Sexual abuse of an 11-year-old child by their step grandfather over a number of years. Child Q1 was 11-years-old when their school made a referral to Children's Social Care due to concerns regarding child sexual abuse (CSA). Child Q1 was living with their parents and siblings at the time of the referral but had frequent contact with their grandmother and step grandfather. Child Q1 has Special Educational Needs (SEN) and attended a Free School in another borough. Following a social work home visit Q1 told Mother that they had been sexually abused by their step grandfather since the age of 4-years-old. Following inadequate Ofsted reports the Free School was closed in July 2017 and therefore staff could not be contacted for further information. Learning includes: prosecution for CSA, where a child has SEN where there is no forensic evidence, and the absence of evidence from a secondary source (in this case the teacher) is problematic; information sharing between and within agencies was not always in line with good practice, resulting in professionals not having all the information available when assessing the risks to Child Q1. Recommendations include: contact the Department for Education Skills and Funding Agency and the Regional Schools Commissioner to raise concerns and make suggestions to enable support from the local authority when Academies and Free Schools are identified as having safeguarding concerns; and raise concerns in relation to lost records/lack of information regarding HR records and possible breaches of the Data Protection Act when Free Schools and Academies are closed.
      
 Title:  Child Q1 serious case review. LSCB: Manchester Safeguarding Partnership Author: Anne Morgan Date of publication: 2020  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.                               Manchester Safeguarding Partnership Child Q1 Serious Case Review This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership (previously Manchester Safeguarding Children Board) Independent Reviewer: Anne Morgan Published by the MSP on the 11th May 2020  MSP Child Q1 SCR Page i  Contents 1.0 INTRODUCTION ................................................................................................................................ 1 2.0 RATIONALE FOR CARRYING OUT A SCR ........................................................................................... 1 3.0 REVIEW PROCESS ............................................................................................................................. 1 4.0 FAMILY COMPOSITION .................................................................................................................... 5 5.0 FAMILY HISTORY PRIOR TO PERIOD UNDER REVIEW ...................................................................... 6 6.0 NARRATIVE AND ANALYSIS FOR PERIOD UNDER REVIEW ............................................................... 7 7.0 RESPONSE TO RESEARCH QUESTIONS ........................................................................................... 12 8.0 LINES OF ENQUIRY ......................................................................................................................... 19 9.0 RECOMMENDATIONS ..................................................................................................................... 20 10.0 AREAS OF GOOD PRACTICE .......................................................................................................... 21 11.0 CONCLUSION ................................................................................................................................ 21      The Manchester Safeguarding Partnership published its new arrangements  in June 2019 and in doing so took ownership of all  Manchester Safeguarding Children Board (MSCB) reviews, strategies and policies.  Find out more at www.manchestersafeguardingpartnership.co.uk  The Manchester Safeguarding Partnership is a multi-agency partnership made up of a wide range of statutory, independent and voluntary agencies and organisations. These all work together to keep children, young people and adults, particularly those who are more vulnerable, safe from the risk of abuse, harm or exploitation.    MSP Child Q1 SCR Page 1 of 21 1.0 INTRODUCTION  1.1 This serious case review has taken place because of MSP (formerly MSCB) having concern that there was a delay by Child Q1’s school in identifying and referring Child Q1 to children’s social care for possible sexual abuse. Additionally there was a concern regarding the effectiveness of multi-agency working both prior to and following the referral.  2.0 RATIONALE FOR CARRYING OUT A SCR  2.1 A meeting of Manchester Safeguarding Children Board’s Serious Case Review (SCR) Panel was held on the 01/09/2017 and a decision made to carry out a SCR. This decision was ratified by the MSCB chairperson on the 02/10/2017 and was based on the criteria as laid out in Working Together to Safeguard Children 2015 (Working Together)1, which refers to Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation 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.   “Cases which meet one of the criteria (i.e., regulation 5(2)(a) and (b)(i) or 5(2)(a) and  (b)(ii) must always trigger an SCR”. Child Q1’s abuse met regulation 5(2) (a), abuse is suspected, and 5(2)(b)(ii), the child has been seriously harmed2 and there is cause for concern as to the way in which the… (agencies)… have worked together to safeguard the child”.   3.0 REVIEW PROCESS 3.1 Scope and focus of the SCR   The panel identified the following key areas to be explored as part of the review. They were:                                                       1 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children March 2015 p 75:  2 Serious Harm in the context of SCR guidance includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:  A potentially life threatening injury;  Serious and/or likely long term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. This definition is not exhaustive.  In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. MSP Child Q1 SCR Page 2 of 21 1. The period of time from when the school had initial concerns regarding Child Q1 to their referral to children's social care (CSC) in July 2017.  2. Child Q1 was reported to have learning difficulties. Did this have an impact on how the school managed their concerns? 3. The School’s safeguarding arrangements.  4. MASH threshold and assessment in cases of child sexual abuse (CSA). 5. Interagency Communication.  The review panel were asked to incorporate the following lines of enquiry into the report. To attempt to provide a better understanding of the following aspects of service provision:  cross boundary working, effectively sharing information regarding family members that can be resident in different local authorities to ensure that this is linked to the child to build a bigger picture  the management of inter-generational sexual abuse and linking families members and other household members to the child to undertake a robust initial screening of the referral to adopt an appropriate level of assessment  was Child Q1’s suggested learning needs and vulnerability referred to any health or education professional for a formal assessment.   3.2 Organisations involved in the Review 3.2.1 It was agreed that the following organisations would be required to contribute to the serious case review:  Manchester City Council Children’s Social Care (CSC)  Greater Manchester Police (GMP)  Neighbouring Education Department3  Manchester City Council Education Department  Manchester University NHS Foundation Trust   GP Practice  Bridgewater Community Health Care NHS Foundation Trust  Manchester NHS CCG  Neighbouring NHS CCG  Manchester City Council Legal Department  Free School (Records Only)4  The Regional Schools Commissioner (once identified as having governance responsibility for Free Schools) - no contribution received.                                                       3 The Education Department, CCG, NHS Trust  and Q1’s school have been anonymised to protect Child Q1 and their family 4 The Free School closed in July 2017 following an Inadequate Ofsted Report. There was minimal information available on the records transferred to Child Q1’s new school.  No staff have been able to be contacted to be part of the review by either the local authority or GMP.  MSP Child Q1 SCR Page 3 of 21  3.2.2 The review panel was made up of senior representatives from the following organisations with the SCR author as chair. The author was Anne Morgan, an Independent Safeguarding Children Consultant commissioned by MSCB. She has extensive experience in carrying out reviews and is trained in the use of a systems approach. The following table illustrates the agencies/professionals who were invited as panel members. Additionally contact was made on several occasions with the Regional Schools Commissioner to inform the review in relation to their role with Free Schools. No response to those contacts occurred. The neighbouring schools safeguarding lead provided information relating to education in the borough and attended the last review panel meeting.  Agency Role Independent Author  Independent Safeguarding Children Consultant MCC Education Department Education Case Worker MCC Children’s Social Care Service Manager (North assessment) Greater Manchester Police Service Detective Inspector Police Public Investigation Unit (PPIU) NHS Manchester CCG  Designated Nurse for Safeguarding Children  Neighbouring NHS CCG  Head of Safeguarding & Designated Nurse for Safeguarding Children  NHS Manchester CCG  Designated Doctor for Safeguarding Children MCC Legal Department Deputy Head of Children and Families (Legal) Group Manchester University NHS Foundation Trust Named Nurse Safeguarding Children  The panel was supported by the MSCB Safeguarding Board Co-Ordinator and Business Support Officer.  The Practitioners involved were: Agency Role Children’s Social Care  Manchester Multi-agency Safeguarding Hub (MASH) Team Manager Children’s Social Care MASH Social Worker Manchester University NHS Foundation Trust MASH Health Visitor lead for Safeguarding Children/MASH  Manchester University NHS Foundation Trust School Nurse Team Lead Children’s Social Care Senior Social Worker Children’s Social Care Social Worker Greater Manchester Police Detective Inspector PPIU Greater Manchester Police Detective Constable MASH GP Practice GP Neighbouring Community Health Care NHS Foundation Trust  Named Nurse  MSP Child Q1 SCR Page 4 of 21  3.3 Time period to be covered 3.3.1 The period covered by the review is January 2016 to September 2017.  3.4 Methodology  3.4.1 Working Together 2015, Chapter 45 identifies the principles to be adhered to in carrying out any Learning Review. This includes the need for  “Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well.   Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children”.    This review was carried out in line with those principles and is proportionate to the incident.   3.4.2 A chronology was produced by the agencies involved, and the professionals working with the family identified (see Footnote 3).  3.4.3 The model used was based on a broad systems approach. However due to the very limited and routine contact professionals had with this family a decision was made to meet with the professionals for an initial discussion and to explain the process and to enable practitioners to talk through their contact with the family and consider the scope and focus of the SCR in relation to their agencies’ involvement. A further meeting was held with this group to share a draft report, and discuss the report’s findings and recommendations. The process was hindered by the unavailability of any education staff from the Free School despite GMP and the local authority making concerted attempts to find their current location.  3.4.4 The process was supported by those panel members who were able to attend these meetings.   3.4.5 Family Involvement: Child Q1 and their parents were informed of the decision to carry out a SCR and invited to meet with the review author and a member of the review panel. Child Q1’s mother, paternal grandmother and aunt took up this offer to meet. A review team member was unavailable for the meeting therefore a social worker who had previously worked with the family attended to support the process. Child Q1’s mother said that her decision to send Child Q1 to the Free School was because of Child Q1’s learning needs and she thought Child Q1 would do better in a small school. Mother reported that this was also the view of Child Q1’s primary school. Once at secondary school she was concerned about the lack of educational support that Child Q1 had received. She advised that Child Q1’s teacher had remained the same for the whole of the school                                                       5 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of March 2015 children p.75    MSP Child Q1 SCR Page 5 of 21 year and whilst she had not attended the parents evening, Child Q1’s mother had been into school to see the teacher in relation to Child Q1’s learning needs. She was therefore surprised that no concerns had been raised with her prior to the home visit. She felt that the home visit was inappropriate and talking to the neighbours about her unprofessional. This made her very angry and, along with the concerns that she had regarding Child Q1’s education she went into school to advise that Child Q1 would not be returning. Child Q1’s mother reported that she was unaware of previous concerns regarding her stepfather and was not aware of why she herself had been subject to a Child Protection Plan (CPP). She felt that the initial support provided by the social worker was good as was the police contact. Later contact was not as positive. She reported that Child Q1 could not understand why there was not going to be a prosecution (a view she and paternal grandmother and aunt also had) and felt that the way the family had been told was not helpful. The whole situation had caused a rift within the family and meant Child Q1 was unable to see her “aunt”. She reported that Child Q1 was now doing well at school and felt that the family were working well together to make sure that the children were ok. Child Q1 was not met as their parents felt it would be too distressing for them. However, when discussing the final report, the family were pleased to advise that Child Q1 was now doing well at school and was far more outgoing than they had been for many years. 3.4.6 Some of the learning identified was outside the terms of reference and timescale of the review. Where relevant this learning has been included in the analysis along with recommendations relating to them.  4.0 FAMILY COMPOSITION Age at time of Incident Relationship to subject Ethnicity Place of residence 11 years old Child Q1 subject White British Manchester 31 years old Mother White British Manchester 27 years old Father White British Manchester 5 years old Sibling 1 White British Manchester 4 years old Sibling 2 White British Manchester 43 years old Maternal grandmother White British N/A 46 years old Maternal step-grandfather White British N/A 13 years old Daughter of maternal grandmother and step grand-father White British N/A  MSP Child Q1 SCR Page 6 of 21 5.0 FAMILY HISTORY PRIOR TO PERIOD UNDER REVIEW 5.1 Child Q1’s mother had been a Looked After Child (LAC)6 for a considerable part of her childhood, due to paternal abuse and neglect. She returned home in her late teens.  5.2 Child Q1’s maternal grandmother commenced a relationship with maternal step-grandfather who had a history of alcohol misuse and was known to the police because of a previous allegation made against him of child sexual abuse (CSA). In 2002 they had a child, a S47 investigation was commenced and a Child Protection Conference held. Their child was made subject to a Child Protection (CP) Plan, under the category of neglect. In 2003 when Child Q1’s mother returned home she was also made subject to a CP plan. Child sexual abuse (CSA) was added as an additional category. Both children remained on CP plans until December 2004 when they were no longer considered to be at risk.  5.3 At some time prior to December 2004 Child Q1’s mother and father had commenced a relationship and Child Q1’s mother was pregnant at the time of the December conference. There is no evidence however to suggest that an assessment of risk to her unborn child was considered as part of the conference decision making. 5.4 Child Q1’s was born in 2005. The parental relationship was at times fraught, with both parents suffering from mental health problems and misusing alcohol. There were also episodes of domestic abuse and in 2006 a Common Assessment Framework (CAF)7 was commenced because of concerns relating to Child Q1. Child Q1’s mother had severe post-natal depression and Child Q1 went to live with their father and paternal great-grandmother although contact was maintained. Child Q1 resided with paternal great grandmother until their (paternal grand-mother's) death in 2006 when child Q1 moved back to live with their mother. In 2009 child Q1 moved with her mother and siblings into paternal grandmother's house to be with Q1's father. 5.5 Child Q1’s siblings were born in 2011 and 2012.  5.6 Between 2012 and 2015 Child Q1 appears to have had four reported urinary tract infections (UTIs) and was seen by the GP on three occasions, however no consideration was given to following these up by referral to a paediatrician or whether there was a non- medical reason for the UTIs. Good practice is to refer after two such infections, and this would have provided an opportunity to do further investigations. 5.7 A further CAF was commenced in July 2015 by Child Q1’s primary school due to concerns relating to Child Q1’s learning difficulties and parental mental health (mother). Child Q1 had been assessed by an educational psychologist and received intervention from a teaching assistant to focus on areas of particular difficulties.  A plan appears to have been put in place at the initial stage                                                       6 A child becomes a Looked After Child (i.e. cared for by the by a local authority where a court has granted a care order to place a child in care, or where a voluntary agreement has been reached with the parents and council’s children’s services department has cared for the child for more than 24 hours. On reaching the age of 18, children cease to be considered looked-after by a council. 7 The Common Assessment Framework (CAF) is an early help inter-agency assessment. It offers a basis for early identification of children's additional needs, the sharing of this information between organisations and the coordination of service provision. MSP Child Q1 SCR Page 7 of 21 of the CAF including a referral to counselling for Child Q1’s mother and a referral to Big Manchester (a family support charity). As the Big Manchester referral was not accepted and the mental health referral made the CAF was closed. However the primary school continused working with Child Q1 regarding their needs; work included focusing on their confidence and transition to high school.  6.0 NARRATIVE AND ANALYSIS FOR PERIOD UNDER REVIEW 6.1 During March and April 2016 Child Q1’s maternal grandmother and step grand-father were seen by their GP. Grandmother was seen for low mood and anxiety, step grandfather with depression and alcohol misuse. No consideration was given by the GP to the impact this may have on their child. This is not examined further as not pertinent to the review and has been addressed outside of the review process 6.2 Between May and July 2016 Child Q1’s primary school attempted unsuccessfully to engage with their prospective secondary school regarding Child Q1’s educational needs.  6.3 In September 2016 Child Q1 transferred from primary to secondary school. The school chosen was a Free School, felt by both mother and their primary school’s head teacher to be the best choice for Child Q1, due to its small numbers and Child Q1’s identified educational needs. Following commencement at their secondary school Child Q1’s mother was provided with photocopies of Child Q1’s educational records to take into school. They did not appear to be part of Child Q1’s records at the time the school closed.  6.4 On the 6th March 2017 Child Q1’s younger sibling aged six years old talked to their teacher about loneliness and told their teacher that their younger sibling (aged five years old) was at home on their own whilst they, their parents and Child Q1 were at a party. Parents were seen in school; they were asked about this incident and advised that mum worked nights and is sometimes in bed but the younger sibling was not left alone. Given the clear concern from the child and the miss-match in information received this was not an appropriate response and should have resulted in a referral to Children’s Social Care (CSC) for investigation. It is not clear why this did not happen.  6.5 On Friday the 14th July 2017 Child Q1’s school made a referral to Manchester CSC where Child Q1 lived. This referral raised a number of concerns including Child Q1’s behaviour towards men… ”Child Q1 will happily approach the male teacher… wanting to hug etc.”  They also reported that Child Q1 was “overly interested in sexual development, sexualised behaviours etc.”  Child Q1 had previously reported to teachers that they ”shaves their pubic area” and also that they had been “sore in their genital area at times”. The referral identified that no direct disclosures had been made and there was no evidence to explain why Child Q1 behaved in the way they did. The referral stated that concerns had been noted over a 9-10 month period, since Child Q1 started the school and: MSP Child Q1 SCR Page 8 of 21 “Although no direct disclosures have been made Child Q1’s teacher… has a history of working with children who have been sexually abused and they began putting the information together and believes Child Q1 could be a victim of sexual abuse” The referral also stated that Child Q1 was one of the most vulnerable children in the school and had learning needs8.  6.6 The previous day a home visit had been carried out by Child Q1’s teacher to discuss the school’s concerns about Child Q1. The teacher was concerned about the home conditions and by information reported by a neighbour who said that there had been a lot of shouting from the house the night before.  At that visit Child Q1’s mother became “very angry and aggressive” and was still reported to be upset when she visited school the following day to advise that Child Q1 would not be returning to the school as their needs were not being met. It was this visit by mother and the removal of Child Q1 from school that precipitated the referral. 67.7 Whilst it would appear that the referral from school was in relation to child protection this was not clear in the referral itself and the school did not discuss the referral with Child Q1’s mother or gain consent to share information. This was not acceptable practice unless the school were concerned that to do so would put Child Q1 at further risk or the child had disclosed sexual abuse. Their management of the referral reflected the concerns expressed by Ofsted in their May 2016 inspection which graded the school as inadequate. The inspection identified poor leadership within the school, a lack of Special Education Needs Co-ordinator (SENCO) as well as out of date safeguarding and child protection policies9. 6.8 It is not clear why the MCC Contact Centre agreed to accept the referral without the parents being aware a referral had been made. This is not normal practice unless to do so would put the child at further risk which was not evident in this case. This meant that when a social worker visited the family had no knowledge of the referral and could have reacted in a very different way. Working in partnership with parents is explicit within the Children Act 1989 and ensures their involvement in the process as well as clarifying which agencies are currently working with the family.  6.9 On Tuesday the 18th July 2017 the referral was transferred from the MCC Contact Centre to MASH for further gathering of information and to gain an understanding of what the sexualised behaviours were and why a referral had not been made previously. MASH enquiries commenced on the 19th July. The case did not go directly to a S47 investigation as no disclosure had been made, however the reported sexualised presentation, which can be indicative that a child has been sexually abused, was from an informant who was reported to be a professional with experience of direct work with sexually abused children This transfer to MASH was five days after the initial referral and outside of Manchester’s timescale for decision making and assessment. The review team were advised that this was due to workload, and whilst this was a clear perception it was not                                                       8At the time of the review the school had pupils in Year 7, Year 8 and Year 9 attending, reflecting the time the school had been open. The proportion of pupils who were eligible for funding through the pupil premium was well above the national average. Many parents chose the school because of its small size and good pupil/teacher ratio (DfE Ofsted Inspection report: 11–12 May 2016) 9 DfE Ofsted Inspection report: 11–12 May 2016 MSP Child Q1 SCR Page 9 of 21 able to be tested for accuracy. The impact in this case was however that vital information from the school was lost due to its closure10; including what the specific expertise the teacher in question had in relation to CSA. Practice at the time of the review was for MASH to identify the level of concern and if a further assessment was needed for this to be carried out on transfer to the local team who would make a decision regarding the type of investigation required. 6.10 Enquires were carried out by all the agencies although not as effectively as they might have been. The MASH health enquiry collated information about Child Q1’s siblings and parents which contributed to the risk assessment that identified that further social work intervention was required. Health information was not requested from school health, as Child Q1’s school was outside of Manchester, to do so would have been good practice as Child Q1 was the subject of the enquiries. This would have identified the previous CAF raised by the primary school and the concerns raised in relation to Child Q1’s learning needs and mother’s need for support. Information relating to family history would also have been available. The health representative in MASH reported that at that time they did not routinely contact health providers outside of Manchester. This was due to a misunderstanding in relation to the process and partly due to the need to provide information quickly. In this case the MASH enquiry was already out of expected timescales so decisions were made with local information only. Subsequent amendments to the MASH health enquiry process, outside of this review, have focussed the MASH health enquiry to prioritise collation of health information proportionate to the presenting concern and risk. Information provided by GMP related to the immediate family and therefore it was not until wider family information was requested that important relevant information with regards to the family history was identified and shared. Initial searches within CSC did not identify the historical information relating to earlier domestic abuse referrals in 2005, mother’s past history or the previous CAFs in relation to the family. This was in part due to changes from paper to electronic records and the fact that CAFs at the time were not held within CSC. Had this information been readily available known risks to Child Q1 would have been identified earlier.  However despite this because of the concerns identified within the referral a decision was made to transfer the case to the local team for further investigation. This was good practice. 6.11 The case was allocated to a social worker who was about to go on annual leave. This was ineffective management and has been addressed outside of the review. A colleague, realising the importance of prompt follow up and the delay that had already occurred, did an unannounced visit on the 28th July.  Child Q1’s mother was unaware of the referral by school and reported to be concerned about the issues raised. Child Q1’s mother was accepting of the social worker talking to all three children on their own and having a discussion with Child Q1 of their understanding of appropriate and inappropriate touching.  This showed a level of skill and competence from the social worker concerned and was excellent practice and resulted in Child Q1 disclosing to their mother later that day that they had been abused by their step grandfather.  6.12 Child Q1’s mother contacted the police later that day informing them of the disclosure, that Child Q1 had reported being sexually abused by their step grandfather since they were four years                                                       10 Following an Ofsted Inspection 11–12 May 2016 and follow up inspection in December 2016 where the school was identified as inadequate a decision was made to close the school in July 2017 MSP Child Q1 SCR Page 10 of 21 old and the last time being the previous week possibly the 20th July 2017. This was two weeks after the initial referral and only came about because a social worker identified the risk, had the necessary skills to gain Child Q1’s mother’s confidence and the confidence knowledge and skill to carry out direct work with Child Q1 and their siblings. This was an excellent piece of work and highlights the importance of professionals who work with children having the confidence to talk to them in an age appropriate way and ask appropriate questions when their behaviour raises concerns. The need for this to occur is an area highlighted in previous Manchester SCRs11 as well as national research12 and is particularly important when CSA is suspected but when there has been no disclosure.  6.13 On the 29th July 2017 a strategy meeting was held in relation to Child Q1 and their siblings. A S47 investigation was commenced, decisions at the meeting included; appointments to be made for child protection medicals, an ABE interview and a referral to the Sexual Abuse Referral Clinic (SARC) by the police. This followed normal practice and was an appropriate response. The referral was received by the SARC on the 31/07/2017 and related to a serious sexual assault on the 20/07/2017 (11 days previously). Following further information received from the police on the 02/08/2017 relating to step-grandfather’s history, a disclosure was made by Child Q1’s youngest sibling regarding inappropriate sexual behaviour; and information was received from Child Q1’s mother advising that Child Q1 had disclosed that step-grandfather had sexually abused them on occasions since the age of four. A decision was made on the 04/08/2017 by the SARC to either see Child Q1 straight away and the two siblings at a later date, or see them all together in 2-3 weeks’ time. Child Q1’s mother made the decision for all the children to be seen together and an appointment was made for 23/08/17. 6.14 On the 7th August 2017 a further strategy discussion was held which included a representative from Manchester school health, Police and CSC. Actions agreed were: to follow up SARC medicals; ABE interviews which had not been actioned which caused delay; a further social worker visit; and a review strategy meeting to be held once all agencies returned from the summer holidays to assess the need to go to a CP conference. The school nurse for Child Q1’s school was not invited and no information was requested which again meant that previous information regarding the family was unavailable. Whilst it is not unusual to hold more than one strategy meeting when not all the information required to risk assess has been gathered, Working Together13 states that an Initial Child Protection Conference should be held within 15 days of the Initial Strategy meeting unless a decision has been made not to convene a conference. The decision to convene or not convene a conference was not formally made and led to some drift in the case. A third strategy meeting was planned but not held. Whilst the decision to cancel it may have been appropriate, with CSC making the decision that the children were Children in Need (CiN) rather than Children in Need of Protection, it would have been more appropriate to have held either the third strategy meeting or a professionals meeting to share information and agree whether or not there was a need for an Initial                                                       11 Child G1 SCR 2018 and Child F1 SCR 2018 12 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia 13 DfE Working Together to Safeguard Children 2015 p40 MSP Child Q1 SCR Page 11 of 21 Child Protection Conference or whether they fitted the criteria for CiN (both parents had acted very appropriately once Child Q1 disclosed the abuse and the concerns raised by the school relating to neglect that do not appear to have been substantiated). A professionals meeting or strategy meeting would have provided an opportunity to explore these issues, ensure all relevant information was available and identify a clear plan of action.  6.15 ABE interviews were requested on the 08/08/2017 and took place on the 09/08/2017.   6.16 On the 23rd August 2017 Child Q1 and their siblings were seen at the SARC clinic. This was some time after disclosure, but due to Child Q1’s mother’s wish for all three children to be seen together. Psychological support was already being provided therefore the delay in this case did not affect the outcome, either from a forensic, physical or emotional perspective.  6.17 On the 18th September 2017, a CiN meeting was held, with representation from CSC and Child Q1’s school. Neither the siblings’ school, school health nor the GP were invited. There did not appear to be any consideration to some of the concerns previously raised in relation to Child Q1’s learning needs or any evidence of follow up in relation to this, i.e. referral to a developmental paediatrician to assess Child Q1’s learning needs and whether they were organic in nature or due to the abuse they had suffered. This was due to a lack of understanding of the role and presumed availability of school nurses. It has since been addressed and features in individual agency action plans and has therefore not been included as a specific recommendation.  6.18 At the time of writing the report the lack of records from the Free School, the inability to identify staff who were at the school and the lack of forensic evidence has hampered the CPS’s ability to provide sufficient information for them to consider a conviction in this case. A decision has therefore been made not to prosecute step-grandfather.  This has caused distress to both Child Q1 and their family.    MSP Child Q1 SCR Page 12 of 21 7.0 RESPONSE TO RESEARCH QUESTIONS 7.1 What factors affected the Free School’s response to their initial concerns in relation to Child Q1 to their referral to CSC in July 2017? 7.1.1 Free schools were given approval in the Academies Act 2010. The Act also stipulated that all new schools had to be academies or free schools. This meant local authorities lost their power to create new schools or monitor them in any way. A concern raised by many Local Authorities at the time of their inception and since. The Free School in this case was part of a business group of Free Schools which was approved by the DfE in 2013. Free schools are set up, through a specific application process, by groups of parents, teachers, charities, businesses, universities, trusts, religious or voluntary groups as non-profit making organisations and are funded directly by central government. Whilst legally they are academies’ and held accountable through the same mechanisms, i.e. the Funding Agreement between the Secretary of State for Education and the Academy Trust which operates the free school or academy, there are some requirements for free schools that are not the case for academies. Specifically free schools must be in response to local demand. For most schools that means there must be a petition from parents in the area naming the school as their first choice. Unlike local-authority-run schools, they are exempt from certain requirements including teaching the national curriculum and are able to use non- qualified teachers. Free schools are often also the school chosen by parents whose children are experiencing difficulties in school and who feel a small school would be more able to support their children’s vulnerability. This was the view of Child Q1’s mother at the time.  7.1.2 Lord Nash14 in his investigation into the effectiveness of Free Schools highlighted problems that new free schools were faced, problems that are often not educational in origin. They included: “New, inexperienced and often isolated trusts needing to upskill themselves to run a school for the first time; instability in principal appointments and senior leadership teams." All of these issues were present at the Free School in question along with the lack of up to date policies and procedures, inexperienced staff and lack of training as identified in the Ofsted Inspection15. Additionally the school did not respond to requests to attend meetings or to pick up Child Q1’s school file from their primary school. Child Q’s mother took a copy of their educational records to the secondary school. There is no evidence to show however that it was ever used to provide either education or social support and was not part of Child Q1’s files at the time of school closure.  This lack of information would have contributed to staff at the school not identifying concerns relating to Child Q1 for some considerable time.  7.1.3 CSA can be difficult to identify unless there is a direct disclosure16, however a child’s behaviours may lead professionals to consider this as a possibility and ask appropriate questions and liaise with other professionals working with the child. This did not occur in Child Q1’s case, with education staff not sharing their concerns or liaising with school health or the previous school to                                                       14 DfE Future Academy System: Lord Nash, Guardian Newspaper accessed 6th June 2018 15 DfE Ofsted Inspection report: 11–12 May 2016 16 Children’s Commissioner; Protecting Children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action Summary November 2015 p10 MSP Child Q1 SCR Page 13 of 21 acquire/share information regarding any previous concerns relating to Child Q1. They were dealing with a child who they knew had learning needs but had not received an assessment since being at secondary school. Lack of knowledge and challenge of Child Q1’s behaviour could have initially led staff to believe that some of their behaviours were caused by their learning needs rather than because they were being abused; however they should also have been aware that children with special needs are three times more likely to be abused than their peers17.  It has not been possible to discuss with staff from the school due to the closure and the difficulty the police and other agencies have had in contacting them. Their view on the situation has therefore not been able to be sought. It would appear though that without the input of Child Q1’s teacher a referral may not have been made.  7.1.4 From the school’s inception the local authority provided support in relation to safeguarding training with various principals attending training for designated safeguarding children leads. Between 2014 and 2016 the school was offered and received whole school safeguarding training, Prevent awareness training and Local Authority Designated Officer (LADO)18 training. This was good practice, however it does not appear to have been embedded in practice as when Ofsted inspected the school in 2016 their report clearly identified poor safeguarding processes. Because there  no requirement by Ofsted or the school to share any reports with the local Safeguarding Board it is difficult to identify and support schools with poor a safeguarding record unless picked up by safeguarding audits including such as S11/S175 audits19.  7.2 Child Q1 was reported to have learning difficulties. Did this have an impact on how the school managed their concerns 7.2.1 Disabled children are at significantly greater risk of physical, sexual and emotional abuse and neglect than non-disabled children.20 Some figures would suggest that they are three times more likely to be abused than their non-disabled peers. Those disabled children at greatest risk of abuse are those with behaviour/conduct disorders. Disabled children are also more likely to be abused by someone in their family compared to non-disabled children and the majority of disabled children are abused by someone who is known to them. Additionally disabled children may disclose less frequently and delay disclosure more often compared to typically developing children21. Ten of the children who were the subject of SCRs in the tri-annual review was identified as disabled with the report identifying that:                                                        17 Ibid p8 18 Now known as Designated Officers: DfE; Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children July 2018 19 DfE Education and Skills Act 2008 20 Sullivan, Vernon and Scanlan 1987; Cross et al. 1993; Sullivan and Knutson 2000; Kvam 2004; Spencer et al. 2005); Jones et al.2012 cited NSPCC David Miller and Jon Brown October “We have the right to be safe” Protecting disabled children from abuse 2014  21 NSPCC David Miller and Jon Brown October “We have the right to be safe” Protecting disabled children from abuse Main Report Prepared by 2014 MSP Child Q1 SCR Page 14 of 21 “physical injuries, challenging behaviours, developmental delays, poor growth, and unhygienic living conditions can all be left unchallenged or attributed to the child’s disability rather than identified as symptomatic of abuse or chronic neglect“22.   And  “Education practitioners need to be alert to the possibility of abuse or neglect with a disabled child, as with a non-disabled child”. The report also emphasises the importance of a child-centred approach in the context of prevention and effective safeguarding and the consequences of not hearing the voice of the child. 7.2.2 In this instance there is evidence that Child Q1 had learning difficulties including dyslexia and that their learning needs had been identified in Primary school. An educational psychology assessment had taken place in Year 4 and Year 6 with clear recommendations as how best to support Child Q1 both academically and socially. Child Q1’s secondary school did not respond to the primary school’s request to attend a transfer meeting or their further email or telephone contact requesting contact being made to enable transfer of records. There is no evidence that this advice was ever acted on once Child Q1 transferred to secondary school; nor is there evidence that a further educational psychology assessment was made or a clear education plan initiated so that changes in learning, mood and behaviour could be adequately assessed. Research identifies that children who have been sexually abused can shut down and present as though they have a learning difficulty. This and the lack of training/ skills within the school and no dedicated SENCO coordinator, all areas identified by the Ofsted inspection in 2016, would have impacted on the delay in a proper assessment of Child Q1’s needs and assessment of their behaviour despite the fact that they did have the same teacher for the period in question; a teacher with reported previous experience of CSA. It was this teacher who carried out the home visit and was responsible for the referral to CSC.  7.2.3 The possible late referral in this instance (without the benefit of records and staff involvement) because a young person has or is perceived to have learning difficulty is not something unique to this case and has been identified in a number of national SCRs as well as a recent Manchester SCR23. It is also not a problem just for education but for all agencies working with children24. However where staff are alert to concerns and able to demonstrate: “Professional curiosity and awareness of possible maltreatment and cumulative risk…..practitioners are able to challenge parents and explore a child’s vulnerability or risk while maintaining an objective, professional and supportive manner”25 timely and appropriate referrals are more likely to occur.                                                       22 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia p70-71 23  MSCB Child I SCR 24  DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia 25  Ibid p141 MSP Child Q1 SCR Page 15 of 21 7.3 Schools Safeguarding Arrangements  7.3.1 Schools have a responsibility to safeguard children. These responsibilities are set out in Primary Legislation26 as well as statutory guidance27. The guidance states that:  School and college staff are particularly important as they are in a position to identify concerns early, provide help for children, and prevent concerns from escalating.   All school and college staff have a responsibility to provide a safe environment in which children can learn.   Every school and college should have a designated safeguarding lead who will provide support to staff members to carry out their safeguarding duties and who will liaise closely with other services such as children’s social care.   All school and college staff should be prepared to identify children who may benefit from early help.  Any staff member who has a concern about a child’s welfare should follow the referral process …. Staff may be required to support social workers and other agencies following any referral.   The Teachers’ Standards 2012 state that teachers, including head-teachers, should safeguard children’s wellbeing and maintain public trust in the teaching profession as part of their professional duties. 7.3.2 Additionally school and college staff need to be aware of systems within their school or college which support safeguarding and these should be explained to them as part of staff induction. This should include:  child protection policies  the role of the designated safeguarding lead   receiving appropriate safeguarding and child protection training including the types of abuse and neglect so that they are able to identify cases of children who may be in need of help or protection  understanding the referral process to children’s social care and the need for multi-agency working  know what to do if a child tells them they are being abused or neglected.   7.3.3 Both Ofsted and the Local Safeguarding Children Boards (LSCB) have a role in ensuring these responsibilities are met; Ofsted through the inspection process and LSCBs through their section 11 audits28.  Whilst the majority of schools take these responsibilities seriously there have been a number of schools have failed their Ofsted Inspections and been found inadequate. For many of these this has included a failure in their safeguarding responsibilities29. Within the period under review only two schools Manchester were identified as inadequate in relation to safeguarding one                                                       26  The Education Act 2002, Academies Act 2010 27  DfE Keeping children safe in Education; Statutory guidance for schools and colleges September 2016  DfE Working together to safeguard children; Statutory Guidance on inter-agency working to safeguard and promote the welfare of children 2015 28 Children Act 2004 29  Future Academy System: Lord Nash; Leaked to the  Guardian April 2014 accessed 8th June 2107 MSP Child Q1 SCR Page 16 of 21 of which was a Free School. The other borough involved did not provide the number of schools found to be inadequate following Ofsted Inspection during the period of review. However they both identified the difficulty in being able to identify when a Free School was failing and the lack of any statutory responsibilities to intervene. This hampered them in providing support to non-local authority failing schools. Despite this the local authority when made aware of any failings they responded to those concerns in a timely manner. In this case the school concerned failed its Ofsted Inspection over a number of areas including leadership and safeguarding which put vulnerable children at risk. It also failed to respond to a request in March 2017 to provide their LSCB with a section 11 audit. Had they done so any failings identified could have been referred back to the Regional Schools Commissioner for action as it reflected the continued poor safeguarding arrangements at the school. Where there is poor leadership within a school and where schools do not take their responsibilities seriously the risk of a pupil not being identified as at risk of harm is increased.    7.4 MASH Threshold and Assessment in Cases of CSA  7.4.1 The LSCB has responsibility to agree with the local authority and its partners the levels for the different types of assessment and services to be commissioned and delivered within its boundaries and to publish a threshold document that identifies the agreed thresholds and the processes in place to access services30.  Concerns about maltreatment may be the reason for a referral to local authority children’s social care or concerns may arise during the course of providing services to the child and family. In these circumstances, local authority children’s social care must initiate enquiries to find out what is happening to the child and whether protective action is required. Local authorities, with the help of other organisations as appropriate, also have a duty to make enquiries under section 47 of the Children Act 1989 if they have reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, to enable them to decide whether they should take any action to safeguard and promote the child’s welfare31.  7.4.2 At the time of this review the Manchester process involved initial referral to the Contact Centre which then referred onto the MASH, for assessment. In most instances the child and family are informed of the action to be taken for this to proceed. This did not happen in this case. Transfer from the contact centre to MASH should occur within 24 hours. In this case the transfer was delayed and took two days. In cases of alleged sexual abuse where there is no direct disclosure, MASH information gathering is then passed onto the District Team who will use it to assess whether to continue to a S47 investigation or CiN assessment. This will takes into account the information available as well as the fact that children rarely disclose until they feel comfortable and able to trust the professional or family member. CSA includes contact as well as non -contact activities and not always will children know or understand that they are being abused which makes it even more                                                       30  DfE Working Together to Safeguard Children 2015 31 Ibid  MSP Child Q1 SCR Page 17 of 21 important that they are provided with information to enable them to talk about what is happening to them and that their voice is heard32. 7.4.3 In this case a further assessment was agreed following agency enquiries and being assessed as Amber33. In cases such as this where there was a lot of information provided which would suggest CSA consideration could have been given to Child Q1 being RAG rated Red34 which would have required a speedier response. The case was transferred for further social work assessment, however this was not actioned until six days later due to the allocated worker being on annual leave. The delay could have been longer had not a social work colleague used good professional judgement and carried out a home visit. This delay showed a gap in management oversight which has since been addressed and was not normal practice.  7.4.4 Whilst there is a clear need for policies and procedures and referral processes when this becomes overly bureaucratic there is little opportunity for professionals to use their knowledge and challenge decisions they do not agree with.  7.4.5 Since this review, MASH process has been made clearer for professionals, with cases that clearly meet S47 thresholds being passed straight to the area teams for assessment. This includes where the referral relates to possible CSA but no disclosure has been made. To do otherwise puts vulnerable children at risk.   7.5 INTERAGENCY COMMUNICATION: WITHIN AND BETWEEN AGENCIES 7.5.1 “Effective safeguarding work depends on collaborative multi-agency working: no one professional retains all of the required knowledge or skills”35  The Tri-annual report by Sidebotham et al also identifies the importance of good multi-agency working in which different practitioners: “Contribute knowledge and expertise, acknowledging their own priorities, while respecting the knowledge, expertise and priorities of other team members.36                                                        32 Children’s Commissioner; Protecting Children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action Summary November 2015 p5 33 AMBER - Complex needs likely to require longer term intervention from statutory and/or specialist services. High level of additional unmet needs - this will usually require a targeted integrated response, which will usually include a specialist or statutory service. This is also the threshold for a child in need (S17 CA 1989) which will require a social care intervention. 34 RED - Acute needs, requiring statutory, intensive support. In particular this includes the threshold for child protection (S47 CA 1989) which will require Social care intervention. These cases may also require immediate police intervention as the child has been identified to be at risk of harm. 35 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham*, Marian Brandon**, Sue Bailey**, Pippa Belderson**, Jane Dodsworth**, Jo Garstang*, Elizabeth Harrison*, Ameeta Retzer* and Penny Sorensen** *University of Warwick **University of East Anglia p165 36 Ibid p. 153 MSP Child Q1 SCR Page 18 of 21 7.5.2 The report sees good communication as central to effective multi-agency working and that it depends on:  practitioner skills  effective systems and processes  a culture that values and promotes information sharing  a culture that enables shared information to be appraised and used to inform decision making and planning (p14). 7.5.3 Additionally Working Together to Safeguard Children 2015 (and more recently Working Together to Safeguard Children 2018) identifies the need for effective sharing of information between professionals and local agencies as essential for effective identification, assessment and service provision. It identifies early sharing of information as the key to providing effective early help as well as being essential to effective child protection services and that all organisations should have arrangements in place which set out clearly the processes and the principles for sharing information between each other, with other professionals and with the LSCB. 7.5.4 Serious Case Reviews (SCRs) have shown how poor information sharing has contributed to the deaths or serious injuries of children. Often it is a fear about sharing information that stands in the way, however in this case there was no agreed pathway for the GP to share information with school nurses which they felt would be a useful way forward. This is being addressed as a single agency action and therefore does not figure in the recommendations below.  7.5.5 The Free School’s failure to effectively access information from the previous school (they did not attend meetings or respond to email/telephone conversations relating to Child Q1) as well as their lack of understanding in relation to safeguarding and special educational needs put Child Q1 at risk. Additionally, there were no clear policies and procedures in place within the school to support this. Had the secondary school for instance attended the meetings at Child Q1’s primary school or responded to requests to contact them and pick up Child Q1’s records they would have known of the previous concerns and CAFA. The information would also have been available from school health records which would have recorded that there had been concerns relating to Child Q1’s development and enabled the school to meet Child Q1’s needs in a more pro-active way.  7.5.6 The transfer of records from one school to another can often cause problems when families move out of borough. It should not be a problem in borough or from feeder primary to secondary schools however it is dependent on the receiving school requesting them.  In this instance Child Q1’s primary school were pro-active in advising the Free School of the need to have the records; however it was Child Q1’s mother who accessed Child Q1’s records and took them to their secondary school. Where a child is vulnerable it would be good practice to ensure the new school had access to those records prior to them changing schools. Failure to do so puts children at risk. There is currently no process for this to occur.  7.5.7 In this Free School’s case it would appear that their lack of action in relation to responding to Child Q1’s needs was not unique to this child, in that they do not appear to have made any records of Child Q1's or other children’s needs, with minimal information available to new schools once the Free School was closed. This lack of information sharing put not just Child Q1 but several other pupils at risk of not having their needs met. MSCB have alerted the relevant local authorities of this MSP Child Q1 SCR Page 19 of 21 fact to ensure that schools taking previous the Free School pupils are aware of the need for follow up.  7.5.8 MASH did not initially gain information from the school nurse for Child Q1’s secondary school as it was not a Manchester school. Whilst in this instance this was because of an individual’s lack of understanding of the process, the review panel were made aware that it often takes longer for health information to be made available to MASH professionals if the child is at a school outside of borough. This has been further exacerbated due to recent changes in the commissioning and provision of health services and lack of access to each other’s IT systems. 7.5.9 There was a delay in relation to information sharing in the initial referral to the SARC, however this was remedied at the second strategy meeting and an appointment made for all three siblings. Information regarding current intervention by other agencies was not passed to the SARC which meant that much of the information available at that appointment is recorded as coming from Child Q1’s mother. Joined up working/ sharing of information between agencies could have reduced duplication in offering of follow up services (counselling etc.) and provided a more joined up approach to the family’s needs. 7.5.10 The decision not to hold the third strategy meeting in September resulted in there being no multi-agency discussion in relation to risk or how the case should progress, i.e. whether Child Q1 and their siblings remained at risk of significant harm or whether a Child in Need meeting was more appropriate. When the CiN meeting was held health was not invited to the meeting which resulted in only school and CSC attending. There were a number of health professionals who would have had something to contribute and a more complete assessment could have been carried out. This failure to invite 'health' is in many instances due to CSC’s lack of understanding of the different roles that different health professionals may have. In this instance it was also in part due to a lack of understanding of the availability of school nurses and lack of involvement by GPs in the CiN process.  Children’s Social Care are currently developing guidelines with their partners in relation to CiN which should address these issues. 8.0 LINES OF ENQUIRY The review panel were asked to incorporate the following lines of enquiry into the report: to attempt to provide a better understanding of the following aspects of service provision. They have been incorporated into the report but also highlighted below. 8.1 Cross boundary working - effectively sharing information regarding family members that may be resident in different local authorities to ensure that this is linked to the child to build a bigger picture  8.1.1 In this review Child Q1 resided in one borough and went to school in another, the same borough that maternal grandmother and step-grandfather resided in. Following the school's concerns regarding Child Q1 they referred appropriately to Manchester Children’s Social Care, the borough Child Q1 resided in. There does not appear to have been any delay in this because of any cross borough issues. There was however a delay in accessing the school nurse’s records due to the health MASH representative not contacting the school nurse as part of the information gathering. MSP Child Q1 SCR Page 20 of 21 This has now been addressed as identified in the narrative and should not in future cause any problems. Early access to historical information relating to the family was not immediately shared as it was not requested however once requested there was no delay in it being accessed and shared.  8.2 The management of inter-generational sexual abuse and linking families’ members and other household members to the child to undertake a robust initial screening of the referral to adopt an appropriate level of assessment  8.2.1 Initial requests for information depend on family information provided by the initial referrer and any information already on CSC’s files. It is unlikely, as in this case, that until further information is gathered and additional family members or an alleged perpetrator is identified that further checks would be carried out.  8.3 Was Child Q1’s suggested learning needs and vulnerability referred to any health or education professional for a formal assessment  8.3.1 Child Q1 had an educational psychology assessment prior to the period under review. This was passed onto their secondary school but no further assessment was carried out. There also appears to have been no regard given to following the recommended support identified in primary school. This meant that Child Q1’s vulnerability and educational needs were not adequately taken into account or risks adequately assessed during the period of time that they were a pupil at the Free School. 9.0 RECOMMENDATIONS  9.1 MSP review the current assessment processes to ensure risk factors relating to CSA are adequately covered. 9.2 MSP seek assurance that single agency CSA training is appropriate to the needs of that agency and feeds into the multi-agency training provided by the MSCB. 9.3 MSP reviews current training to assure itself that staff can recognise and been confident in addressing CSA. 9.4 MSP assure themselves that CSA training is embedded in local practice through audit.  9.5 MSP contact the DfE Education Skills and Funding Agency and the Regional Schools Commissioner to raise the concerns highlighted in this report with suggestions as to a way forward to enable support from the local authority when Academies and Free Schools are identified as having safeguarding concerns. 9.6 MSP contact the DfE Education Skills and Funding Agency and the Regional Schools Commissioner to raise the concerns highlighted in this report in relation to lost records/lack of information regarding HR records and possible breaches of the Data Protection Act where Free Schools and Academies are closed. MSP Child Q1 SCR Page 21 of 21 9.7 MSP share the learning from this review with the other borough involved for them to implement an action plan based on the recommendations. 10.0 AREAS OF GOOD PRACTICE 10.1 The Education Lead for Safeguarding in the area of the Free School was pro-active in offering and providing safeguarding training to the school following its inception in 2013. 10.2 The social worker who identified the need for a visit to be carried out whilst their colleague was on annual leave and then spoke to the children on their own showed a high level of professionalism and confidence in their practice. 11.0 CONCLUSION 11.1 Identification of CSA can be difficult and take patience and time. It requires skilled working with the ability to engage and listen and understand what a child is telling you. Additionally it requires supportive training, policies and procedures to be in place, good interagency working and sharing of information, with professionals respecting each other’s assessments and professional knowledge. This did not always happen in this case.   