Sexual abuse of a 15-year-old adolescent by her older brother in 2015. Child H1 had made a previous disclosure at age 12. Child H1 lived with her parents and Sibling 1 and Sibling 2. She had a history of temporary school exclusions, and reported being bullied at school; episodes of missing from home; self harm and suicidal ideation; non-attendance at CAMHS; and reports to the police about her behaviour in the community. In 2015, mother informed children's services that H1 had disclosed sexual abuse by Sibling 1 18 months earlier. Section 47 enquiries were made, and Sibling 1 was accommodated, but later moved back home. Learning identified includes: when Early Help is delivered without holistic access to information and there is no plan with agreed outcomes, it is a challenge to monitor the impact of the intervention; it is important that efforts are made to understand why young people are engaged in behaviour described as "risk taking" and "challenging"; it is essential that practitioners recognise cultural influences on children and families from diverse communities. Identifies good practice around use of multi-agency resources and information sharing between the nurse practitioner and the school nurse. Recommendations include: to audit and monitor how the voices of children and young people inform assessments and interventions.
      
    Serious Case Review No:  2018/C7028  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1 Child H1 SCR FINAL JULY 2017     Local Safeguarding Children Board  Serious Case Review  - Child H1 (July 2017)   This Serious Case Review was commissioned by the Independent Chair of the Local Safeguarding Children Board (LSCB) in July 2016 following a recommendation by the LSCB Case Review Sub Group. The circumstances regarding the serious harm of a child with concern about the way in which agencies worked together met the criteria for a Serious Case Review in accordance with Working Together to Safeguard Children (2015)1. Incident which resulted in the Serious Case Review In June 2015 Child H1 disclosed that she had been sexually assaulted by Young Person 1 (YP1)2.  H1 had made a previous disclosure that she had been sexually abused by her older brother Sibling 1, H1 was 12 years old at the time and Sibling 1 was 14 years old.  The family received support from Early Help Services and H1 was subject to a Child Protection Plan and subsequently an Interim Care Order was granted by the Court. At the time of the Review H1 had returned home to live with her parents. The Family  The family comprised of H1, Mother, Father, Sibling 1 aged 14 years and Sibling 23 aged 13 years4. Sibling 1 became a looked after child following the disclosure that he had sexual abused H1 and has lived in a foster placement apart from a brief period when he returned to the family home. H1, Sibling 2 Mother and Father live in the family home. The family identify as belonging to an ethnic minority and lived mainly in Local Authority 1 during the timeline of this Review.   Legal Context .           Regulation 5 of the Local Safeguarding Children Board (LSCB) Regulations 2006 sets out the functions for LSCB’s. This includes the requirement for LSCB’s to undertake Reviews of serious cases in specified circumstances. Regulation 5 (1) (e) and (2) set out a LSCB's function in relation                                                            1 Working Together to Safeguard Children (HM Government, 2015) 2 H1 was aged 12 years 9 months and YP 1 was 16 years 9 months at the time  3 Sibling 2 has a diagnosis of Dyspraxia and learning difficulties 4 Age of siblings at the time H1 disclosed the sexual abuse by Sibling 1 2 Child H1 SCR FINAL JULY 2017  to Serious Case Reviews, namely:  5. (1) (e) undertaking Reviews of serious cases and advising the authority and their Board partners on lessons to be learned.       (2) For the purposes of paragraph (1) (e) a serious case is one where:            (a) Abuse or neglect of a child is known or suspected; and      (b) Either (i) the child has died; or (ii) the child has been 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.  Methodology An intensive multi-agency Child Practice Review (CPR)5  was identified as the most appropriate and proportionate model to conduct the Review. The CPR process supports practitioners to reflect on cases in an informed way and the Review report focuses on learning and practice improvement. The CPR methodology provides a learning tool for Local Safeguarding Children’s Boards to use when it is important to consider how agencies worked together. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the Review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These will be included in the final report of the Review or in an action plan as appropriate. This Review has been conducted in accordance with the principles for Serious Case Reviews set out in Working Together (2015), which:  Recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did  Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight  Is transparent about the way data is collected and analysed   Makes use of relevant research and case evidence to inform the findings   Working Together (2015) states that Serious Case Reviews should  Identify improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice  Clearly identify what lessons are to be learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result.                                                            5 The CPR is also referred to as the ‘Welsh Model’ for more information see; Protecting Children in Wales Guidance for Arrangements for Multi-Agency Child Practice Reviews (Welsh Government, 2012). http://www.sewsc.org.uk/fileadmin/sewsc/documents/Published_SCR_CPR/Child_Practice_Review_ Guidance_-_Welsh_Government.pdf   3 Child H1 SCR FINAL JULY 2017  The Review Process A Review Panel comprising of managers from relevant agencies was established in accordance with the guidance. The panel was chaired by a senior manager from Children’s Services. Dr Catherine Connor, an independent Lead Reviewer, was commissioned to work with the panel and to author the final report. A timeline of significant events with a brief analysis of agency involvement was provided by each organisation. Agency timelines were merged to produce an interagency timeline of key events which was reviewed and analysed by panel members with reference to the agreed Terms of Reference for this review. The Review Panel sought to identify factors which influenced the actions of practitioners and agencies and further understanding about how multi-agency systems impacted on this case.  Good practice was recognised and opportunities for inter and intra agency learning and practice improvement were highlighted. Fourteen Practitioners who had direct involvement with H1 and the family attended a Learning Event to further understanding of the factors which influenced decision making and practice during the timeframe for this Review. Practitioners said that they appreciated the opportunity to reflect on this case and identified opportunities to change and improve practice. The views of Practitioners will be presented throughout the Review.  Practitioners attended a second meeting with the Lead Reviewer to comment on a draft report of the Review findings and initial analysis. Family involvement The Lead Reviewer and Chair appreciated the willingness of H1, Mother and Father to participate in this Review6. The focus of discussions with the family was to understand how H1, Mother and Father had experienced the intervention and support provided by agencies and whether, from their perspective, there had been missed opportunities to provide support. It was evident that H1, Mother and Father were very upset and angry about intervention by Children’s Social Care (CSC) which had resulted in H1 being subject to an Interim Care Order and removed from the family home. Although H1 had returned to live at home at the time of the meeting with the Lead Reviewer and Chair, it was a challenge to focus the discussion on the involvement of agencies and practitioners during the provision of Early Help support and the implementation of Child Protection processes. H1 was very clear about the fact that she had been bullied at School and did not think this had been taken seriously by staff. H1 said that she wanted to attend full time education and she was very dissatisfied and unhappy with the one hour per day timetable that was provided whilst at School 3. H1 spoke highly of the Child Sexual Exploitation (CSE) Team Practitioner and it was evident that this relationship was valued by H1.  The views of H1, Mother and Father will be reflected throughout this Review.                                                            6 H1 met with the Lead Reviewer and Chair separately from Mother and Father. 4 Child H1 SCR FINAL JULY 2017  Review timeframe The timeline agreed by the Review Panel for consideration was from August 2013, the beginning of support by Early Help Services, until April 2016 when H1 was made subject to an Interim Care Order. The timeline was divided into three periods: August 2013 – March 2015  Initial referral to the Local Authority Families Team until H1 disclosed sexual abuse by Sibling 1 April 2015 – September 2015 Multi-agency response to the disclosure by H1 that she was sexually abused by Sibling 1 until the Initial Child Protection Conference (ICPC) October 2015 – April 2016 Provision of multi-agency support and intervention to implement the Child Protection Plan until H1 was subject to an Interim Care Order  Use of a systems perspective throughout the analysis will provide an opportunity to understand the complex sequence of events and explore the factors which influenced the way in which agencies worked together to safeguard H1.  Circumstances resulting in the Review Key Period 1 - August 2013 - March 2015 Initial referral to the Local Authority Families Team until H1 disclosed sexual abuse by Sibling 1 During this period H1 was on the roll of four schools (two primary and two secondary) and received three five day exclusions and a further one day exclusion. H1 was also reported missing from home on two occasions and was admitted to hospital overnight for observation and assessment on two occasions due to self-harm and suicidal ideation. Mother consented to work with the Local Authority Families Team in August 20137. Two months later Sibling 1 was arrested for Breach of the Peace following what was described in the Police report as an unprovoked attack on Sibling 2.  H1 was 11 years at the time and witnessed the incident. The Police made a referral to CSC and information was shared with Health. In October 2013 there were emerging concerns about the inappropriate behaviour and language of H1 towards other children and unauthorised absence at Primary School 1. In November 2013                                                            7 The family were identified for support as part of a data exercise based on poor school attendance linked to the Troubled Families Initiative. The Families Team are part of Children’s Services in Local Authority 1, but include practitioners from other agencies, and provide interventions to children and families under a number of initiatives, both at early help and statutory levels of intervention. 5 Child H1 SCR FINAL JULY 2017  the Families Team Practitioner recorded that Mother had a black eye, issues with people in her community, was fearful for her family and planned to move to Local Authority 28. The Families Team Practitioner provided Mother with contact numbers to obtain advice and support. Efforts were made by School 1 to locate H19 during a period of absence in January 2014. Confirmation was received that H1 was attending School 2 in Local Authority 2 and records were transferred. Two months after starting at School 2 H1 had 15 unauthorised absences and it was recorded that H1 found it difficult to settle and that other pupils made reference to her ethnicity. H1 was readmitted to School 1 in March 2014 following a return to Local Authority 1.  H1 received support from the Behaviour Team and a mentor at School 1. Mother informed school that she was considering home education however H1 told teachers that she wanted to remain at School 1. The Pupil Welfare Officer (PWO) informed CSC that the family had been known to Local Authority 2 in 2013.  In March 2014 Mother informed the Police and CSC about serious threats of a sexual nature allegedly made by a friend of Sibling 1 towards Mother and H1. It was decided by CSC that additional needs and concerns could be addressed by the Families Team. In May 2014 Father advised the PWO that unauthorised absences were due to Mother taking H1 out of the area. It was recorded that advice and guidance were provided and the case was closed to the Pupil Welfare Service. A member of the public informed the Police that Sibling 1 had made threats to harm another young person. No further action was taken at the request of the child’s mother who stated that they were frightened of repercussions from the family of H1. This information was shared with the Families Team practitioner. In May 2014 Mother informed School 1 that she was waiting for an appointment with Child and Adolescent Mental Health Services (CAMHS) however Mother and Father did not respond to a letter to arrange an initial consultation and H1 was subsequently discharged. In June 2014 following concerns expressed by Mother that H1 was associating with older boys the Families Team practitioner completed one to one work with H1 to explore sexual health and healthy relationships. H1 was excluded from school for the first time at 11 years of age in July 2014. The exclusion letter from School 1 to parents noted that; the attitude of H1 towards staff has become completely unacceptable, particularly in recent weeks. The first multi-agency meeting took place the day after the school exclusion. This was recorded as a Troubled Families Review meeting and was attended by the Families Team practitioner and colleagues from the Pupil Referral Unit. School 1 were not aware of the meeting. In August 2014 the Nurse Practitioner (at the GP Practice) made a referral for H1 to CSC and was                                                            8 This represented a move of well over 100 miles 9 School 1 made repeated phone calls to the family and other schools in an attempt to locate H1 6 Child H1 SCR FINAL JULY 2017  advised by letter from the Duty Team that needs would be met by the Troubled Families Service10. At the same time Mother had informed CSC that Sibling 1 continued to be violent towards Sibling 2 and was refusing to attend school.  It was recorded that no further action was required as the case was open to the Families Team. In September 2014 H1 transitioned to secondary education and attended School 3. During the first week H1 was excluded for what was recorded as persistent disruptive behaviour. On the same day Mother received a fine following prosecution due to the persistent absence of Sibling 1 from school.  Mother reported H1 as missing from home for the first time in September 2014 this was allegedly due to being grounded by parents following the exclusion from School 3. H1 returned home after a couple of hours, a safe and well check was conducted by the Police and a Multi-Agency Safeguarding Hub (MASH) referral was submitted 11 . Mother informed the Families Team practitioner that Father had found H1 with a group of young males however this was denied by H1. Mother was advised by the Families Team practitioner to contact the Police should H1 go missing from home again. In October 2014 H1 was admitted to hospital overnight after presenting with deliberate self-harm and suicidal ideation. Mother and Father informed staff at the hospital that they were concerned that they could not keep H1 safe at home and they planned to take her to stay with her Aunt in a different Local Authority area12 whilst they attended to other family issues. A discharge summary in GP records details the information that was provided to parents about available support and action to take to keep H1 safe. H1 received a further exclusion from School 3 in November 2014 for what was recorded as a violent assault on another pupil. A multi-agency meeting was held due to concerns about the poor school attendance of Sibling 1, Sibling 2 and H1.  Following a managed move to School 4 H1 started a trial period in December 2014, however H1 returned to School 3 in February 2015. H1 received one hour of education each day on a one-to-one basis in the library at School 3. It was recorded that Mother and H1 were very unhappy with this provision and both stressed their disagreement with the very limited provision of education in discussion with the Lead Reviewer and Chair for this Review. During this time period the Nurse Practitioner worked proactively to share information and raise concerns with other agencies 13 and parents about the non-attendance of H1 at CAMHS. In January 2015 Mother was given a food voucher after informing the Families Team practitioner                                                            10 Troubled Families is a national programme of targeted intervention for families with multiple problems and delivered by the Families Team in local authority 1 11 The MASH in Local Authority 1 only accepts Police referrals and is the means by which information about Police concerns can be shared with key partners (including Children’s Services) and multi-agency information collated to enable more informed decision making. Referrals are used by Police Officers to report children or adults with vulnerabilities and graded as high, medium or standard risk. This grading is used to prioritise responses. 12 This was the neighbouring local authority and the aunt’s address was around 10 miles from the family home. 13 The Nurse Practitioner liaised with the School Nurse, Families Team Practitioner, School 1 and 3, CSC, Pupil Welfare Service and CAMHS 7 Child H1 SCR FINAL JULY 2017  that the family had no food.  A case note in CSC records states that H1 was reported missing from home for a second time however there is no evidence that this was reported to the police. Records indicate that during a home visit in February 2015 H1 disclosed to the Families Team worker that she had been self-harming due to bullying at school. One week later H1 was admitted to the adolescent unit for assessment after presenting at hospital for the second time with low mood and evidence of self-harm. H1 informed medical staff that she was having problems with pupils and teachers at school.  H1 received a further exclusion from School 3 in March 2015 following a physical assault on another pupil. Two days later H1 disclosed that she had been sexually abused by Sibling1. Key Period 2 March 2015 – October 2015 Multi-agency response to the disclosure by H1 that she was sexually abused by Sibling 1 until the initial Child Protection Conference In March 2015 Mother informed CSC that H1 disclosed14 that she had been sexually abused 18 months previously by Sibling 1. Following a Strategy Discussion15 between the Police Public Protection Unit and CSC a joint home visit was made during which H1 repeated the disclosure. Immediate safeguarding needs were addressed, Mother and Sibling 1 left the family home and H1 and Sibling 2 remained with Father whilst further enquiries were made.  A High Risk MASH referral was submitted and a criminal investigation commenced. Mother and Aunt refused to support the investigation, declined to provide statements and Mother would not provide permission for H1 to take part in a video interview16. Following Section 4717 enquiries H1 and Sibling 2 were closed to CSC18 and Sibling 1 was accommodated19 as Mother and Father had made serious threats to harm him.  In April 2015 the Families Team Practitioner informed the Social Worker for Sibling 1 that he had been seen at the home address. At a multi-agency meeting Professionals20 shared concerns that H1 was not being safeguarded as Sibling 1 was known to be going to the family home when H1 was present.  H1 attended hospital following a physical assault by an 18 year old. It was recorded that H1 informed paramedics that she was being bullied at school and that she wished she was dead. CSC records indicated that no further action was taken as the case was said to be a                                                            14 H1 made the disclosure to Aunt 15 A Strategy Discussion is held when a child has suffered or is likely to suffer Significant Harm. The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry. 16 Achieving Best Evidence Interview (ABE) to progress a joint child protection investigation 17 Under Section 47 of the Children Act 1989, if there are reasonable grounds to suspect that a child is suffering or is likely to suffer Significant Harm, a Section 47 Enquiry is initiated. This is to enable the local authority to decide whether they need to take any further action to safeguard and promote the child’s welfare. 18 Closure summary stated that Families Team would provide parenting support and H1 would be referred to CAMHS 19 Under section 20 of the Children Act 1989 which allows a child to be accommodated by the local authority, but it must be agreed to by those with parental responsibility. 20 School staff, the PWO and Families Team practitioner 8 Child H1 SCR FINAL JULY 2017  criminal matter. H1 spoke to the Nurse Practitioner from the GP Practice about feeling unsafe at home21  and with the consent of H1 the Nurse Practitioner shared this information with the School Nurse to provide an opportunity for H1 to receive support in school. H1 told the Nurse Practitioner that she wanted to attend school. At the same time Mother informed the Nurse Practitioner that H1 was too upset to attend school and requested a sick note. The Nurse Practitioner noted the discrepancy between the views of Mother and H1 regarding school.   In April 2015 H1 received a further school exclusion from School 322 Mother did not attend a reintegration meeting and informed School  3 that H1 was having flashbacks, not sleeping and was afraid to leave the house. However H1 was not at home when the PWO visited to offer support and did not attend school until September.  The School Nurse informed the Nurse Practitioner from The GP Practice that H1 had been excluded from school following the physical assault of a peer, the Nurse Practitioner recorded23 that it was important to understand the cause of H1’s behaviour. In addition the School Nurse advised that Mother had continued to state that H1 was too distressed to attend school and the Nurse Practitioner recorded a concern that H1 was being intentionally socially isolated. In May 2015 Father attended hospital following an overdose. Father was discharged from the Primary/Intermediate Care Mental Health Team (PIMHT) in June due to lack of engagement. In June 2015 H1 made a second disclosure24 of sexual assault by YP1. H1 also disclosed that she had sexual intercourse when 10 years old with YP 2, now aged 15 years. A MASH referral graded as high risk was submitted and information was therefore shared with other agencies. A Strategy Discussion took place between a Police representative from the multi-agency CSE team25 and a manager from CSC. It was agreed that a joint Section 47 enquiry with completion of a Child and Family Assessment (CAFA) was required. Home tuition was in place at this time, H1 had not been in school since March 2015 and attendance was 35%. Following this second disclosure the Families Team practitioner made a referral to CSC. H1 took part in a Police interview which resulted in the arrest of YP 1 and also the arrest of Sibling 1 in July 2015. Sibling 1 was released on Police Bail for an AIM26 assessment to be carried out by the Youth Offending Service with conditions not to communicate with H1 or attend the family home.                                                             21 H1 said that the doors were always unlocked and Sibling 1 was allowed freely into the house. 22 For threatening behaviour and verbal abuse 23 Recorded within GP  Medical Notes 24 H1 disclosed to Aunt, Mother was informed and reported the disclosure to the Police 25 The CSE Team in Local Authority 1 consists of CSC, Police, Health and Education practitioners. The focus of work is to safeguard vulnerable children and young people under the age of 18 who are sexually exploited and to identify, target and prosecute associated offenders 26 In accordance with the LSCB Harmful Sexual Behaviour policy 9 Child H1 SCR FINAL JULY 2017  H1 attended the local sexual health service in July 2015 accompanied by the Families Team practitioner. Shortly afterwards a joint home visit27 was made by the Families Team practitioner and the CSE team social worker who advised Mother that she would be undertaking an assessment. Mother shared concerns about H1 contacting males by phone from her bedroom and said that H1 had been returned by the police at 2.30 one morning as she was walking the streets. It was recorded by the CSE team social worker that concerns were substantiated but H1 was not judged to be at risk of significant harm or at risk of Child Sexual Exploitation and a Child in Need plan was proposed. A Child and Family Assessment was not completed.  Less than a week following the conclusion of the Section 47 enquiries H1 was reported missing from home by Mother and found two days later by police in London. A Strategy meeting took place to discuss the missing from home episode and following a further Section 47 Enquiry it was decided that the case met the criteria for an Initial Child Protection Conference. In the course of Section 47 Enquiries H1 was interviewed28 about pictures of a sexual nature that had been found on her laptop. H1 insisted that she had taken the pictures herself however there were concerns about H1 being vulnerable to exploitation.  Mother informed the social worker for Sibling 1 that prior to running away H1 was in the company of adult males and she was not sure how to keep H1 safe at home. Mother requested that H1 was taken into care and stated that she overemphasised what had happened between her and Sibling 1. It was recorded in a Case Note by CSC that Mother was advised that she had a legal duty as parent to safeguard H1 and a multi-agency meeting would be arranged to identify support and intervention. During a home visit by CSE team social worker and health practitioner H1 was seen alone and with parents. H1 requested to be taken into care and disclosed physical abuse by Mother but did not want to make a statement to the police. H1 also reported that Father had responded inappropriately when H1 was threatening to self-harm. H1 also told the Families Team  practitioner on a separate home visit recorded to have taken place on the same day that she was unhappy at home, scared of things kicking off and made threats that she would run away.  An Initial Child Protection Conference took place in September 2015 and H1 was made subject to a Child Protection Plan under the category emotional abuse with a secondary category of sexual abuse and Sibling 2 was subject to a Child Protection Plan under the category of emotional abuse. Key Period 3 October 2015 – April 2016  Provision of multi-agency support and intervention to implement the Child Protection Plan until H1 was subject to an Interim Care Order  In October 2015 Sibling 1 received a Youth Caution for the offence of sexual abuse of H1. It was noted in the record of a telephone discussion between the police and Social Worker for Sibling 1                                                            27 Part of the Section 47 Enquiries 28 By the Police and CSE team social worker 10 Child H1 SCR FINAL JULY 2017  that a written agreement would be put in place between CSC, Mother and Father to ensure that H1 and Sibling 1 were not left alone together. In a separate discussion between the Police and CSC on the same day it was recorded that Mother planned to move Sibling 1 back into the family home and a Child and Family Assessment was required to ascertain the risk that Sibling 1 posed to H1.  H1 received support and advice with contraception during this period however Mother was not in agreement with this. The case was closed to the Families Team in October 2015 as Mother was very unhappy with the report submitted by the Families Team practitioner for the ICPC and refused to work with her.  There were ongoing concerns regarding school attendance, H1 was excluded from School 3 due to an alleged physical assault on a member of staff.  Mother refused to send H1 to school for a reduced timetable and H1 requested a return to mainstream schooling. Reports were submitted to the Police about the behaviour of H1 in the community which included a disability hate incident. It was recorded in minutes of a Core Group that the escalation in the behaviour of H1 was linked to the return home of Sibling 1. This view was shared by Practitioners who attended the Learning Event.  H1 was initially discussed at a MACSE29 meeting in October 2015, information was shared, current risks discussed and actions agreed. H1 was discussed regularly at MACSE meetings during the time considered by this Review, not all discussions were recorded. At a meeting in November 2015 between Mother and the social workers for Sibling 1 and H1 Mother self-reported that she was managing the risks by moving the bedrooms apart and making sure that H1 and Sibling 1 were not left alone together.  It was recorded in the multi-agency chronology that there had been no progress with the CP plan that had been in place for two months.  At the Review Child Protection Conference in November 2015  Sibling 2 was stepped down from a Child Protection Plan and H1 remained subject to a plan under the category of emotional abuse as it was thought that she was no longer at risk of sexual abuse/exploitation. In December 2015 the social worker for Sibling 1 became the allocated social worker for H1.   H1 was reported as missing from home in January 2016 and was located by Police at a friend’s address. A high risk MASH referral was submitted as H1 was considered vulnerable to CSE and this information was shared between CSC, Health and School 3. At a Core Group attended by Mother and Father in January 2016 professionals expressed concern about lack of case management by the local authority. Further disagreement between professionals was noted in the minutes of a Core Group in February 2016.  At this time H1 was said to be living between her parents and aunt as she struggled with boundaries being put in place at home. Information was received from the CSE team practitioner about the use of social media which risked increasing the vulnerability of H1 and Mother repeated                                                            29 Multi-Agency Child Sexual Exploitation (MACSE) meetings are a forum in which practitioners review and co-ordinate their response to high risk victims, offenders and locations.  11 Child H1 SCR FINAL JULY 2017  that she was worried about H1 having contact with older males.    H1 was admitted to hospital on two occasions in February 2016 following incidents of self-harm and auditory hallucinations. A high risk MASH report was submitted as there were concerns that the mental health of H1 had deteriorated. Information was shared with CSC, School 3, and Health. H1 absconded from hospital and refused to return. H1 was not supported by Parents to attend a follow up CAMHS appointment following discharge from hospital. A Practitioner from the CSE team visited H1 to discuss the recent hospital admission. Mother continued to disagree that H1 should receive any contraception although H1 had requested a service. Mother had an argument with H1 about the provision of contraception and was subsequently admitted to hospital following an overdose. H1 was said to have smashed up her room and Mother discharged herself from hospital the following day.  H1 ran away from home with a knife in March 2016 and Mother alleged that she had been allowing boys into her room at night. H1 told the police about anxieties regarding the living situation at home and said that she was having flashbacks of the abuse by Sibling 1 and said that the relationship with her mother was very difficult. H1 said that she would continue to run away from home.  At the MACSE meeting in March 2016 it was recorded that a CSE team Police officer and social worker would liaise to progress to a Legal Planning meeting30 due to escalating risk and no change in circumstances for H1.  H1 was reported as missing from home at the beginning of April 2016 and some weeks later was admitted to hospital overnight having taken an overdose with intent to self-harm. H1 was arrested at the hospital for a public order offence. A telephone strategy discussion took place to consider a Police Protection Order if H1 was reported missing before a suitable placement could be sourced. An Interim Care Order was granted by the court in April 2016. ANALYSIS: Practice & Organisational Issues Identified                                                                    Four thematic areas emerged during this Review and the analysis focussed on key practice issues within each area identified to maximise learning for the Local Safeguarding Children Board.    The Family; voice of the child, parenting capacity   Early Help; early intervention and support , application of thresholds  Multi-Agency Work; Information sharing, strategy discussions, Section 47 Enquiries and  assessment, child protection processes, Missing from Home, School attendance and escalation of concerns                                                            30 A Legal Planning Meeting is held to discuss the way forward in a particular case, where an application for a legal order may be required. 12 Child H1 SCR FINAL JULY 2017   Cultural influence The Family Voice of the child H1 spoke to different professionals during the timeframe for this review31. H1 told the Families Team practitioner and hospital staff about bullying at school and problems with teachers. H1 said that she wanted to attend full time education however frequent exclusions and changes of school made this difficult.  As episodes of self-harm and missing from home incidents increased the heightened emotional distress of H1 was evident and H1 told hospital staff that she self-harmed because she couldn’t cope and she made disclosures to practitioners about wanting to die. H1 presented at hospital with auditory and visual hallucinations which H1 said had been triggered by visits of Sibling 1 to the family home32. It was not evident how the views of H1 were assessed or shared and there was little evidence that the voice of H1 had any influence on the provision of intervention and support. H1 told the Lead Reviewer and Chair that she put on an act of being ‘hard faced’ to protect herself and that she felt judged by people because of past behaviour. H1 said that she did not trust anyone and was trying to forget the things that had happened in the past. There was little evidence of a multi-agency approach to consider the holistic needs of H1 and the family and limited consideration was given to develop a deeper understanding of how past experiences specifically the sexual assault by YP1 and sexual abuse by Sibling 1 may have impacted on H1. There has been extensive research on the impact of sexual abuse on children some of which has been summarised by the NSPCC.33  Sexual assault has immediate and long-term consequences that can be devastating for the physical, emotional and relational health of the victim (Bloom34). The emotional distress of H1 as evidenced by incidents of self-harm, episodes of missing from home and other risk taking behaviour of increasing seriousness was addressed with limited effectiveness by agencies. The behaviour of children can be a clear indicator of their emotional state and on occasions H1 presented as very needy at School 1 and School 3. Whilst efforts were made to support H1 at school these focussed on the management of behaviour. Efforts to support H1 by the Families Team and Schools 1 and 3 were not coordinated and as school exclusions continued and risk taking behaviour escalated it was evident that interventions had limited impact and were not effective.                                                            31 The views of H1 was recorded by the Nurse Practitioner, CAMHS, CSC and Families Team practitioners 32 Practitioners within CSC, Early Intervention, Police, PWO, CAMHS, School and the GP were all aware at some time during this Review that Sibling 1 visited the family whilst H1 was there following the disclosure of sexual abuse. 33 www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual-abuse/signs-symptoms-effects/ 34 Understanding the Impact of Sexual Assault: The nature of Traumatic Experiences. Bloom, S. from Sexual Assault: Victimization across the Lifespan: edited by A. Giardino, E. Datner, and J. Asher. GW Medical Publishing, Maryland Heights, Missouri, 2003 (PP. 405‐432) 13 Child H1 SCR FINAL JULY 2017  There appeared to be a lack of professional curiosity within all agencies to understand the cause of H1’s behaviour and this was not explored in a systematic way that addressed the influences of school, peers and family on H1. In the absence of an effective Early Help assessment it is not possible to state with confidence what H1 was attempting to communicate by her behaviour. Learning points from previous SCRs have highlighted the importance of recognising behaviour as a means of communication and the implications of doing so for practice. (Ofsted (2011) p1835, Sidebotham P. Brandon M. (2016) p11836). Although the wishes and feelings of H1 had been shared directly with practitioners these were not reflected consistently in records or considered within assessments and issues were frequently reported from the perspective of Mother. Professionals did not share a clear understanding of H1’s wishes and feelings and there were missed opportunities to respond constructively in a way that validated the views of H1 and may have reduced the distress experienced.  Parenting Capacity Practitioners had a limited understanding of the capacity of Mother and Father to support H1 which contributed to an over-optimistic view of the ability of parents to appreciate risk and recognise the necessity to safeguard H1. Omission to complete a parenting assessment was acknowledged by the Review Panel and Practitioners at the Learning Event as a significant oversight and missed opportunity to learn about how Mother and Father parented H1, Sibling 1 and Sibling 2.  Mother and Father both stressed in discussion with the Lead Reviewer and Chair that they would ‘do anything’ to support H1 and said that they had been ‘crying out for help’ to assist with the difficulties that they had experienced with all the children. These comments by Mother and Father were inconsistent with reports that H1 had not been supported to attend CAMHS appointments and on occasion Mother refused to support the attendance of H1 at school and actively encouraged H1 to remain at home. In addition Mother and Father37 refused to cooperate with CSC at times.  Police were unable to interview H1 following the disclosure about sexual abuse by Sibling 1 as Mother refused to give permission and neither she nor Aunt would cooperate with Police enquiries. There was a view expressed by some professionals at the learning event that H1 appeared to have been blamed at times for making the disclosure and causing trouble for Sibling 1, this appeared to be supported by a record within CSC which noted that Mother informed the Social Worker that she had over emphasised the incident that occurred between H1 and Sibling 1. There was no evidence that consideration was given to the impact of this response on the wellbeing and safety of H1. In October 2015 Mother informed the Police that Sibling 1 would be returning home following the                                                             35  The voice of the child: learning lessons from serious case reviews Ofsted 2011  36  Sidebotham P., Brandon M. et al Pathways to harm, pathways to protection: a triennial analysis of serious case reviews   2011- 2014 London: Department for Education 2016 37  Father refused to allow entry or discuss concerns with a social worker on one occasion when Mother and Children were not present 14 Child H1 SCR FINAL JULY 2017  withdrawal of Bail conditions.  In discussion with the Lead Reviewer and Chair, Mother said that she had been asked to take Sibling 1 home and she felt backed into a corner to agree, however there was no evidence within case notes or minutes of meetings to support this view.  At the Learning Event Practitioners stated that Mother had undermined the placement of Sibling 1 whilst in foster care38. Whilst practitioners stated that they were aware of Mother’s actions to interrupt the stability of placement for Sibling 1 this knowledge did not inform assessments or influence the intervention and support that was offered to the family. In the absence of a comprehensive parenting assessment there was limited understanding of the factors which influenced the response of Parents to specific incidents39. There were concerns about Mother and Father not acting in the best interests of H1 on occasions, however the reasons for this were not explored and no effective challenge was made. It was acknowledged by the Review Panel, Practitioners at the Learning Event and detailed in agency records that the response of Mother and Father may have been influenced by their particular culture. The influence of ethnicity and culture on intervention provided is discussed later within this analysis. Sibling 1 was accommodated for his own safety due to the physical threats made against him by Mother and Father. Recording of Section 47 Enquiries in March 2015 noted that there were clear concerns relating to the disproportionate response of parents to the behaviour of Sibling 1. However, there was no evidence that this response was explored with Parents and a further opportunity to gain insight into their understanding and parenting capacity was not taken.  At the Learning Event and Review Panel meetings professionals stated that there was a combination of factors that contributed to this response. Practitioners described the presentation of Mother and Father as very forceful and it is possible that staff were intimidated. There was an over-optimistic view within agencies, unsupported by evidence, that parents were able to protect H1.  Whilst Father had periods of absence from the family home there were times when he was active and influential in the care of the children particularly with regard to school attendance.  Minutes of a Core Group in September 2015 noted that “Father should be approached to discuss the issue of him becoming actively involved in decisions regarding H1”. In meeting with the Lead Reviewer and Chair it was evident that Father had at times been actively involved and influential in the provision of care and support for H1. There was limited effort by professionals however to engage Father consistently and the records of all agencies focussed on interaction with Mother.  A summary of learning from serious case reviews by the NSPCC40 highlighted the important role that men play in the lives of children. Whilst the necessity of working proactively to involve Father was recognised as a need this was not reflected in the support and intervention provided. Limited engagement with fathers is a well-rehearsed theme within Serious Case Reviews                                                            38 Sibling 1 was said to have made significant progress whilst in foster care 39 Disclosures by H1 of sexual abuse by Sibling 1 and incidents when H1 was excluded from school, self-harmed and went missing from home. 40 Hidden men: learning from case reviews , NSPCC  2015 15 Child H1 SCR FINAL JULY 2017  nationally. Despite recognition of the benefits of father inclusive health and family services, services are still heavily weighted in favour of mothers, and appear slow to change 41. The influence of the family’s culture on the involvement of Father will be addressed later in this analysis.  The parental relationship was not assessed although there were indicators of family arguments42 and at the Learning Event Practitioners stated that Mother had alleged that Father did not support with the children.  The early help assessment noted that Mother initially reported that she and Father had separated and then resumed their relationship in 2015. In discussion with the Lead Reviewer and Chair there was no reference to difficulties within their relationship and Mother and Father presented as united in the care of H1. Mother said that Father was fully supportive and gave examples when he had been physically active in seeking the whereabouts of H1 when she was missing from home. Mother and Father experienced challenges with their own emotional wellbeing and both were hospitalised overnight on separate occasions during the timeline considered for this Review43. The impact of parental mental health on H1, Sibling 1, and Sibling 2 was not considered effectively although it was noted in the early help assessment that “Mother’s mental health does impact on the children, Mother has a lack of understanding around the self-harming of H1 and rules and boundaries are inconsistent”.  There is extensive research evidence that demonstrates the impact of parental mental health problems on children. A Social Care Institute for Excellence guide to parental mental health and child welfare (SCIE 2011) 44 highlights key recommendations for practice which include:  assessment of the whole family  effective planning to meet the individual needs of each family member.  As evidenced within this Review the process of assessment was not adequate, planning was not effective and the needs of H1 and other family members were not holistically addressed. The need to improve the quality of parenting assessments was identified by an internal review undertaken by Children’s Services in early 2017.  The parenting assessment template is under review and training for Practitioners has been planned.                                                               41 http://www.fatherhoodinstitute.org/wp-content/uploads/2014/10/Burdett-Report-Final-Version-June-18-2014.pdf  42 The records of Sibling 1 and Sibling 2 were not reviewed in detail, however at the Learning Event Practitioners shared information about historical parental conflict and concerns of Mother that Sibling 1 was behaving like his father. Parental conflict was not identified as a significant concern during the timeline considered for this Review.  43 Father took an overdose at the time H1 made the second allegation of sexual abuse and Mother took an overdose following an argument about H1 receiving a contraceptive implant.     44 Think child, think parent, think family: a guide to parental mental health and child welfare SCIE 2011 p.6 16 Child H1 SCR FINAL JULY 2017  Early Help Services Early Intervention and Support The early help framework in place in Local Authority 1 during the review timeframe provided a continuous assessment tool (form) to assess and plan early help interventions that also served as the referral form for higher tier interventions, if necessary. The framework emphasised the expectation that local agencies should work together to provide early help assessments and interventions for children and families. The Families Team provides intensive family support and intervention in homes and supports the delivery of early help in Local Authority 1. It is important to note that whilst Families Team had significant involvement with the family of H1, the delivery of early help remains the responsibility of all agencies involved with children, young people and their families.  Initial support and intervention by the Families Team focussed on improving school attendance and preventing anti-social behaviour. It quickly became apparent that issues were more extensive and complex and included the violent behaviour of Sibling 1, additional needs of Sibling 2 and the emotional wellbeing and increasingly challenging behaviour of H1. There was little evidence that consideration was given to these additional areas of concern as they emerged specifically the vulnerability of a child with disabilities known to be at risk of violence from a sibling.  The early help assessment for H1 was incomplete and it was unclear how changes would be evidenced and monitored. H1 was assessed to have complex needs, described in the LSCB Threshold Document as “Children whose vulnerability is such that they are unlikely to reach or maintain a satisfactory level of health or development”. There was reference within the assessment to H1 being frightened in case Sibling 1 returned to the family home however there was no analysis of risk or plan to ensure that H1 was effectively safeguarded.  In discussion with the Lead Reviewer and Chair, Mother likened meetings with the Families Team practitioner to having chats over a cup of coffee which were supportive at times but did not lead to change. At times the intervention by the Families Team practitioner was not robust enough to address emerging concerns. It was unlikely that discussions about healthy relationships with the Families Team Practitioner were an adequate response to Mother stating that H1 was associating with older males. There was insufficient managerial oversight to monitor the effectiveness of interventions or increase in risk. In the absence of a clear plan to address the complex needs it was difficult to identify any improvement or deterioration in the level of health and development needs of H1.  During this Review Practitioners were open about some historical challenges with the delivery of intervention and support to families by the Families Team which was said to lack effectiveness and focus. Various factors contributed to the limited impact of early intervention and support which included inadequate and incomplete assessment, poor information sharing and ineffective multi-agency partnership working. Working Together 2015 states that an early help assessment carried out for an individual child and their family should be clear about the action to be taken and services to be provided (including any relevant timescales for the assessment) and aim to ensure 17 Child H1 SCR FINAL JULY 2017  that early help services are coordinated and not delivered in a piecemeal way45.  It was acknowledged by Practitioners at the Learning Event and the Review Panel that there have been significant improvements in the delivery of intervention by the Families Team which includes the introduction of an improved management structure and a case management system. There was an increased confidence expressed by the Review Panel and Practitioners in the effectiveness of the revised assessment, planning and Review processes used by the Families Team.  Support provided by Families Team practitioners must now relate to an agreed plan focussed on outcomes with clarity about how the work will make a difference for the child and family.  Whilst there have been positive changes to systems and processes it was evident that some challenges remain. It was acknowledged during discussions at the Learning Event and meetings of the Review Panel that there was limited appreciation and understanding between the Families Team and CSC regarding the responsibility and contribution of each service area. It was evident from information provided for this Review that limited integration and lack of cohesiveness between the Families Team and CSC had a direct impact on the quality of intervention and support provided to the family of H1. Whilst there has been an improvement of professional relationships between the Families Team service and CSC and examples of good practice were evident, it is important that further development is encouraged to promote consistent and effective partnership working to focus on the needs of children and families.  There was an opportunity for practitioners from the Families Team and CSC to work together on a parenting assessment and this may have improved coordination and increased the effectiveness of subsequent interventions. The provision of Early Intervention and Support was at times confusing for the family, Mother complained that too many professionals were involved and more importantly the needs of H1, Sibling 1 and Sibling 2  and risks they were exposed to were not identified or appropriately assessed. The need to integrate Families Team and CSC services has been identified in previous reviews and audits in Local Authority 1. Communication days have taken place between the managers of the Families Team service and CSC to develop greater cohesiveness between the services and to facilitate cooperation and coordinated working practice. Further events are planned with Practitioners to progress this development. Application of Thresholds It was acknowledged amongst Panel members and Practitioners during the Learning Event that there were significant errors of judgement regarding the application of thresholds for H1. Agencies worked independently, intervention was reactive and each new concern appeared to be managed in isolation. It was a challenge for practitioners to assess the needs of H1 and the family and this was made more difficult due to the lack of a chronology within case records.                                                              45 Working Together, 2015 p 14 18 Child H1 SCR FINAL JULY 2017  A pattern emerged in which new concerns or incidents were reported to CSC, information was shared with the Families Team Practitioner and the case closed to CSC as it was considered that support needs and risk could be managed by the Families Team. It was the consensus of all professionals involved in this Review that the decision to close the referral for H1 in 2015 following the disclosure against Sibling 1 was not based on a thorough assessment of need or risk.  There was limited communication between CSC and the Families Team and a lack of clarity about the decision making process which resulted in the judgement that the Families Team could manage risk and provide effective intervention in response to new information of increasing concern regarding the wellbeing of H1.  Mother and Father did not contribute to a plan nor did they have an understanding about how support and intervention to address emerging needs would be provided. In the absence of an assessment and the attendant lack of communication it was not evident that there was a shared understanding of emerging needs amongst professionals and Mother, Father and H1.  In addition it was not possible to have confidence that the Families Team had the capacity, skills or the agreement of parents to provide and sustain effective intervention. Internal audits undertaken by CSC have identified inconsistent management of decision making following an initial contact with CSC. It is known that discussions take place and there are constructive professional relationships to enable rapid consideration of cases, however this was not evidenced sufficiently within this Review. Following the referral to CSC by the Families Team practitioner in September 2015 it was decided that the threshold had been reached for consideration at an ICPC. The Independent Chair of the ICPC expressed concern that the case had not been referred earlier and it was recorded that the threshold for child protection intervention had been met earlier.  Whilst there was consensus among professionals that H1 and Sibling 2 were made subject to a CP plan there was evidence that thresholds continued to be inappropriately applied.   A Review Child Protection Conference took place eight weeks after the ICPC and Sibling 2 was stepped down from a CP plan without a full assessment of risk or need and the category of Sexual Harm was removed from the CP Plan for H1.  Practitioners at the Learning Event stated that this was a unanimous decision made by all professionals at the meeting, however given the information that was known at the time it is evident that this decision was flawed and should have been challenged by the Independent Reviewing Officer (IRO). The decision made at the Review Child Protection Conference was contradicted by the Police two months later. A high risk MASH referral was submitted due to H1 being considered a high risk of Child Sexual Exploitation when missing from home. There was limited collaboration between 19 Child H1 SCR FINAL JULY 2017  agencies and inconsistent assessment of the level of risk and intervention required.  There was no evidence that Think Family46 principles were considered by practitioners to inform intervention. The needs of H1, Sibling 1 and Sibling 2 were considered separately and it was recorded that that Sibling 2 and H1 were exposed to unassessed risks. Whilst much work was taking place to support H1 and the family this was fragmented, lacked coherence and appeared to be reactive to incidents of increasing seriousness. It was clear from agency records and information shared at the Learning Event that Practitioners worked hard to support the family and work was time consuming, challenging and reactive with little opportunity to reflect on practice. Practitioners expressed an appreciation for the reflective learning opportunity afforded by participation in this Review47.  During the course of this Review, the Local Safeguarding Children Board has agreed a new Threshold Document with increased clarity about levels of need, assessment of risk and provision of support and interventions. Training will be offered across the multi-agency partnership and effective and consistent implementation will be monitored by the LSCB. Multi-Agency work Information Sharing The first multi-agency meeting took place the day after H1 was excluded from School 1 for the first time in July 2014. School 1 were not invited and were unaware of the serious incident that had taken place at the family home48. There was no opportunity for School 1 to consider how this experience may have impacted on H1 before excluding her from School. Practitioners acknowledged at the learning event that they did not fully understand or appreciate the role of CAMHS. Practitioners were not aware of the duty phone line and consultation service offered by CAMHS prior to making a referral.49 H1 was referred to CAMHS by the GP and the Families Team Practitioner and referrals were subsequently closed due to non-attendance.  The GP Practice recorded that H1 alleged not to have known about the appointments and was very upset to have missed them. Letters to inform that a CAMHS referral had been closed were forwarded to the GP and referrer.  An early outcome of this Review is that all school nurses (even if they are not the referrer) will receive a copy of the discharge letter from CAMHS which will state the reason for discharge from the service. This information will provide School Nurses with greater opportunity to support and encourage young                                                            46 Think Family means securing better outcomes for children, young people and families with additional needs by co-ordinating the support they receive from children’s, young people’s, adults’ and family services. www.education.gov.uk/publications/eOrderingDownload/Think-Family.pdf 47 Practitioners said they would work to reflect on their work more frequently with colleagues and would appreciate a procedure to enable this.  48 The abuse on Sibling 2 by Sibling 1  49 The Families Team practitioner made a referral to CAMHS for H1 to receive bereavement counselling which is provided by other agencies. This would have been identified in a telephone consultation prior to an inappropriate referral being made. 20 Child H1 SCR FINAL JULY 2017  people to attend appointments with CAMHS.  Examples evident during this Review of limited information sharing included: school were not informed of the first incident when H1 was missing from home; the Families Team practitioner was not aware that Mother had refused to engage with the Police investigation following the disclosure by H1 and agencies were not aware that the Pupil Referral Unit had assessed it necessary to have two people present when delivering home tuition due to Mother becoming aggressive towards staff at school. Had a multi-agency meeting taken place it is likely that this information would have been shared and intervention provided in a more holistic way. The Nurse Practitioner proactively shared information about H1 not attending CAMHS and concerns that H1 was being intentionally socially isolated by Mother with the Families Team practitioner and the Pupil Welfare Officer. There was no record to evidence whether this information was shared with other agencies or addressed with Mother and H1. In the absence of a clear plan to inform support and intervention it was a challenge for practitioners to assess the value and relevance of new information as it was shared.  Medical records noted details of a telephone conversation between the Nurse Practitioner and School Nurse regarding abuse by H1 on another pupil in which the Nurse Practitioner stressed the need to understand the factors that may be influencing behaviour of H1. This was the first example within the timeline of a professional stating explicitly that it was important to understand why H1 was behaving in the way rather than reacting to the immediate incident.  Strategy Discussions, Section 47 Enquiries and Assessment Following the disclosure that Sibling 1 had sexually abused H1 a Strategy discussion took place between the Police and CSC and S.47 enquiries were made.  Intervention initially focussed on the physical separation of H1 and Sibling 1. Following Section 47 enquiries H1 and Sibling 2 were closed to CSC Sibling 1 was accommodated due to parental threats of harm.  Recording of S.47 enquiries was limited and the impact of the sexual abuse on the emotional wellbeing of H1 was not considered. Intervention focussed on the immediate risk and need to separate H1 and Sibling 1 and the emotional wellbeing of H1 was overlooked. It was acknowledged by the Review Panel that the recording of the Strategy Meeting following a second disclosure by H150 was not to the required standard and contained limited contextual information and few details of the discussion. Health partners were not involved in the Strategy Meeting. It was decided to undertake a CAFA as part of S.47 enquiries, although there was no record of what was discussed to inform this decision. The decision following the Strategy Discussion to undertake a CAFA was not actioned.  The delay was eventually identified by a manager and the assessment progressed with urgency. It would appear that previous managerial                                                            50 H1 alleged sexual assault by YP 1 and under age sex with YP2  to Aunt, Mother was informed and reported the disclosure to the Police 21 Child H1 SCR FINAL JULY 2017  oversight had not been adequate or this would have been addressed earlier. H1 was reported as missing from home by Mother in August 2015 and was found by Police two days later in London. The Strategy Meeting following this incident was well attended and evidenced good information sharing about the specific incident. A high risk MASH referral was submitted by the police and a return home interview was completed. Agency records noted that H1 was at high risk of CSE. It was recorded in the outcome of the S.47 enquiries in September 2015 that H1 was seen and spoken to alone however there was no detail about what H1 said during the discussion, information about previous concerns was incomplete, reference was made to self-harm and missed CAMHS appointments, however there was no information about missing from home episodes and school exclusions.  It was acknowledged by members of the Review Panel and by Practitioners at the Learning Event that recordings of the strategy discussions and S.47 Enquiries did not adequately evidence the extent and quality of effective multi-agency discussion and co-working.  The Review Panel acknowledged that the inconsistent quality of S47 enquiries had also been identified at recent reviews and audits of the front door. Training has taken place and learning communicated back into teams. A new and more effective template for S.47 enquiries and Strategy Meetings is being developed by CSC Senior Managers.  Child Protection Processes Parents did not attend the first Core Group and minutes of the meeting evidence some information sharing, however there was limited discussion about the CP plan. It was recorded that the social worker for H1 would liaise with the social worker of Sibling 1 about his potential return to the family home, however there was no record in CSC Case Notes that a discussion took place. Whilst professionals expressed concerns about the possible return home of Sibling 1, these were not escalated and no action was taken to ensure that H1 would be appropriately safeguarded.  It was recorded in the multi-agency chronology prepared for this Review that Core Groups were infrequent, ineffective and did not confirm the detail of the Child Protection Plan outlined at the ICPC.  Since 2016 CSC Managers have received a fortnightly report regarding the completion of statutory visits to enable clear oversight, challenge and support to ensure that visits are within the required timescale. It was acknowledged by the IRO at the Learning Event that poor practice should have been challenged more robustly. Limited managerial oversight and absence of reflective practice contributed to a lack of appreciation about the vulnerability of H1 which may have been linked to lack of understanding 22 Child H1 SCR FINAL JULY 2017  about the risks associated with sexual abuse in families.  Yates51 describes an intuitive decision making process influenced by a practice mind set of ‘siblings better together’ when working with families in which sibling abuse has occurred. This mind set comprises three underlying perspectives: children as vulnerable and intending no sexual harm to others; sibling relationships as non-abusive and of intrinsic value; and parents as well-intentioned protective. These perspectives encourage a focus on immediate safety rather than emotional harm, and could be said to extend Dingwall et al.’s52 ‘rule of optimism’. There is a danger of the victim child becoming lost. The decision making process regarding H1 and Sibling 1 focussed on actions to ensure the immediate safety of both. There was very little attention given to the emotional harm experienced by H1 who was not effectively safeguarded and it could be stated that her needs were lost in the protection process. There was a delay by Managers to authorise Statutory visits and lack of challenge when visits were out of timescales. In addition records of some visits were confusing and inconsistent with a lack of clarity about who was spoken to and whether the child had been seen. Some CSC supervision records evidenced initial reflective discussion about the case although this did not lead to any change in the intervention provided. In December the social worker for Sibling 1 (Social Worker 1) became the social worker for H1 in response to information from the family and other professionals about difficulties in contacting the social worker for H1. This appears to have been a decision led by Social Worker 1 with limited managerial oversight. It was clear from information shared at the Learning Event that Social Worker 1 received a limited handover and was required to undertake statutory visits and core groups as a priority. At the Learning Event Social Worker 1 stated that it was a challenge to manage the case given the varied and complex needs of all the children. Social Worker 1 focussed on re-establishing a positive working relationship with the family in order to implement the CP Plan. The third core group took place in January which resulted in a further period of unassessed risk between Sibling 1 and H1 as they lived in the same house for two months and the behaviour of both escalated significantly during this time period.   Mother and Father attended the core group in January 2016 (the first in three months) and concerns were expressed by parents and other professionals about the lack of case management by CSC. School records indicated that H1 was in the care of aunt53 however this was a family arrangement and CSC had not been informed that H1 was not at home. It would appear that managerial oversight during this time was not rigorous enough and there was insufficient                                                            51 Yates, P. (2017); ‘Siblings as Better Together’: Social Worker Decision Making in Cases Involving Sibling Sexual Behaviour, The British Journal of Social Work 52 Dingwall, R., Eekalaar, J. and Murray T. (1983); The protection of children: state, intervention and family life, Oxford: Blackwell. 53 It had been recorded by the IRO following the ICPC that H1 should spend minimal time with Aunt  23 Child H1 SCR FINAL JULY 2017  oversight to effectively safeguard H1, Sibling 1 and Sibling 2.  At a meeting in November 2015 between Mother and the social workers for Sibling 1 and H1 Mother self-reported that she was managing the risks by moving the bedrooms apart and making sure that H1 and Sibling 1 were not left alone together. Mother did not appear to understand the requirements of the Child Protection process and said that she was unaware of home visits and core group meetings. There was no record that Mother and Father had been provided with a copy of the CP plan or the dates of meetings. There was a significant omission to safeguard a young person which was not identified at practitioner or managerial level, or by the Independent Reviewing Officer.   It was reported in the timeline for this Review that there had been no progress with the CP plan during the first two months.  Use of a written agreement between CSC and Mother and Father to ensure that Sibling 1 and H1 were not left alone was not appropriate or adequate to ensure the safety of H1.  There was no clarity about how the written agreement would be monitored or what the consequences would be should conditions be breached. There is considerable evidence that written agreements provide a false sense of assurance to professionals. It is unlikely that the written agreement was of benefit to H1 who told professionals that she did not feel safe in the house when Sibling 1 was present.  Records of the Core Group in February 2016 inappropriately detail disagreement between professionals about intervention and support which resulted in further fragmentation of the safeguarding process. It would have been more constructive and in the best interests of H1 had the professionals had a pre-meeting to discuss different views about how to proceed. Mother attended this Core Group which did not progress an assessment of risk or review how Mother and Father were managing to safeguard H1.  Given the ongoing concerns and unassessed risk it was difficult to understand the decision to remove Sibling 2 from a CP plan and to remove the category risk of sexual harm from H1 who remained subject to a CP plan under the category risk of emotional abuse. It was evident that much work had been completed by the CSE team however there had not been a sufficient time lapse to confirm whether the information and support provided had led to a sustained change in the behaviour of H1 and reduction in the risk of CSE. It was recorded within the Review Child Protection conference minutes that H1 was not at risk of sexual exploitation and also that Sibling 1 was an unassessed risk. These statements are contradictory and illustrate a lack of coherence in the recording of child protection processes.  At the Learning Event Practitioners spoke about high caseloads and rapid turnover of staff which was unsettling for the workforce. The need to embed the early help framework and improve managerial oversight, monitoring of practice and quality of assessments have been identified as issues within this Review. It is important that any actions from this review build on the work currently in progress to improve service delivery for children and young people in Local Authority 1. Response to Missing From Home H1 was reported a missing from home on 4 occasions during the course of this Review. It was 24 Child H1 SCR FINAL JULY 2017  known that there were also times when Mother and Father did not report H1 as missing.  H1 went missing from home for the first time in September 2014. Mother informed the Families Team practitioner H1 had been missing from home and found by her father with older males although this was strongly denied by H1.  There was no evidence that this information was shared in supervision by the Families Team practitioner who advised Mother to contact the police should H1 go missing again. There was a lack of understanding about the H1’s vulnerability and the potential risk of CSE whilst missing from home. A second missing from home episode was reported in January 2015. It was unclear who had made the report and there was no further information about how this was managed or whether the information was shared with other agencies. The missing from home episodes suggest that there was little or no improvement in behaviour management and escalation of risk as whilst missing H1 was vulnerable and at risk of CSE.   Records indicate that H1 went missing in response to the boundaries imposed by parents as a consequence for being excluded from School 3. H1 returned within three hours and a safe and well check was conducted by the Police. A MASH referral was not made and therefore information about H1 missing from home was not shared with CSC, Health or School. It appears that this incident was treated in isolation and the Police Officer may not have been aware of the context regarding school exclusions and CAMHS referrals.  There were some examples of good practice following missing from home episodes. There was evidence of multi-agency cooperation between the Police and the CSE team. H1 had a good relationship with staff from the CSE team it was thought that she would be more likely to make a disclosure about where she had been and who she had been with to CSE team practitioners. In addition it is likely that H1 would have felt more supported having the return interviews conducted by people that she was familiar with. Previous audits have identified that submission of MASH referrals as a contact generates work with limited outcome. Managers are reviewing procedures and practice to enable more efficient and effective processing of MASH referrals. School attendance Poor school attendance for H1 and Sibling 154 was a long standing concern for professionals. H1 experienced much disruption in educational provision due to school exclusions, refusal by Mother to allow attendance55 and movement to different areas.   School 1 provided support to H1 and made significant efforts to locate H1 and share information with School 2 when the family moved area. The Pupil Welfare Service provided intervention and support to enable H1 to attend school or an alternative provision following exclusion. Mother received a fine due to Sibling 1 not attending school and Minutes of a Core Group in October                                                            54 Initially Sibling 2 had poor attendance however this was resolved following a change of school and improved travel arrangements to facilitate attendance 55 Due to a reduced timetable or alleging that H1 was too distressed to attend school 25 Child H1 SCR FINAL JULY 2017  2015 noted professional concerns that cultural difference was sometimes used as an excuse for not attending education.   It was identified during this Review that attendance procedures were not rigorously or consistently applied by School 3.  There were specific concerns about the use of recording codes when H1 was accessing educational activity off-site or within another establishment and when excluded.  It is essential that attendance is appropriately recorded to ensure that the whereabouts of children is known and can be checked. This is of particular importance for those children known to be vulnerable and at risk.   School 3 is under new management and attendance procedures have been reviewed. Centralised systems have been introduced and there is greater control over registration procedures.  A meeting is planned between Senior managers of School 3 and CSC to discuss the learning from this Review and ensure that changes are implemented effectively and consistently. Escalation The LSCB has an agreed escalation process, which is covered throughout LSCB training. The procedure is not implemented consistently; although, as noted by members of the Review Panel, concerns are discussed among practitioners and across agencies and, at times, senior managers in CSC are contacted directly to resolve an issue.  There was consensus amongst Practitioners that H1 was at risk due to Sibling 1 being allowed back into the home when H1 was present. Whilst there was a clear concern that H1 was not being safeguarded, limited action was taken to reduce the risk to H1. It was evident from CSC records that professionals had some concerns about the management of this case by CSC. Core groups and statutory visits were out of timescale, however professionals did not escalate concerns further than sharing information with the Social Worker for Sibling 1.  Whilst these concerns were valid it was not appropriate for professionals to express disagreements in meetings with Mother and Father present. Given the challenge to engage Mother and Father in the child protection process this was an opportunity to progress multi-agency work and address prior drift.  It is important that all agencies and practitioners recognise their duty to cooperate in activities to safeguard children. As the Child Protection Plan for H1 had been in place for four months with little progress and increased concerns this should have been escalated through the appropriate channels.  Practitioners at the Learning Event were aware of the formal escalation process and said that they would implement this in the future following the reflection on practice during this Review process.  An issue resolution was raised by the Safeguarding Service Manager regarding Sibling 2, as 13 days following the ICPC there was no record of the CP Plan on the relevant case records.  Implementation of the escalation process has been highlighted in other reviews and audits, resulting in an updated process being adopted. This review endorses recommendations previously made to promote the effective use of the escalation process across all partner agencies of the LSCB.  26 Child H1 SCR FINAL JULY 2017  Cultural Influence Agency records referenced that the family of H1 were from an ethnic minority community however there was no evidence that meaningful consideration was given to the ethnicity and culture of the family during the intervention and support provided.  It was recorded in the S.47 Report following the disclosure of abuse by Sibling 1 that the family were from an ethnic minority community and Parents were worried about their community hearing about the sexual abuse as this would bring shame on the family. The record also included the fears of Sibling 1 about a community backlash. There was limited evidence that the anxieties of the family were considered or impacted on assessments and intervention provided.  The Review Panel noted that the culture of the family was not adequately taken account of in assessments and interventions.   Records indicated that H1 complained of being bullied as a consequence of her ethnicity at School 2, although this was not substantiated.  It was not evident what action had been taken to address the allegation or whether support had been offered to H1. In discussion with the Lead Reviewer and Chair H1 said that she was bullied but nothing was done about it.  Issues within the their community led to movement of the family; in November 2013 a Families Team Practitioner recorded that Mother spoke about disagreements with people in their community and planned to move to Local Authority 2 as she was fearful for her family due to repercussions within the community. On their return to Local Authority 1 in 2014 Mother informed the Families Team practitioner that they experienced racial abuse in Local Authority 2 and decided to return. In June 2015 Mother informed the Families Team Practitioner that the family were planning to move due to the shame felt due to H1 associating with older boys. The impact of these cultural stresses on the family was not effectively addressed by practitioners. In discussion with the Lead Reviewer and Chair, Mother stated that in her culture education was not prioritised. It was the view of some Practitioners at the Learning Event that culture was used by Mother to support non-attendance at school. However, Mother also stated that she was not happy when H1 was on a reduced timetable and the ambivalence of Mother towards H1 attending school was not addressed. The different views expressed by H1, Mother and Father about school were not explored and there was a missed opportunity to gain a greater appreciation of Parental views and cultural influence regarding attendance at education. In addition it was likely that the negative view of Mother regarding H1 receiving sexual health support was influenced by her cultural background, however this was not explored. Practitioners at the Learning Event were clear that their knowledge of the family’s particular culture was limited and this was shared by some members of the Review Panel.   27 Child H1 SCR FINAL JULY 2017   Practice issues  Changes that have taken place during the process of this review School School 3 is under new management and attendance procedures have been reviewed. Centralised systems have been introduced and there is greater control over registration procedures.  Health School Nurses are informed when a young person has been discharged from CAMHS   Good Practice Identified During this time period the Nurse Practitioner at the GP Surgery worked proactively to share information and raise concerns with other agencies and parents about the non-attendance of H1 at CAMHS. It was recorded that information was shared in a timely way and H1 was seen by the School Nurse and offered an open appointment.  The CSE team practitioner and Police completed joint Section 47 enquiries as it was thought more appropriate for someone already working with H1 to obtain a disclosure – this was good practice and evidence of good use of multi-agency resources. School 1 worked proactively to identify where H1 was located when she did not attend school This was good practice by School 1 to ensure the safety of H1, the lead for children missing from education in Local Authority 1 was informed and supported efforts to confirm the whereabouts of H1. On return to School 1 H1 was reintegrated into the class she had previously left in to support established relationships.  Following the specific disclosures of sexual abuse H1 told the Nurse Practitioner about feeling unsafe at home because the doors were always unlocked and Sibling1 was allowed freely into the house. The Nurse Practitioner, with consent of H1, shared this information with the school nurse to ensure that H1 had support in school.  Learning and Recommendations Learning Point 1 When Early Help support is delivered without a holistic assessment to inform a plan with agreed outcomes it is a challenge to monitor the impact of intervention. Practitioners may develop a false 28 Child H1 SCR FINAL JULY 2017  reassurance about the effectiveness of their support to children, young people and families.   Question for the Board How can the Local Safeguarding Children Board seek assurance about the quality of Early Help assessments and ensure that intervention is making a difference for children and families? Learning Point 2 Without a holistic (multi-agency) assessment, factors which increase or decrease risk within the family, community and environment may be overlooked and make it more difficult to assess and evidence the appropriate level of need for a child or family. Recommendation 1 The Local Safeguarding Children Board should review assessment tools to ensure that information required to evidence decision making regarding the level of need/risk is easily accessible.  Learning Point 3  The development of positive relationships between agencies and professionals at all levels is important to promote multi-agency cooperation and effective intervention when supporting children and families. Absence of partnership working can result in duplication of resources and agencies working in isolation with limited impact. Recommendation 2 The Local Safeguarding Children Board should actively promote the development of constructive professional relationships between the Families Team and CSC. Recommendation 3 The Local Safeguarding Children Board should consider the development of an annual event to celebrate good practice and promote partnership working. Learning Point 4 In the absence of a parenting assessment it is a challenge for Practitioners to have clarity about the capacity of parents to understand safeguarding concerns and confidence in the ability of parents to protect children. This may result in practitioners having unrealistic expectations of parents and the vulnerability of children could increase. Recommendation 4 The Local Safeguarding Children Board should undertake an audit of parenting assessments to monitor quality and ensure that training is implemented across the workforce.   29 Child H1 SCR FINAL JULY 2017  Learning Point 5 It is important that efforts are made to understand why young people may be engaged in behaviour described as ‘risk taking’ and ‘challenging’. When the focus of intervention is on behavioural change it is possible that underlying emotional distress could escalate and risk taking behaviours increase. Question for the Board How can the Local Safeguarding Children Board ensure that all partners recognise that young people may be communicating distress through their behaviour and ensure that intervention is focussed on support to understand and reduce distress rather than change behaviour? Learning Point 6 When children and young people speak directly to Practitioners it is not sufficient to record what has been said. If the voice of young people does not inform assessments and subsequent interventions it is likely that they will not feel listened to, intervention may not be appropriate and challenges could escalate. Recommendation 5 The Local Safeguarding Children Board should audit and monitor how the voices of children young people inform assessments and interventions.  Learning Point 7 It is essential that practitioners recognise the cultural influences on children and families from diverse communities. An ability to demonstrate cultural competence will enable practitioners to intervene with respect when required to promote the best interests of children and young people.  Question for the Board How can the Local Safeguarding Children Board ensure that the practice of all partners is culturally sensitive and focussed on the needs and best interests of children and young people? Learning Point 8 In addition to ensuring the immediate safety of children following sibling abuse it is important that consideration is given to their emotional wellbeing and risk assessments are completed in a timely way to ensure the safety of all. Recommendation 6 The Local Safeguarding Children Board should satisfy itself that when action is required to ensure the immediate safety of children and young people consideration is given to their emotional wellbeing and support is provided in a timely way.  30 Child H1 SCR FINAL JULY 2017  Learning Point 9 Appropriate recording of Strategy Meetings and S.47 Enquiries is essential to evidence decision making processes and multi-agency actions to address identified risks.  Recommendation 7 The Local Safeguarding Children Board should seek assurance that the templates used to record Strategy Meetings and S.47 Enquiries facilitate the effective recording of information to evidence multi-agency discussion, information sharing and agreed action to safeguard children and young people. Learning Point 10 Omission to use formal procedures to escalate safeguarding concerns may result in children and young people being subject to unnecessary risks. Recommendation 8 The Local Safeguarding Children Board should promote and monitor the use of the escalation process. Learning Point 11 When Early Help support is provided by a single agency (the Families Team) the efforts of other agencies (schools) to support young people may take place in isolation. Multi-agency partnership work to provide Early Help support to families and young people can become fragmented and lack effectiveness.  Question for the Board How can the Local Safeguarding Children Board ensure that the provision of Early Help for children and families is coordinated, effective and recognised as the responsibility of all agencies?         31 Child H1 SCR FINAL JULY 2017  Statement by Reviewer I make the following statement that prior to my involvement with this learning Review:-  I have not been directly concerned with the child or family, or have given professional advice on the case. I have had no immediate line management of the practitioner(s) involved.  I have the appropriate recognised qualifications, knowledge and experience and training to undertake the Review. The Review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer   Catherine Connor (Signature)  Date June 2017   Chair of Review Panel  (Signature)  Date July 2017     