Three siblings, Samuel (17), Shay (15) and Joy (13), known to services as potential victims of criminal exploitation. In 2022 Samuel was involved in two altercations and received knife wounds. In December 2022, Shay was arrested regarding an assault with a knife which led to another arrest for class A drug possession. Learning themes include: working with the family, alongside the wider contextual issues regarding child criminal exploitation and serious youth violence; evaluation of assessments and interventions; the role of schools; use of knives and police and criminal justice interventions; use of social media and agency assessment of its significance; extra-familial harm versus criminal activity; use of the National Referral Mechanism (NRM); and managing the needs and risks of siblings. Recommendations for the Partnership include: adopt the term 'extra-familial harm' to describe 'child exploitation'; review the existing system of alerting senior managers to 'high risk' children in children's social care; ensure that front line practitioners have a clear understanding of adolescent development and the impact of ACE's/trauma; consider a multi-agency learning audit for children involved in the Section 47 process where there is an extra-familial harm concern; school leaders should review the effectiveness for children of separate 'on site' alternative learning provision; embed training on children's use of social media and its associated risk factors into existing training; ensure one safeguarding partner takes sole responsibility for tracking children subject to the NRM process; and where extra-familial harm is evidenced ensure siblings are appropriately assessed and interventions are put in place.
      
 Title:  Local child safeguarding practice review: Samuel, Shay and Joy. LSCB: Pan Dorset Safeguarding Children Partnership Author: Ian Vinall Date of publication: 2023  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.                             1 Pan Dorset Safeguarding Children Partnership Local Child Safeguarding Practice Review  Samuel, Shay and Joy                             Ian Vinall  Independent Author  June 2023       2 1. Introduction 1.1 The subjects of this Local Child Safeguarding Practice Review are three siblings, Samuel1 (aged 17), Shay (aged 15) and Joy (aged 13). All three children lived with their mother, Michelle, and her partner. Although birth father lived nearby, his only contact was with Joy.  1.2 In August 2022, Samuel had an altercation with two individuals and he received knife wounds consistent with Grievous Bodily Harm. 1.3 In September 2022, Samuel was involved in a second unrelated altercation and was stabbed with a knife. His significant injury required hospital treatment. 1.4 In December 2022, Shay was arrested and interviewed regarding an assault with the use of a knife. When he was arrested, a significant amount of class A drugs was found, and he was also arrested for Possession with Intent to Supply (PWITS).  1.5 At the time of these incidents Samuel and Shay’s case was open to the Complex Safeguarding Team (CST) because of concerns of them being criminally exploited.  2.       Methodology 2.1 The report author met with Michelle, Samuel, Joy and their maternal aunt as part of the review.  Shay and the children’s birth father chose not to engage with the review. Assessments, care plans, meeting minutes and single agency service reports were analysed by the author to form a chronology of the children’s circumstances together with reflective discussions with practitioners who have worked directly with the children and family or have significant knowledge of the children’s circumstances. Together, these processes identified the Key Practice Themes which were tested by two practitioner events. The agreed time frame for the review was between October 2021 and December 2022. The children remain subject to child protection, youth custody and looked after child processes.  3. Protected Characteristics2 3.1 The family are white British and do not assign to a particular religion or faith. Michelle and the children’s father are separated, and Michelle has undertaken most of the children’s care throughout their childhood, albeit with support from her partner in the last four years. Michelle has two job roles to support her family financially. There were historic concerns at school about the physical presentation of the children.  3.2 Whilst not deemed a protective characteristic, the two boys were formally notified of their NRM status, highlighting them both as potential victims of exploitation. The boys  1 Not their real names. 2 Discrimination: your rights: Types of discrimination ('protected characteristics') - GOV.UK (www.gov.uk)    3 may be victims and perpetrators of exploitation and this presents challenges to agencies. 3.3 The scale of the boy’s criminal activity has impacted on the whole family, including the trauma of armed police raids on the family home.  3.4 Both boys have been permanently excluded from school and spent periods in alternative learning provision.  3.5 Shay has been diagnosed with ADHD and his learning needs and presentation suggests that mainstream education did not recognise his speech, language, and communication needs. He only received specialist intervention at the point of involvement from the Youth Justice Service.  3.6 The area in which the family live is seen as a relatively prosperous area yet wealth is not evenly spread and significant pockets of deprivation and inequalities exist. Both boys misuse drugs and alcohol and locally, the rate of deaths from drug misuse is higher than that of England. For younger people, the rate of hospital admissions for substance misuse aged 15-24, and the percentage of 15-year-olds who have taken cannabis in the last month is significantly higher compared to England3. 4. The Children’s Story 4.1 Children’s Social Care records begin in 2016 owing to Shay’s behaviour at school and violence towards his mother and siblings. The family engaged with Early Help support and there was no further agency contact until 2020. Shay was then at risk of permanent exclusion due to ‘persistent disruptive behaviour’ and ‘unidentified learning needs’ impacting on his behaviour in school. The Team Around the Family plan was disrupted owing to the COVID-19 lockdown. Shay was placed in alternative education provision and subsequently returned to mainstream education.  4.2 The family’s first involvement with statutory safeguarding agencies was in October 2021 when the police were alerted to a social media post of Samuel holding a ‘zombie knife’.  4.3 Between October 2021 and December 2022, there were nine Section 474 investigations opened on the children and three child and family assessments undertaken. The first assessment in October 2021 prompted the completion of the first of four Child Exploitation Screening Tools (CEST). These highlighted and restated the boys increased risk of criminal exploitation and significant involvement in criminal activity. They repeat the impact on them of their unmet learning needs, school exclusions and increasing use of drugs and alcohol.  The risk levels and  3 BCP JSNA 2022  4 Section 47 Children Act 1989   4 needs of Joy are commented on in the context of her increasing concern for the welfare and safety of her brothers and feeling unsettled by constant police involvement.  4.4 A National Referral Mechanism (NRM)5 referral was made for Samuel, yet police records indicate that he did not engage with the NRM process. The ‘reasonable grounds’ test for the NRM was confirmed in December 2021 with a ‘conclusive grounds’ decision made four months later in April 2022. An NRM was completed for Shay in December 2022. 4.5 A referral was made to the specialist Complex Safeguarding Team (CST) in November 2021, but this was assessed as not meeting their threshold suggesting there was limited information regarding exploitation. As a result of these judgements, the children became subject to child in need plans and transferred internally in Children’s Social Care to the Child and Families First Team (CFF). From March 2022 the CST took case responsibility for the boys and held monthly non-statutory Exploitation Team Around the Child Meetings (ETAC). Joy remained open to the CFF. 4.6 Michelle engaged with the assessments and plans yet expressed concern about not being able to keep the boys safe outside of the family home and her ability to assert effective boundaries. A plan was developed which included: - Michelle attending a “Triple P Parenting Course’6 - Emotional wellbeing support for Joy. - Support for Shay’s learning needs. - Direct work with Samuel and Shay regarding child criminal exploitation and knife possession. - Support in relation to substance misuse. - Hold a Family Network Meeting.  - A male family support worker was allocated to provide mentoring and support to the boys.  - The newly allocated social worker from CST would make twice weekly visits to the family.  5 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. Modern slavery is a complex crime and may involve multiple forms of exploitation.   6 Triple P gives parents simple and practical strategies to help them build strong, healthy relationships, confidently manage their children’s behaviour and prevent problems developing.   5 - The social worker and support worker supported Samuel with college applications. 4.7 The two stabbing incidents in August and September 2022, led to the referral for a local child safeguarding practice review. The rapid review process also led to a referral to the Legal Gateway Meeting and in November 2022, the children became the subject of their first initial child protection conference. Despite all agencies stating they felt the threshold was met for the children to be subject to a child protection plan, the independent conference chair overruled this decision as they felt a child protection plan would only replicate the original plan. The second initial child protection conference was held in January 2023 and the children became subject to child protection plans.  4.8 Between October 2021 and December 2022, the boys were arrested on at least 13 separate occasions. The offences included, possession of a large zombie knife, affray, attempted shoplifting, the possession of knives, domestic burglary, robbery, possession with intent to supply, possession of cannabis, assault, GBH with intent, wounding, animal cruelty and theft. The boy’s social worker noted that both boys increasingly began wearing expensive designer clothing. Samuel consistently reported he was not under any influence from others or being exploited. There was either significant delay in progressing most of the investigations into the criminal matters or they were closed with no further action.  4.9 A Section 47 enquiry took place in early April following an incident where Joy, aged 12, was encouraged to get into a vehicle of an unknown man. Although her vulnerability to sexual exploitation was significantly heightened, Joy was removed from the child in need plan in May 2022.  4.10 Samuel completed his GCSEs in June 2022 with support from his social worker. It was reported that the situation at home seemed much calmer and positive and Shay had started to engage with reintegration into school.  4.11 In early August, it was agreed at a review ETAC that Shay no longer needed intervention from CST and the ETAC process was closed for him.  4.12 Michelle continued to struggle at home and completed an e-consultation with her GP in August 2022. She requested advice on managing Samuel’s aggressive and violent behaviour. She stated that social workers and youth workers were unable to suggest a way forward. The GP suggested looking on the CAMHS website and to also contact Samuel’s school.  4.13 When Samuel was stabbed in August and September, plans to move the family out of the area for their protection were not implemented but various safety measures were   6 proposed to keep the family safe in their home. A Dorset Police Response Plan was in place to flag any 999 calls for a priority response. All police officers working in the Bournemouth, Christchurch and Poole (BCP) Council Local Policing Area or in roles that take them into the BCP area coming on shift, received a daily briefing about the family.  4.14 Both Samuel and Shay’s arrests offered opportunities for ‘reachable moments’7 whilst in police custody. However, police were unable to engage them.  5. Key Practice Themes 5.1 There are key practice themes which seek to understand how agencies engaged and worked with the family, alongside the wider contextual issues regarding child criminal exploitation and serious youth violence. The review also advocates the need to move from the terminology ‘child criminal exploitation’ to ‘extra-familial harm’ which better describes the experiences of Samuel and Shay and other young people in similar circumstances. These terms are used interchangeably in the review report. This analysis is thematic and should be read in the context of learning from the children’s experience. Recommendation: Safeguarding Partners adopt the term ‘extra-familial harm’ to describe ‘child exploitation’ which mirrors the changes Pan-Dorset.  6. Good Practice (identified by the agencies) - The children’s social worker from CST has worked hard to engage the children with a relationship-based approach and had been the one consistent professional in the children’s lives for over a year.  - Samuel was supported to achieve his GCSE grades.   - There was some progress in achieving Shay’s educational goals. - The CST have provided high levels of visiting and intervention and have been responsive to new and escalating risks. - There have been swift multi-agency responses to further incidents of concern. - There has been evidence of multi-agency working to try and manage the risk more effectively, including the use of Criminal Behaviour Orders and an enforceable doorstep curfew as part of Samuel’s Referral Order. - There has been good communication and timely information sharing between agencies, attendance at meetings and the ETAC Plan was regularly reviewed.  7  The notion that something happens it opens up a moment in time in which it is possible to reach and work with a child or young person who previously agencies have been unable to engage.  The key is recognising and seizing the moment.      7 - There has been a recognition and understanding of the risks for Joy by the professional network and a police response plan which supports the safeguarding of Joy in particular. - The Youth Justice Service accurately assessed Samuel’s speech, language and communication needs and this was shared with the family and wider network.  7. Evaluation of assessments, interventions, and plans 7.1 From November 2021 there have been multiple meetings held by police, Children’s Social Care and partner agencies including the strategic exploitation and knife crime meetings. The boys were reported missing on at least three occasions yet this is likely to be significantly more. There is a significant increase in offending behaviour from November 2021 and the police built an intelligence picture with each interaction with Samuel and Shay and highlighted this to other agencies in January 2022. Multiple ‘Need to Know’ documents were raised by the CST to senior leaders in Children’s Social Care, yet there was it was not clear how these were responded to. Recommendation: The existing system of alerting senior managers to ‘high risk’ children in Children’s Social Care and in the multi-agency safeguarding partnership would benefit from review. 7.2 It is difficult to evaluate how these assessments, meetings and interventions impacted on the boy’s outcomes. Despite intensive twice weekly support from CST, regular ETAC meetings, multi-agency information sharing and good partnership working, agencies have been unable to reduce the contextual safeguarding risks or reduce the serious violent incidents for the boys. Agencies have struggled to engage the boys in any activity that has reduced their level of offending or their risk of exploitation.  7.3 It took too long for safeguarding agencies to identify that Samuel and Shay were at risk of criminal exploitation, despite there being clear triggers and intelligence. Referral processes and decision-making accessing specialist CST support were not followed. This was compounded by the high threshold for accessing the CST and the determination as to what constituted actual evidence of exploitation against the evidence of emerging risk factors. This delayed Samuel’s access to specialist support. Disagreement between teams in Children’s Social Care were escalated to senior managers but this took too long to resolve and was not a ‘child led’ decision. Specific team remits, threshold criteria and limited flexibility appear to have led to the delay.  7.4 Although there is good engagement from Michelle, the assessment of parenting capacity and wider family is lacking. To understand the dynamics of exploitation an   8 understanding of parenting capacity and history is essential. Without analysis of the family’s circumstances, this can lead to inappropriate interventions that have little benefit. At stages in the process, Michelle and her partner are deemed as a couple struggling to cope with managing the boy’s behaviour, having an inability to keeping them safe yet doing their best under very challenging circumstances. At other times, they are deemed neglectful, providing inadequate supervision, and prioritising their own needs above the children. The Section 47 enquiry that prompted for the children’s case to progress to a second ICPC was following Michelle and her partner going away for a weekend break without informing professionals. Michelle made alternative care arrangements yet this was deemed to place the children more at risk than they previously were. 7.5 There are repeated references to referring Michelle to a Triple P parenting programme. This materialises three months after the original decision yet it is not clear what benefit Michelle gained from this process or the impact this has had on the child’s lived experiences. The children’s father is an absent voice. Despite his poor relationship with the boys and the known history, his involvement was not given adequate consideration. An assessment of the wider family and their role would have added value to the agency responses and safety planning.  7.6 There is limited understanding of the children’s earlier childhood experiences and how these earlier experiences may have impacted upon them. Much has been written regarding the impact on children of Adverse Childhood Experiences (ACE’s)8. These are highly stressful and traumatic experiences occurring during childhood or adolescence and can be a single event or prolonged threat to safety. All three children have experienced ACE’s, some are still very current and the assessments needed more detail on how the children’s lived experiences impacted on their development and how agencies may be able to intervene. Whilst Samuel described a somewhat blasé attitude to his experiences as a victim of knife crime, it remains that he is still a child and developmentally and emotionally he may not be able to process what happened to him. Exploited children can be exposed to repeated trauma through violence and abuse (either victim of or witness to) and can also experience trauma because of their own violent behaviour. Caregivers are also likely to experience trauma linked to their child’s exploitation9. 7.7 Adolescent development also features less in the assessments and plans. There has been much recent research into the science of the adolescent brain and how  8 https://uktraumacouncil.org/research_practice/aces-research 9https://yjresourcehub.uk/images/County%20Lines%20Pathfinder/Child_Criminal_Exploitation_Emerging_and_Promising%20_Practice_Approaches_County_Lines_Pathfinder_2022.pdf   9 safeguarding agencies need to adapt their approaches to reflect how this influences children’s decision making. Recommendation: The safeguarding partnership should assure themselves that adolescent development becomes a ‘practice fundamental’ to ensure that front line practitioners have a clear understanding of the adolescent stages of development and the impact of ACE’s/trauma. 7.8 Transitions for children can be significant events and Shay struggled significantly with the transitions in his schooling. This may have been an opportunity to provide more bespoke support particularly children who are already identified as struggling in primary education.  7.9 The purpose of the regular ETAC meeting was to ensure that all available information was shared and considered, needs and vulnerability identified and planned for, a trigger and disruption plan completed, roles and responsibilities clearly defined and timescales agreed. These meetings were primarily attended by the CST, Children’s Social Care and the police. Of the six meeting minutes reviewed, schools attended three times and health attended no ETAC meetings. School nursing professionals report they do not have the capacity to attend ETAC meetings so there is no health input into safety planning. Primarily, only two agencies were involved in safety planning and the assessment of risk. Given the nature of child criminal exploitation and the community wide issues it raises, other agencies do need to be more actively involved. Michelle and the boys were not always part of these ETAC meetings. Michelle, the boys, and the wider family could have been seen as a ‘safeguarding partner’. True collaboration with all family members could possibly have built upon the protective capacity of the agencies involved10. It would be important to analyse how much the parents, carers and wider family are engaged as a protective factor in situations of exploitation. Children’s parents, carers and wider family should be appropriately engaged as a ‘safeguarding partner’ in developing safety plans and addressing risk outside of the family home. 7.10 In August 2022, BCP Children’s Social Care began to review the use of the ETAC process. This work concluded that the ETACs offered no assurance regarding the level of risk nor the management of that risk and there was a need to return to the use of Section 17 and Section 47 arrangements. This work concluded in Sept 2022, and it took several months to get to the point of replacing the process.   10 https://tce.researchinpractice.org.uk/tce-consortium-partners/   10 7.11 From the end of April 2023, the CST ended the ETAC meeting process and now only use the existing statutory processes11 to manage the risks for children being exploited. BCP council have recognised that the ETAC had limited impact and this review has highlighted how ineffectual those meetings have been in addressing the boy’s outcomes.  Recommendation: BCP Council should review the changes to the ETAC process following implementation to ensure the changes are achieving more positive outcomes and reducing the risk for children.  7.12 It took several months and nine Section 47 enquiries before a decision was made to progress to an initial child protection conference (ICPC) which highlights the dilemma of how agencies manage this type of extra familial harm. The first child and family assessment confirmed that both boys were being drawn into criminal activity and being targeted or groomed by others. It concluded that the circumstances of the boys met the threshold at Level 4 of the Pan Dorset Continuum of Need Threshold Document. Given this, it is perplexing as to why CST did not consider the threshold met for their involvement, why the CEST concluding that no referral to CST was required, or whether any existing statutory child protection process were needed to safeguard the children. At this time, the existing ETAC process was considered an effective multi-agency risk management meeting and therefore the statutory process were not required to manage the risk. This approach failed to consider that all three children had suffered significant harm.  7.13 The decisions by the independent child protection conference chair at the first ICPC were not formally challenged, escalated, or dissented against by any professional attending the conference at the time which suggests a lack of knowledge or confidence to challenge what appeared to be a flawed decision. Concerns were raised by the Service Manager and Team Manager in CST informally with the conference service but these are not recorded or formalised. Whilst child protection conference chairs do have these decision-making powers in policy, it is rare to oppose all agencies considerations of risk and harm. It would be appropriate to remind agencies attending child protection conferences that they have the executive power to formally oppose, dissent and escalate decision making in the child protection conference process. 7.14 Three or more Section 47 enquiries on an individual child within a 12-month period should have prompted some management oversight. No agency felt the need to use  11 Children Act 1989   11 the existing escalation process to alert senior managers to the children’s circumstances.  Recommendation: A multi-agency learning audit should be considered for children involved in the Section 47 process where there is an extra-familial harm concern. This should involve feedback from children and parents/carers.   Recommendation: The safeguarding partnership should seek assurance that repeat Section 47 enquiries are subject to review and management oversight.  7.15 The community factors that influence children’s decisions should also be the subject of assessment, focusing on relationships, community profiles, wider societal issues, and support mechanisms in local communities. Analysis of these collective assessments could assist in determining appropriate interventions that match understood and assessed needs and address community-based issues. The current child and family assessment process may not meet these expectations and timeframes and a more bespoke specialist assessment process may need to be considered.  This could also lead to determining what services may need to be commissioned at a local level. Recommendation: In cases of child exploitation, the assessment service should put in place a checklist so that the child and family assessment explicitly analyse parental capacity, wider family and the impact and influence of the wider community and contextual factors.    7.16 The CEST is a tool to assess risk and safeguarding agencies are expecting its use to be increased by a wider number of professionals. The CEST completed in November 2021 indicated that Samuel and Shay were at ‘medium’ risk of exploitation which only increased to ‘high’ risk following the NRM conclusive grounds decision for Samuel. There should be an avoidance of a ‘tick box’ exercise to complete this assessment.  The analysis should encourage practitioners together to consider how to prevent the escalation of behaviour and/or exploitation. Whilst the CST remained on the periphery, the offer to the family at the time did not appear to match the complex needs that were emerging regarding criminal exploitation and criminal behaviour. Recommendation: The new CEST tool implemented in BCP should be reviewed within 6 months’ time to ensure this remains fit for purpose.    12 8. The role of schools 8.1 Prior to October 2021, the family were known to support agencies and particularly regarding Shay’s additional learning needs and his ability to manage in mainstream education. His additional learning needs, poor educational attainment, non-engagement in education and temporary or permanent exclusions had the potential to be significant triggers in increasing his vulnerability to exploitation. The impact of school exclusion is frequently mentioned in professional research and policy regarding serious youth violence12/13 and can be a significant trigger for increased association with exploitation. However, a focus on school exclusion in these contexts can also lead to other issues being ignored. These collective sources of information should prompt professionals to consider earlier intervention with children who may be experiencing temporary or permanent exclusions. 8.2 Michelle described feeling ‘let down’ by the education system with Shay never engaging in or managing mainstream education.  Both boys were not subject to any formal assessment of their educational needs. An Education, Health and Care Plan (EHCP) assessment for Shay, may have indicated that his special educational needs required more specialist education provision. Legally, if parents think their child needs more help than the school can provide, they can ask for an assessment. In Shay’s circumstances, Michelle did not have the knowledge or experience to push for this.   8.3 When Shay moved to alternative learning provision it appeared to meet his needs and he thrived with smaller classes and less pressure but this arrangement was always intended to promote his reintegration back into mainstream schooling. He moved to a mainstream secondary school in Year 9 and into the schools ‘on site’ alternative learning provision. This school provided an individual education plan for Shay and he was on a reduced timetable. However, Shay told his mother that he felt further isolated in this environment and ‘different’ because of being in a mainstream school but being educated away from the other pupils. This only appeared to reinforce his negative perception. As part of BCP’s Special Educational Needs and Disability (SEND) improvement journey, there have been a series of initiatives to address the issues for children with special educational needs. This has included the expansion of ‘on site’ alternative learning provision. Whilst this may address the immediate need for school places for children with special educational needs, it may not be effective for all children. There are no indications that this approach has been  12 Vulnerable Adolescents Thematic Review February 2019, Croydon Safeguarding Children Board  13 http://www.preventknifecrime.co.uk/wp-content/uploads/2019/10/APPG-on-Knife-Crime-Back-to-School-exclusions-report-FINAL.pdf   13 evaluated and therefore may benefit from review as to how this approach has improved educational outcomes.  Recommendation: School leaders should review the effectiveness for children of separate ‘on site’ alternative learning provision.   8.4 Shay displayed limited engagement at school and disrupted his mainstream schooling in attempt to return to the previous alternative learning provision that he found so positive. There was subsequent agreement and funding for a placement at the alternative learning provision this but at this stage Shay had disengaged from education and learning and this has been difficult to recover.  8.5 There had been ongoing worries at school for the emotional wellbeing of Joy in the context of the boy’s behaviour, yet she was managing her schooling well.  8.6 Whilst his attendance was relatively low, Samuel did engage with school but events outside of school influenced and impacted upon his education and learning. He was educated off site due to his risk and had periods of fixed term exclusion. Practitioners have reflected that Samuel’s view of his schooling may have reinforced his identity with direct quotes including, ‘people were scared of me..I ran that school’.  8.7 The schools needed help and guidance with the growing issues of serious youth violence and its impact. They acknowledged that these issues had been outside of their frame of reference yet criminal exploitation, gang culture, county lines and knife crime had significantly increased over the last two years and this was impacting on the school environment. They raised worries that schools were expected to manage highly complex children with special needs alongside criminal behaviour that may occur outside of school with little support from partner agencies. They report that this behaviour then plays out in school and can be difficult to manage. Whilst schools do play a key role in the shared support of children in their schools and local communities, it is important to consider how much burden is placed on the school to provide support to children where other agencies may need to step in and work alongside them. Safeguarding agencies could be more proactive in their support to the school. A partnership approach prior to exclusion at an earlier stage has the potential to prevent children spiralling into exploitation. They also can provide significant information regarding children’s friendships or associates that add value to the mapping of exploitative relationships. 8.8 The context of the school landscape in the area highlights additional challenges. 80% of schools are part of academy trusts which means the local authority has little influence in decisions made regarding children’s education or lack of it. 98% of   14 schools in BCP are currently rated as good or outstanding. This is in contrast with permanent exclusions being twice the national average. In quarter 4 (October to December 2022) there was a 51% increase in exclusions compared with the previous quarter 3. There has equally been an increase in the numbers of children moving to a part time timetable or ‘missing out on education’. In the BCP Children’s Services Overview and Scrutiny Committee Reports of June 2023, it highlights that schools are struggling to access good quality alternative provision and those alternatives are currently full. The report notes that the length of time taken for children to have an EHCP approved is impacting on the length of time children remain in schools without the required funding to support those children. The subsequent result is permanent exclusion. The increasing complexity of children’s needs has led to schools struggling to offer effective early help support and a ‘perceived lack of easily accessible support services that address pupil behaviour and issues within the family and community that cause challenging behaviour’. The report remarks that many academy trusts use a ‘behavioural approach’ in class where a more ‘relational’ approach is less of a focus. There is research evidence that highlights the crucial importance of understanding a child’s behaviour from their context, with potentially multiple influences which impact behaviour. The “Improving Behaviour in Schools Guidance Report’14 produced by the Education Endowment Foundation in 2021 emphases the relationship-based approach with pupils and personalised approaches needed to manage individual needs and behaviour. Early identification and prevention work in schools is key to good outcomes for children and whilst there is in place educational psychology and inclusion work with schools to ensure early identification of need, these interventions might benefit from wider partnership engagement to address extra-familial risks identified at an earlier stage, thus potentially avoiding children experiencing more risk when excluded from school.  9. The use of knives and police and criminal justice interventions 9.1 Samuel has relayed that he has carried a knife because of the fear of violence and victimisation, linked to the belief that other children in his community also carry knives and would be prepared to use them. Samuel perceives he has ‘social status’, respect, influence, and power over other children through carrying a knife, evidencing using a knife and being a victim of a knife crime himself. Instant communication via social media serves to reinforce this perception. Samuel has also relayed his role as the ‘ideas man’ in the context of criminal activity. Increasingly as Samuel has been  14 https://d2tic4wvo1iusb.cloudfront.net/production/eef-guidance-reports/behaviour/EEF_Improving_behaviour_in_schools_Report.pdf?v=1688535022   15 involved in criminal activity and potentially being exploited by criminal gangs, his need to carry a knife for protection has increased. There is published academic research which is useful in helping to understand the background factors that are associated with knife carrying.15  9.2 Dorset Police report that there was a reduction in knife crime incidents in the BCP area in 2022-23. However, the Youth Justice Service16 highlighted that child offences in BCP have increased in number and proportion. Analysis reveals special educational needs and temporary and permanent exclusions from school feature highly in this cohort emphasising the need for better interventions with schools at an earlier stage.  9.3 Samuel and Shay have been involved in the illegal supply of drugs and this appeared to be driving their use of knives to threaten but also to provide perceived safety. There have been several recent knife related crimes in the BCP area involving children and subject to ongoing investigation.  9.4 A BCP council Community Safety Report (December 2022) showed that over a 12-month period December 2021 and November 2022 there were 531 occurrences related to knife crime in BCP reported to police and within that, 203 occurrences were deemed to involve the physical presence of a knife. 10–19-year-olds were disproportionately represented in this dataset, making up 25.2% of the suspects and 20.1% of victims. 10–19-year-olds were also disproportionately represented within possession offences with 40.2% of suspects involved in possession offences aged 10-19. The interviews with professionals noted that this was an emerging issue that was not getting the prominence it required in both policy, practice and leadership and has only recently received the increased scrutiny it deserved.  9.5 Samuel and Shay did not get the level of interventions needed at an earlier point in their lives to impact on their increasing use of knives and violence, including the use of preventative and interventionist methods such as the increased involvement of the police neighbourhood teams to interrupt and disrupt Samuel and Shay’s activity.  9.6 Dorset Police have confirmed that significant investment has led to a more consistent workforce yet the significant role of the neighbourhood policing team for children at risk of exploitation cannot be underestimated.   9.7 The Police and Crime Commissioner (PCC) in Dorset has made representations that Dorset Police is one of the lowest funded police forces in the country and resources are significantly stretched. Whilst accepting the significant role of neighbourhood  15 Security, respect and culture in British teenagers' discourses of knife‐carrying, Marek Palasinski et al, Liverpool John Moores University 16 Youth Justice Partnership Board and Children’s Services Overview and Scrutiny Committee June 2022.    16 policing in addressing the risks for children, the force has had to focus its resources on first response policing which diverts officers away from neighbourhood teams. The neighbourhood policing teams can make a significant difference if they were authorised to remain in role for longer periods of time and be allowed to develop those relationships without moving to other police priority areas of policing. This short-term approach does not meet the needs of vulnerable children as there are positive outcomes to be achieved in relationship-based interventions.  9.8 The BCP Knife Crime Task and Finish Group has been in operation since May 2022. This multi-agency partnership meeting reviews the available intelligence and identifies the children and adults carrying and using knives. Samuel and Shay have remained on this meeting agenda since the inception of the group and RAG rated Red, highlighting the risks to themselves and others. The neighbourhood policing team17 was tasked to undertake the ‘tactical’ work with the children, attempting to build rapport with the family, ‘door stepping’ and building a developing intelligence picture regarding their contacts and involvements. At this time, the police team known as IMPACT dealt with ‘high-risk’ children harmed by or at risk of exploitation and worked closely with the neighbourhood policing teams who worked alongside ‘low risk’ children. The Inspectorate of Constabulary and Fire & Rescue Services post inspection review of how well Dorset Police kept children safe was published in 2022. It highlighted the significant resourcing problems in IMPACT and that work had to be redistributed to other teams, some without the skills and experience to deal with them. In the short term, Dorset Police acknowledged the resource gap and implemented short term measures to address this. Dorset Police has since implemented the Police Safeguarding Hub which carries out the same role as IMPACT but ensures that ‘low risk’ cases also receive more specialist responses. This team investigate exploitation with a view to identifying those that are perpetrators of exploitation. They offer opportunities for ‘reachable moments’ with children when in custody.  9.9 Multi-agency discussions regarding the oversight of children experiencing extra-familial harm began in the summer of 2022 and in January 2023, multi-agency partners introduced the Missing, Exploited and Trafficked (MET) Panel. Focusing on emerging risks in the community and the identification of children being exploited and targeted police actions against perpetrators. It took several months to implement    17 A team of police officers and police community support officers who predominantly patrol and are assigned to police a local community. Teams often comprise specialist officers and staff with expertise in crime prevention, community safety, licensing, restorative justice and school’s liaison. Response teams are assigned to deal with emergency and priority calls.   17 those changes which may be reflective of the challenges of implementing new systems and arrangements when agencies have previously viewed arrangements as successful at meeting risks and needs. Recommendation: The governance of these various panels and forums and how they interact should be made explicit with clear governance, reporting lines and accountability.   9.10 Samuel was convicted at court and sentenced to a 12-month Referral Order in November 2022 for offences committed in October 2021 some 13 months after committing the offence. That Order did not commence until January 2023. Samuel and Shay appeared in court in December 2022 for an offence of GBH committed in February 2022. Of Samuel’s eight outstanding offences from October 2021 up to January 2023, five led to no further action or were dismissed. Shay received a Youth Restorative Disposal (YSD) in April 2022 for a possession of cannabis offence. The YSD was delivered by the Safer Schools and Communities Team with no involvement from the Youth Justice Service.  9.11 This pattern of arrests, charges and no further action decisions impacted upon Samuel to the extent where he started to perceive himself as ‘invincible’ or in the words of his mother, ‘untouchable’ and that he could ‘get away with it’. Samuel himself relayed that he needed a swifter response to his charges as by the time he was sentenced, he had ‘forgotten’ about them. He was open enough to say that earlier sanctions may have impacted on his behaviour. Since coming to police notice in October 2021, he was regularly involved in what was described as a ‘shocking multitude of offences’. Professionals have argued that some of these reported offences could have been prevented if he had received swifter sentencing responses and more external controls were put in place at an earlier point. Some of the delay was related to the awaited outcome of the National Referral Mechanism (NRM).   9.12 The local safeguarding children partnership has since reflected that if agencies cannot rely on timely criminal justice outcomes does the welfare response adequately manage the risks. This review would suggest that it may not.  9.13 Following the stabbing incidents, and following senior leadership meetings, a detective inspector in the Criminal Investigation Department was tasked to review four different investigations that were ongoing regarding Samuel. There were four different officers in charge of those investigations and this detective inspector became the Senior Investigating Officer with oversight of all four. They found no evidence of criminal exploitation and no obvious pattern to the offences, appearing opportunistic and sporadic. None of the investigations involved adults and appeared to be children   18 involved in territorial drug running with the additional use of knives and offensive weapons. This senior leadership oversight and approach might well be used in other situations where children are involved in criminal exploitation. This was reportedly already in place in Dorset Police through the ‘Weekly Tasking Meeting’ and this may benefit from being more multi-agency but adds yet another layer of oversight which does not appear connected to other forums. The detective inspector has reflected that as Samuel was becoming an ‘emerging problem’ more proactive interventions should have been used to address the emerging risks.  10. Use of social media and agency assessment of its significance 10.1 Samuel’s decision to share his Instagram post was the key trigger to statutory agency involvement with the children. There was other evidence that Samuel was sharing images on social media related to his interest in drug use, knives and criminal activity. These have been the subject of police review as part of evidence gathering and they have identified other individuals that Samuel has interacted with. There is no information in the child and family assessments of the significance of Samuel’s social media use.  10.2 The “Fixing Neverland’ Final Report18 published by Crest Advisory in October 2022 considers the underlying causes and drivers of serious violence. The significance of social media and its indirect driver of violence is highlighted in the report alongside its use in the recruitment of children into being exploited criminally to distribute drugs and the push factor in glamourising drugs and violence for financial gain.  10.3 It highlights that social workers are often discouraged from using social media to engage with children to avoid crossing professional boundaries but reflects that most children now live their lives through social media. It is possibly the one place that confirms the child or young person’s views, feelings, wishes and experiences. It suggests that agencies leave huge gaps in understanding of the child ‘s world by not examining the interactions expressed via social media. The report argues that children who are vulnerable are more susceptible and influenced by radicalising concepts on social media.  10.4 Whilst the report makes a series of national recommendations, there are considerations regarding local action or activity. Not commented upon in detail is the how children’s use of social media is assessed alongside other vulnerabilities. It should be included in all child and family assessments and be considered in the context of risk and need with possible interventions to address this especially at a  18 https://www.crestadvisory.com/post/report-fixing-neverland   19 preventative level. The report also proposes local campaigns to highlight the healthy and unhealthy use of social media. Lastly, it proposes that local child safeguarding practice reviews (LCSPR) should routinely review and assess the child or young person’s use of social media with technology firms required to provide access. It is not clear whether this has ever been requested as part of an LCSPR and it may be time to test this as part of learning from reviews.  Recommendation: Child and family assessments should consider and analyse the risks associated with children’s use of social media; particularly where extra-familial harm is highlighted.  10.5 The Pan Dorset Child Exploitation Risk Assessment document does ask those completing the assessment to judge using a number scale as to the child’s increased use of technology but it does not identify a specific risk factor regarding the child’s use of social media.  Recommendation: The safeguarding partnership should assure itself that children’s use of social media and the risk factors associated with it are embedded into the existing training offer.   11. Complex Safeguarding Team (CST) 11.1 At the time of the review the CST was a small team working alongside children and their allocated social workers. The social workers also held a small caseload of children who are deemed ‘high risk’. The CST workers provided targeted interventions for complex safeguarding delivering a relational and youth engagement approach to working with children with complex needs and multiple vulnerabilities. This includes children missing from home, exploited through gang association, criminality, and those suffering harm through sexual exploitation. The threshold for a referral into the service was determined using the CEST and child and family assessment. The CST has had three changes of Service Manager during the review period.   11.2 It was recorded that Service Managers in Children’s Social Care discussed the need to transfer the children’s case to the CST in November 2021 yet concluded that the CST would complete work with Samuel on criminal exploitation alongside the CFF social worker. Samuel remained at ‘moderate risk’ until the NRM confirmed ‘conclusive grounds’ that he was being criminally exploited and Samuel was then identified as being at significant risk and the case was accepted by the Police   20 IMPACT Team. There remained confusion about case allocation and accountability and the CST social worker was eventually allocated to Samuel and Shay.  11.3 The complexity of the CST service model meant that Joy’s needs continued to be met via a child in need plan and the boys under the separate process of the ETAC. Despite, the new Corporate Director in Children’s Social Care being clear that children should not be dual allocated, at the time, the children’s needs were assessed and reviewed separately. The chronology of involvement clearly indicated the impact of her sibling’s behaviour had on Joy, yet her needs and risks were not the given equal weight in the context of the boy’s behaviour. The fact that Joy’s child in need plan ended in May 2022 reinforced this position.  11.4 The CST social worker has been a consistent part of the children’s lives for a year. Their relationship-based approach enabled them to continue working with the boys, despite increasing evidence of extra-familial harm and criminal activity by both boys. Holding and managing significant risk for children can impact on individual social workers and they can feel despair at not being able to influence the situation. This level of responsibility can lay heavy on social workers and can ominously increase if the young person is the victim of violence. The level of risk held by this team is significant and it can and does have an emotional impact on the staff that work within it. There are supervision and support mechanisms in place but there was a sense that the sole responsibility for some of the children rests with one or two professionals until the situation escalates.  11.5 Decisions to escalate the children’s risks to a Legal Gateway Meeting was considered by some frontline professionals to be unhelpful and time consuming at a point of crisis. Throughout the involvement of CST, there had been engagement from Michelle and despite her challenges in managing the boy’s behaviour, there was limited substantiated evidence to suggest that they were at risk of significant harm because of her inability to safeguard them. The Legal Gateway Meeting alienated Michelle and she felt blamed for the children’s exploitation and criminal behaviour. Professional anxiety at the time of these decisions, whilst well intentioned, had the opposite effect in addressing the children’s risks and needs. 11.6 The recently published Independent Review of Children’s Social Care19 proposes a national framework for the multi-agency response to safeguarding from harm to children that originates outside the family. This may be highlighted in the refresh of Working Together to Safeguard Children due for publication in 2023 and agencies may need to plan for this possibility.  14. MacAlister J, 2022    21 11.7 The CST focus has primarily been on re-engaging the boys in education and attempts at diverting them away from exploitative relationships. Direct work was found in relation to their substance misuse and of direct work with a specific contextual safeguarding focus, which went beyond mentoring and relationship building. Other agencies made assumptions that CST were undertaking ‘intensive work’ on child exploitation, yet this work was never evaluated in ETACs or other strategic meetings. It was never clear what outcomes were intended. This reflected comments from Michelle, who relayed she was never clear what the purpose of the visits to the family home were, the interventions or what was being achieved.  11.8 Following the stabbing incident in September a concerted effort was made to move the family as part of ‘circuit breaker’ to provide safety to Samuel and his family. Joy was described as a ‘gibbering wreck’ following this incident and the police wrote to the CST in September 2022, confirming that Dorset Police could not ensure the family’s safety. Michelle remains angered by the lack of decision making on this issue. She recalls making every effort to support the plan but this was changed at the last minute and the family remained living in the community and feeling very unsafe. Although, police put in place target hardening, the fact that they could not ensure safety, was deeply worrying to Michelle and had a very negative impact on Joy. These decisions are complex in nature and do not always ensure the safety of the child or family is secured, even for a short period. 11.9 The CST capacity is unable to meet the increasingly complex needs of this group of children. The high thresholds that exist have been put in place to ensure that the children at highest risk can access this more specialist support. This small team does not have the capacity to do both preventative and specialist work. It highlights that knowledge and skills in extra-familial harm should not be confined to a small number of professionals. The current approach negates the roles and skills of other professionals who should have a role to play to effectively prevent or safeguard a young person. The ‘referral’ to a more specialist service, with the expectations that may come with it, potentially removes the responsibility and accountability of others. There is a positive professional view of the CST from other partner agencies yet the specialist nature of the team does not support wider responsibility and accountability for this cohort of children.  11.10 The role of CST was under review and proposals for re-design began from July 2022 and CST staff were consulted on proposed changes. In August 2022, the whole of the Safeguarding and Early Help directorate in Children’s Social Care was reviewed and it was agreed to reduce the number of managers in the CST. This coincided with diagnostic reviews of early help services in BCP at levels two and three of the   22 threshold criteria. Family support workers in the Targeted Support Service were tasked to undertake bespoke pieces of work including working with children where risk was associated with extra-familial harm. CST at the time were working with a very small number of children and social workers had caseloads of between two and ten children. The team was reaching a small number of children and the intention to train more family support workers to deliver extra-familial harm interventions opened the opportunity for more children to be worked with. 11.11 As of April 2023, the CST underwent a restructure which changes the remit of the team. The team is reducing its staffing numbers and children will only be referred into the team following an initial screening from the Multi-Agency Safeguarding Hub (MASH). The CST team will then complete a child and family assessment and the completion of the CEST. The team will instigate the child protection process for those reaching this threshold and will hold those children in the team if subject to child protection processes. Core groups will meet every four weeks and there will be three monthly reviews of the plan with the Service Manager to avoid drift. If the child meets the child in need threshold20, these children will be returning to the local CFF teams for intervention. The youth workers in the newly restructured CST, will work alongside social workers for those children. Whole family working remains a challenge to the CST and will be agreed on a case-by-case basis. Children of medium and low risk children will be managed via the CFF, Targeted Support and Early Help support. Implementation of this approach is currently delayed following feedback.  11.12 The changes in team leadership of the CST, the team remits, staffing and the process and systems over the period of the review may reflect some of the challenges highlighted in effectively meeting the needs and risks of this group of children. This has been recognised by the leaders in Children’s Social Care and the changes proposed are aimed at addressing these issues.  Recommendation: These practice changes to the CST and Early Help support require evaluation as part of the implementation programme.  12. Extra-familial harm versus criminal activity 12.1 The views from the professional network regarding the boys were conflicted. As both boys increased the level and seriousness of their offending, the welfare lens from some professionals was almost disregarded. The belief that children have a choice as to whether they continue to engage in criminal activity fails to recognise the factors  20 Section 17 Children Act 1989   23 that drew them into criminal behaviour in the first place, notably as victims of exploitation. Two possibly competing approaches with the same children and their family has the potential to confuse the focus of interventions to prevent future harm and provide safety. It is argued that the messages given to children in these circumstances must be professionally consistent.  12.2 The Police Safeguarding Hub reached a ‘tipping point’ with Samuel when he began targeting other children in criminality. As intelligence grew about the behaviour of Samuel, the more the team felt he was more of a ‘ringleader’ than being exploited. They describe having no clear picture of adults involved who might exploit Samuel but were proactive in developing the plan for a Criminal Behaviour Order. The team shifted their approach as information and intelligence began to suggest that Samuel was the ‘exploiter’. This team advocated strongly for Samuel and the family to be moved out of county. They described this approach as ‘putting an expensive plaster on a gaping wound’. They reflect that had interventions been considered earlier for Shay it may have had an impact on his increasingly criminal behaviour. The team believe that Shay was criminally exploited by Samuel. There were emerging indications that Shay was involved with adults who may have been exploiting him and this is subject to ongoing enquiry.  12.3 At an ETAC in July 2022, it was reported that ‘identifying perpetrators of exploitation and even getting charges to stick in relation to his offending is proving very difficult’. It was relayed that many of the investigations relating to Samuel would be dropped due to a lack of evidence or identification issues. It was relayed that the police did not want to criminalise exploited children but there was a worrying number of offences that were not deemed ‘exploitation related’ and that Samuel was unlikely to see ‘any consequences’. Concerns were raised that the youth justice service did not have role in earlier intervention. As no charges or convictions were made it limited the ETAC’s ability to put in place restrictions that could support disruption of negative peer relationships for Samuel.  12.4 The impact of police interventions to address criminal harm and risk where children are concerned requires a multi-agency approach. This requires the police to proactively involve other agencies in overt police responses to harm and threat, including police raids and an understanding of the covert activity being undertaken to assess risk and harm in the community. The police are understandably reluctant to share this covert activity and confirm that ‘intelligence training’ will address this issue for multi-agency partners.  12.5 There was some evidence to suggest that Samuel was being criminally exploited much earlier than the decision of the NRM In April 2022. The evidence included   24 agency identification of him going regularly missing, carrying weapons, using more than one mobile phone, having excessive amounts of money, being found in possession of different types of drugs, being secretive and refusing to share information about his associates, violent behaviour, possession of counterfeit money and changes in his behaviour highlighted by his mother which indicated some associated trauma with being exploited. All these risk factors suggest that Samuel was being criminally exploited. The fact that the growing police intelligence picture indicated no substantiated proof of criminal exploitation presented a practice and intervention dilemma. This may have reinforced the sense of feeling ‘stuck’ with how best to respond to their safeguarding needs alongside their significant criminal activity and which should take priority. Keeping the children in focus when making decisions about how to safeguard and support them means seeing the child or young person behind the presenting behaviours. 12.6 There was positive multi-agency working highlighted yet some of the interventions by agencies appeared in isolation of the activity of others. Interventions could have been carried out jointly and whilst this may present challenges it does reinforce to children that there is a joined up and consistent approach to their needs and risks whether it be both exploitation and consequent criminal activity.  12.7 Children impacted by criminal exploitation need to be seen as victims and safeguarded first. When they then engage in serious youth violence and significant criminal activity, this presents a practice challenge to safeguarding partners. Legal routes must be followed to address their offending behaviour and at the earliest opportunity to potentially achieve change, yet a welfare lens should always be used to understand the context behind that offending behaviour.   13. Use of the National Referral Mechanism (NRM) 13.1 Samuel’s criminal cases were delayed for long periods while waiting for the NRM decision on whether he was being exploited. The NRM ‘conclusive grounds’ decision can provide mitigation for sentencing or possibly lead to the case being discontinued and the social worker was keen for this to be before the court in Samuel’s case. The delays and uncertainty can make it harder to respond effectively to crimes arising from exploitation.  13.2 The review found some confusion and lack of awareness locally about the purpose of the NRM and how it might help. The social worker saw the NRM as positive in that it treated Samuel and Shay as victims rather than offenders and could keep them out of the criminal justice system. This approach conflicted with other professional views, who found it frustrating that the NRM decision could influence Samuel’s more overt   25 offending behaviour. Having the referral to the NRM accepted did not automatically mean that Samuel would not face criminal charges.  13.3 The Safer BCP Partnership Community Safety Partnership Plan for 22/23 has identified several priorities relevant to the findings of this review, including references to the NRM. The Annual Plan is developed from an annual strategic assessment of crime, anti-social behaviour, substance misuse and reoffending. It includes three priority areas all relevant to this review, including: ‘tackle violent crime in all its forms, keep young people and adults-at-risk safe from exploitation, including online risks and work with communities to deal with antisocial behaviour (ASB) and crime hotspots, including ASB linked to substance misuse. The plan has strategic plans and actions alongside key performance indicators.  13.4 There is no multi-agency shared record of which children have received an NRM reasonable or conclusive decision or any NRM’s currently in process.  Recommendation: One safeguarding partner in BCP needs to take sole responsibility for tracking children subject to the NRM process.  Recommendation: The local safeguarding children partnership and the community safety partnership should ensure any cross-partnership priorities are reviewed together to assess their effectiveness.   14. Managing the needs and risks of siblings  14.1 Extra familial harm has an intra-familial context. The references to Joy throughout agency intervention during the review period, suggested an increasingly anxious and traumatised child by not only the fear of what may happen to her brothers and the safety of her family and their home, but the anxiety following armed police raids, the perceptions of her peer group of her family circumstances and the gradual reality that the siblings would be in different care arrangements as the risks escalated. It is unclear as to why it felt necessary to close Joy’s case, perhaps with a sense of over optimism in relation to their own needs being effectively met. This approach gave little consideration to her own trauma. The focus on the boy’s behaviour of safeguarding agencies meant that Joy was lost in the professional line of sight and she continued to suffer as a result. It highlights the need for safeguarding agencies to increase a ‘family focused’ approach to exploitation and whilst some interventions are targeted, they are done so in the context of how this may affect the whole family. Practitioners need to be alert to the nuances of family risk and need and be more questioning of their own decisions.     26 14.2 The changes in social workers working with Joy depending on her status in the child safeguarding and welfare system did not allow for a focused relationship developing with her. The changing status of the children’s case from early help, children in need and child protection did not lead to consistency of practitioner and this was only achieved partly by the CST social worker. Changes of worker owing to agency team remits is not child centred.  Recommendation: The safeguarding partnership should assure itself that siblings of children where extra-familial harm is evidenced, are being appropriately assessed and intervention put in place to support their needs.   15. Previous Local Child Safeguarding Learning Reviews 15.1 In June 2022, the Pan Dorset Safeguarding Children Partnership published a learning review with the title “A Multi-Agency Thematic Summary: Extra Familial Harm”. This considered the sad death of Child M and made a series of recommendations. Whilst the Action Plan has been in place prior to the report’s publication, there are three areas of significance to this review which have remained unresolved and are relevant to the learning for this review. Rather than repeat these recommendations, the Action Plan from this review should include reference to the learning review published in 2022 which set timescales for completion by September 2022 and January 2023.   A. The Child Exploitation (CE) Screening Tool should be completed at all levels of intervention from early help and statutory levels of assessment when exploitation is the main risk and should form the basis of multi-agency decision-making with the family on whether a referral to the Complex Safeguarding Service is needed.  A multi-agency audit of 20-40 children at risk of CE should be completed, led by the Partnership’s QA Group. to check individual children are accessing the right service at the right time according to need and achieving the desired outcome.  The scoping of the audit should consider any barriers to completing the CE Screening tool. B. The Director of Education and Skills should consider the development of a multi-disciplinary programme to proactively support pupils at risk of exclusion, particularly where due to substance misuse and/or criminal exploitation. It should also be considered how parents/carers can co-produce policies and protocols going forward.   C. Responsibilities to be clarified between CSP/PDSCP re child exploitation.       27 16. Conclusion 16.1 Samuel, Shay, and Joy have suffered extra-familial harm and despite some resilience shown by the children, their lived experience has been one of ongoing trauma. Despite the concerted efforts of the multi-agency partners, they have been unable to reduce the harm the children have experienced. The complexity of managing children in these circumstances cannot be underestimated. It becomes increasingly more complex when those children move from being exploited to potential exploiter. It challenges the multi-agency professional network, each with their differing priorities and contexts. Children impacted by criminal exploitation and then engaging in serious violence need to be seen as victims first and safeguarded as opposed to being criminalised. This presents a practice challenge at the point at which a young person’s criminal activity reaches a threshold that requires intensive work to protect the public.  16.2 The review is advocating support to be provided at a lower threshold and more engagement with preventative work. The teams involved in assessing and intervening in child criminal exploitation and criminal activity, alongside other agencies and schools, would benefit from joining together earlier to support children at risk. There is a need to ensure that once there are indications of potential child exploitation, earlier intervention is put in place to divert children away from exploiters. The specialist knowledge in these teams needs to be shared to ensure that all agencies understand their role in safeguarding children in these circumstances. There should not be reliance on referrals to ‘specialist teams’ to support children, particularly if their thresholds only permit those at highest risk to receive services. There may be benefits in the CST and the Police Safeguarding Hub working more closely together, including possible co-location.  There are opportunities to join up the CST and Police Safeguarding Hub at the assessment stage providing better collaboration focused on the needs and risks of children and interventions that are then jointly run.  16.3 This area of practice is challenging and tireless work, yet the purpose of interventions and subsequent outcomes for children need to be clearly defined.  