries  4.42 The partnership working and decision making at Strategy Meetings and Section 47 Enquiries was not always effective. Furthermore Section 47 Enquiries were not always instigated when it would have been appropriate to do so.  4.43 On 18th December 2003 the child protection plans in place for both children in respect of physical abuse ended.   4.44 Within 7 months of this decision Child F was seen with bruising at school and when asked said “I fell. My dad didn’t do it.’’ This was reported by the school to Children’s Social Care but did not prompt a Section 47 enquiry.  4.45 Within 12 months i.e. in December 2004, Child F was taken to the A & E department with an injury to her finger. The reason for the injury was given as ‘fighting with a sibling’. The injury was said to have happened 3 weeks prior to the A & E visit. Bruising, swelling and a slight deformity to the finger were noted. Within the context of this family’s recent history this injury should have prompted a safeguarding concern.    4.46 On 5th July 2005 Social Services were contacted by the Head Teacher at Child G’s school reporting that the previous day staff from the school had observed Child G (8 years old at this time) being dragged from the car by FS123 and then dragged into school by his hair. Concerns were raised by representatives from school that at some point Child G had been put in a car boot and that his sister had been using his blood testing kit. The police spoke to Child G, MCFG and FS123 who all denied that Child G had been assaulted and gave an alternate version of events. The matter was not taken further by the police. A S47 Enquiry was commenced by Children’s Social Care on the same day and Child G was seen at school and corroborated the version of events given by FS123 and MCFG i.e. that he had not been dragged into school by his hair(please see Appendix 1 in reference to this incident).  4.47 Given the family context and history this willingness to believe FS123 and MCFG and not view an 8 year old’s denial of an assault as questionable  31  (despite the perspective of the school staff that an assault had taken place) demonstrated lack of critical professional judgement and scepticism. 4.48 On 26th October 2007 Child F’s school contacted Children’s Social Care to report that Child F had been overheard (by a parent) saying that FS123 had bitten her finger to stop her touching the house alarm. This ‘accidental disclosure’ took place in a shop. 4.49  Section 47 enquiries were instigated on 2nd November 2007. The Family Support Investigation (FSI) states that Children’s Social Care did not obtain details of the parent or shop keeper. There is also indication on the FSI that three teachers had been made aware of the allegation. It is unclear if these teachers were informed by the parent together or separately and what they did with this information. The school was closed for half term and therefore the teachers were unavailable, it is unclear if the teachers were ever spoken to about this matter.  A social worker attended at the family home and was told by Child F that she had bitten herself and that she had fallen. She had a faint mark on her finger and denied that FS123 had assaulted her. Given the minor nature of the mark on her finger a decision was made (although it is not clear by who) not to have Child F undertake a medical.  4.50 At the same time as speaking to Child F, children’s social care spoke with FS123 who also denied assaulting her. It was agreed that Child F’s parents would receive support via Child In Need arrangements and the Section 47 enquiries were concluded on 11th November 2007.  4.51 The willingness to believe the denials of FS123 and Child F without speaking to the parent who overheard the disclosure or any of the school staff who were recorded as having heard the parent’s report did not constitute a thorough enquiry and again demonstrated a lack of critical professional judgement and scepticism.  4.52 In October 2010 a referral to Children’s Social Care was made by Child F’s school. Child F had just turned 13 years of age. Child F had reported that bruising had been caused by FS123 hitting her.  4.53 The school’s concerns were that Child F had bruising and the explanation for how the bruises had been caused was inconsistent.  The detail of the referral states that Child F’s demeanour was ‘shaking and nervously playing with things, not looking us in the face and asking that we didn’t tell social services’.  Child F was also reported to state how much her Dad spends on her and how much he spoils her.  In addition to this, she is reported to have stated that her mother has told her that ‘It is her last chance to be happy’.  Additionally commentary within the school’s referral details as follows:   32  “I know Child F quite well and the behaviour she is exhibiting is unusual. I am worried about her and the way she presented herself, the nervousness, jittery and protesting about how well stepdad (FS123) treats her. My gut feeling is all is not well and that things are happening in the home.” 4.54 This triggered an initial assessment and a visit was undertaken to see Child F.  Child F reported that the allegations were untrue and that she had not said this.  Child F reported that she had sustained the injuries playing and falling off a roundabout.  Child F did state that physical chastisement was used by FS123 at times.  Child F reported that this was only when she deserved it and that she needed to be hit as it was the only time she would listen.  Child F reported that her FS123 lightly tapped her hand or bottom.   4.55 Child F was recorded as having discussed home life fondly and raised no concerns.  As a result of the information gathered the assessment was closed with no further action and no further enquiries were made.  4.56 This episode did not trigger a Section 47 enquiry however given the family history and context and the explicit concerns of Child F’s school there should have been a different response. Child F’s statement that her stepfather used physical chastisement including tapping her hand or bottom should, in itself, have prompted a different response especially given that Child F was 13 years old at this point.  4.57 On 1st July 2013 following the anonymous report to the children’s charity that Child F was being sexually abused by FS123 the police contacted Children’s Social Care. The information provided was that on 27th June 2013 the police had visited the family following a 3rd party anonymous report that Child F had confided in a friend that FS123 had been sexually abusing her.  The police reported that they had visited the home following the report and had spoken to MCFG and Child F within the family home. Children’s Social care records indicate that “No further action was taken by the police records highlight that F had been spoken to by the police and denied the report stating that it had been made maliciously.   Upon receipt of the referral departmental checks were undertaken and contact made with involved agencies.  The police reported that they considered the report to be malicious, further contact with school identified that there were no safeguarding concerns however friendships were identified as an issue and school reported that F would tell friends information but when questioned by school would deny this. No safeguarding concerns were raised by the involved professionals; therefore no further action was taken by the department”.     33  4.58 Again, given the family context and history this episode added further to the likelihood that Child F (and potentially her siblings) were at risk of serious harm the decision not to enquire further is difficult to understand but could be attributed to the gaps in information sharing from the police and school and this may well have impacted on the decision making had this been provided.   4.59 Section 47 enquiries were instigated following Child F’s disclosure of sexual and physical abuse on 24th July 2013. The Section 47 Enquiries were completed on 27th August 2013.  These enquiries identified that the children were considered to have suffered significant harm however were not thought to be at risk of continuing harm as FS123 had left the family home and his contact with the children was supervised.  It was recorded however that when Child F told MCFG of the abuse it is alleged that MCFG stated that FS123 was her “only form of happiness”. This should have caused doubt that MCFG would protect Child F’s siblings from harm caused by FS123 and that she may not be honest about contact arrangements. 4.60 Given the conclusion that the children were considered to have suffered significant harm and given MCFG’s reaction to Child F and her suspected collusion with FS123 it is difficult to understand why a decision was not made, at this point, to make all of the children subject to child protection arrangements.  The sharing / obtaining of historical information to inform current practice and service provision.  4.61 The obtaining and sharing of historical information to inform practice was critical to the safeguarding of the children in this case (as in many others).  4.62 Information was obtained and was shared and in some cases led to good practice and service provision e.g. the transfer of information from the Preston Health Visiting Service to the Wigan Health Visiting Service however please also see 4.77 below.    4.63 However on the whole historical information about MCFG and FS123 did not inform how risk and need were recognised, understood and responded to.  4.64 Agencies held information about the family which had built up (and continued to build) over a decade starting with the birth of Child F in 1997. This information came from a steady stream of contact with midwives, health visitors, A&E, nursery and schools, secondary health services, the police and Children’s Social Care.   4.65 This information which concerned the children and the adults in Child F and Child G’s family highlighted several complex and compounding issues which  34  meant that there were many ‘red flag’ indicators that extreme vigilance, scepticism and critical judgement were required when working with the family. These indicators included:   MCFG’s relationships with males who posed a potential and proven risk to herself and her children.  Ongoing neglect of Child F and Child G (the neglect of Child F was not explicitly identified as such as much of the focus was upon Child G’s serious health needs)  Pattern of possible non accidental injuries.  MGCFG’s concerns about MCFG’s ability to look after the children.  MCFG’s mental health needs  MCFG’s possible cognitive difficulties.  FS123’s implication in the serious injury of a 6 month old baby.  The children’s history of making allegations followed by retraction or denial which was not viewed as a pattern or a symptom of physical and/or sexual abuse by all agencies who were involved.  The information held regarding MCFG’s knowledge that abuse was taking place and her reaction following Child F’s disclosure of sexual abuse. 4.66 Given this family history any allegation of physical and/or sexual abuse should have been responded to assertively. 4.67 There is little evidence that assessments or investigations at any time adequately analysed the interaction between these known risks and the protective factors within the family environment The process of transfer from another local authority and the appropriate reviewing of current protection plans.  4.68 Child F and Child G were subject of child protection arrangements in Lancashire in February 2000 because of neglect.   4.69 In June 2000 a decision was made to step down the arrangements and although there are no records of the rationale behind this decision the indications are that MCFG was still neglecting the needs of her children e.g. missing health appointments in respect of Child G. Furthermore Child F suffered bruising and injury (including a ‘black eye’) in June and December 2000 and March 2001.    35  4.70 Child G again became the subject of child protection arrangements in February 2003 because of neglect specifically focused around his health needs. Child F was not made subject of child protection arrangements.  4.71 In May 2003 during a Child Protection Review Conference concerns were noted about MCFG’s new partner FS123.   4.72 MCFG moved with the children to live with FS123 in Wigan in June 2003.  4.73 On 20th June 2003 an Incoming Child Protection Case Conference took place in Wigan and information was provided by Lancashire County Council highlighting concerns about MCFG’s ability to meet the health needs of Child G.  In addition to this further concerns were raised regarding FS123.  It had been disclosed to Lancashire County Council that in 2000 FS123 had been interviewed, alongside others in respect of serious injuries sustained by a 6 month old child.  During the CPCC Lancashire County Council confirmed that written agreements were in place in respect of supervised contact between FS123 and the children whilst a further assessment was undertaken.   4.74 Both Child F and Child G were made subject of Child Protection Plans in Wigan.   4.75 Child G was subject of dual registration in respect of both neglect and physical abuse.   4.76 On 26th June 2003 the first Core Group Meeting was held.  Records highlight that discussions were held about family activities however it was identified that at this time FS123’s mother (PGS123) could not be considered to supervise contact arrangements due to information linking her to the incident in 2000 where a number of adults including FS123 were considered as possible perpetrators of physical abuse.   4.77 It is not clear from the records available to this review if the transfer of child protection arrangements from Lancashire to Wigan included other highly relevant information for example:  MCFG’s previous relationships with men who posed a risk to herself and her children.  MCFG’s wider family connections with alleged perpetrators of sexual abuse.  MCFG’s disclosure of childhood sexual abuse.  MCFG’s overdose. 4.78 Much of the focus was on the possible risk to the children posed by FS123 and the neglect of Child G’s health needs.   36  4.79 In addition, when the family moved from Preston to Wigan the report provided by the Preston Social Worker stated that MCFG had “learning difficulties / a personality disorder”. It is not clear that this was qualified or quantified in respect of the impact on MCFG’s parenting capacity during the transfer of the child protection arrangements.  4.80 The handover of care from Preston Health Visiting Service to Wigan Health Visiting service was comprehensive and did include information about the historical context detailed above but it is not possible to conclude from the records available to this review that all of this information was shared during the transfer of child protection arrangements. Summary  4.81 This serious case review demonstrates the critical importance of a family’s complex history as an indicator of future risk and need and whilst complexity of risk and need is not always obvious within a family; in this case there were several long standing indicators that Child F and Child G were suffering neglect and physical and emotional harm.  4.82 Child F and Child G’s family history appears to have included inter and multi-generational abuse. This history was highly relevant to any assessment of MCFG’s need for therapeutic and other support as became a very young parent.  4.83 MCFG struggled to cope as a parent from the birth of Child F onwards. It may be that her own history of childhood abuse had compromised her parenting ability. Factors that are known to be associated with risk to babies and very young children (Ward et al 2012) include parents who have experienced abusive childhoods themselves and have not come to terms with the abuse.  4.84 Additional risk factors include domestic abuse and environmental stressors such as housing and we know that MCFG experienced domestic abuse and very unstable housing; moving several times when Child F and Child G were young infants. Significant protective factors are the presence of a supportive non-partner, wider family and informal support and parent’s insight understanding and capacity to change. Severe risk of harm is most likely where there is an absence of protective factors.  Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers.    4.85 Furthermore, children who have been sexually abused and exploited as MCFG may have been, are more likely than other children to be re-victimised both as  37  adolescents and adults. They are also more likely to have been targeted by the perpetrator specifically because of their particular vulnerabilities (Conte, Wolf, & Smith, 1989, Elliot, Browne, & Kilcoyne, 1995). This increases the likelihood that MCFG and by default, her children, would be vulnerable to further abuse.  Conte, J., Wolf, S., & Smith, T. (1989). What sexual offenders tell us about prevention strategies? Child Abuse and Neglect, 13(2), 293–301.   4.86 MCFG’s consecutive relationships with 4 men who posed a potential risk to herself and her children (who were very young at the time) certainly indicated that this was the case. 4.87 MCFG’s parenting capacity and her possible learning or cognitive difficulties were an issue of concern from the birth of Child F onwards but there was no formal assessment of this and there were no plans put in place for any long term support or intervention to ensure that MCFG and her children were safe and thriving despite the fact that there were several significant indicators that her capacity to parent was compromised.   4.88 The family moved to Wigan in 2003 with agencies involved in the transfer of child protection arrangements. During the decade that followed there was a steady stream of contact with those agencies i.e. police, Children’s Social Care, health visitors, secondary care services which should have ensured that Child F and Child G remained on the safeguarding ‘radar’.   4.89 This steady stream of contacts however was not recognised as a pattern within the family context and the majority of incidents which caused the contact with agencies was dealt with as a single incident and was not ‘cross referenced’ with the other incidents or the family’s history.  4.90 Furthermore the established link between neglect and physical abuse was not considered despite the significant number of known injuries to Child F from the age of 10 months onwards.     38  4.91 An important theme that arises from many SCRs is how well professionals ensured that children were at the centre of the service delivered or at the centre of child protection or child in need plans.  4.92 Child F and Child G came into contact with a range of professionals throughout the period under review and they were, on occasion, asked direct questions about some of the alleged incidents of physical and sexual abuse. 4.93 In these circumstances any interaction with either child warranted careful planning and skilful and sensitive handling. The reality however was very different. For example Child F was spoken to by the police in the street outside her home and in front of her mother in relation to the anonymous reports that she was being sexually abused. 4.94 The voices of Child F and Child G were effectively ignored or not believed on some occasions 4.95 This serious case review also highlights the necessity of good reflective supervision and management scrutiny in all agencies to minimise the effect of common issues such as not recognising the pattern of retraction and denial, not recognising that Child F as well as Child G was experiencing neglect, not recognising the pattern of risk in MCFG’s relationships with males. The role of managers to stand back and help practitioners unpick and fully appreciate the complexities of a situation was missing in this case.                    39   Recommendations  Multi Agency Recommendations  4.96 Using the learning from this serious case review multi-agency training and awareness raising is required to ensure that practitioners demonstrate professional curiosity and scepticism around fathers and other males who are associated with high need or complex families particularly where there has been a potential history of sexual and other abuse. The LSCB partners should evidence how this training and awareness raising has impacted upon practice particularly in respect of risk assessments within an agreed timescale. 4.97 It is essential that the use of family history and genealogy to identify and assess patterns of risk should be embedded in practice. Single agencies should provide details to the LSCB of how they will monitor the use of family history and genealogy for example through supervision and case audits. 4.98 It is essential that the learning from this Serious Case Review is used by the LSCB partners to assess their practice approach to families with similar histories to Child F and Child G’s. In particular how practice and supervision are influenced by the understanding of the long term impact of unresolved childhood trauma and abuse, maternal mental illness and /or cognitive functioning on parenting capacity. For example practitioners should be able to evidence that risk and need assessments have taken account of these issues. 4.99 WSCB should use the learning from this Serious Case Review to ensure that neglect in all its manifestations is understood and responded to by multi agency practitioners and that the well evidenced link between neglect and physical abuse is considered in all cases and that evidence of this is recorded in case files and supervision records. 4.100 WSCB and partners should review what currently happens when there are concerns a parent or parents have a cognitive or learning difficulty which may impact upon their parenting capacity and ensure that there is a clear and accessible referral and assessment protocol between agencies.   40  4.101 WSCB and partners should, at the earliest opportunity, share the learning from this review concerning patterns of children and young people’s disclosure (including retraction and denial) in cases of physical and sexual abuse and commit to ensuring that all children and young people who make allegations of sexual or physical abuse receive a ‘gold standard’ response drawing from the very valuable research, studies and best practice guidance which are widely available. Evidence that children and young people have been listened to and their wishes and feelings have been understood, respected and taken into account in decision making and planning should be a core element of the ‘gold standard’ response. 4.102 Using the learning from this review WSCB and partners should prepare a briefing for practitioners to outline the difference between evidential thresholds in criminal and civil proceedings and what this may mean for the children and young people with whom they are working.    Single Agency Recommendations  Greater Manchester Police  4.103 Greater Manchester Police should ensure that the learning from this review is shared with the cohort of officers trained to carry out ABE interviews and reinforce the importance of pre-interview planning and the importance of consulting with and joint planning with partner agencies including children’s social care. 4.104 Greater Manchester Police should consider its ‘frontline’ response to children and young people who allege (or about whom there are concerns) that abuse is taking place and ensure that the learning from this review is shared and translated into improved practice. 4.105 Greater Manchester Police should review its practice of evidence gathering in cases where a child or young person has alleged abuse specifically in asking schools and other agencies whether or not a child or young person tells lies. This should be informed by research and best practice. 4.106 Greater Manchester Police should instigate a discussion with the Crown Prosecution Service in order to routinely receive feedback about the quality of ABE interviews particularly when a decision is made not to proceed with criminal proceedings and ensure that practice is reviewed accordingly.     41  Children’s Social Care   4.107 CSC managers should use every opportunity (induction, supervision, training) to embed the requirement for Social Workers to read and understand a child’s and family’s history, and for the worker’s manager to prioritise and protect the time needed to do so.  This message should be supported by guidance about key documents and the use of chronologies, to support better understanding of family history and patterns.     4.108 A means of monitoring whether this has been done should be put in place for all children who are subject to a Child in Need Plan, Child Protection Plan, or Care Plan as a looked-after child.      Education 4.109 The WSCB Education Sub Group should assure itself that safeguarding leads within each school in the Borough should ensure that they and other relevant staff have a good understanding of the important role that teachers and schools in play in the way in which children and young people disclose or attempt to disclose physical and sexual abuse.   Conclusion  4.110 Child F and Child G suffered neglect from birth onwards. It is likely that Child F in particular also suffered physical abuse as a young baby onwards. The capacity of their mother to care for and safeguard her children was compromised but because she did not undergo a comprehensive parenting or cognitive assessment it is not clear whether this was because of her own childhood experiences of trauma and abuse, because she had a cognitive impairment and/ or mental health condition or a combination of all these factors. Whatever the cause the impact was that Child F and Child G suffered significant harm including exposure to domestic abuse, neglect and physical and sexual abuse. 4.111 This harm was compounded by the way in which agencies responded in particular to Child F’s disclosures of physical abuse and later of sexual abuse and also led to the continued abuse of Child G beyond the point at which Child F left the family home. 4.112 In conversation with the Lead Reviewer both Child F and Child G confirmed that they had been afraid of the consequences of telling the truth to agencies about the abuse (physical and sexual). These consequences were threatened by MCFG and FS123 and included physical punishments. The children were also told that the family would be split up if they told anyone what was happening.  42  4.113 Child G in his conversation with the Lead Reviewer confirmed that he was too afraid of FS123 to tell the truth about what was happening within the family. He said that the safest thing for him to do was to keep his head down and keep quiet.  4.114 Child F in her conversation with the Lead Reviewer said that she wanted professionals to understand that when a child or a young person tells them that some form of abuse is occurring, however confused or conflicting that disclosure may be, they should be believed. She also wanted professionals to understand that children and young people will be under huge pressure not to tell the truth and to change their story if or when they do. 4.115 The Lead Reviewer and the Serious Case Review Panel would like to thank Child F and Child G for their courage and their honesty in speaking to the Lead Reviewer. What has changed since this Serious Case Review began?  4.116 There has been a wide ranging response from social care; 4.117 Since 2013 there has been a full service review within the specialist assessment service; this identified a set of actions both immediate and long term to address service issues and ensure the provision of appropriate service. This included:  Systemic supervision training has been accessed by social care managers  Significant changes have occurred to the duty service in respect of management of information received.    Chronology training has been provided to all social care staff to embed the importance of considering the holistic picture  There has been a full audit of all social care cases to ensure the learning around the significance of chronologies on the child’s file has been implemented.  Quality assurance meetings are held between Social Care and Health Colleagues in order to share information and address any problem areas.    Arrangements are now in place to ensure all ABE interviews are attended or the evidence observed by social care staff      43    References  Achieving Best Evidence in child sexual abuse cases - a joint inspection HMCPSI and HMIC December 2014 Conte, J., Wolf, S., & Smith, T. (1989). What sexual offenders tell us about prevention strategies? Child Abuse and Neglect, 13(2), 293–301. Ministry of Justice Achieving Best Evidence in Criminal Proceedings: Guidance on interviewing victims and witnesses, and guidance on using special measures 2013    No One Noticed No One Heard: A study of disclosure of Childhood Abuse NSPCC 2013 Sorenson, T., & Snow, B. (1991). How children tell: The process of disclosure in child sexual abuse. Child Welfare, 70(1), 3 15. Summit, R. C. (1983).  The child sexual abuse accommodation syndrome.  Child Abuse and Neglect, 7, 177-193.     Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers.   Working Together to Safeguard Children 2015       