Death of a 16-year-old child from natural causes whilst in custody at a Young Offender Institution. Review does not consider the circumstances of Child I's death. Child I lived with his mother, father and older sibling. For much of his childhood there were no known concerns but after transition to secondary school difficulties rapidly emerged. History of school exclusions, violence, theft, carrying weapons; arrested several times in possession of Class A drugs. Child I was placed in foster care and later entered Local Authority care under a voluntary section 20 agreement. At the time of his death, Child I was on remand for murder. Child I was a Black child. Learning includes: practitioners need to recognise 'subtle moments' that might present clear opportunities to help and protect a child; where children are identified as needing early help, it is important that parents and carers fully understand what this involves in respect of a coordinated, multi-agency approach to help and protection. Recommendations include: ensure that policy, procedure and practice relating to critical moments (both well established and those less obvious) is sufficiently robust to ensure effective safety planning; work with schools to ensure that they are able to identify children who show persistent behavioural difficulties; ensure that a multi-agency response to the persistent disruptive behaviour of children is sufficiently described in threshold tools; explore with primary and secondary schools how multi-agency involvement could be improved both prior to and at the point decisions are being made about permanent exclusions.
      
 Title:  Serious case review: Child I. LSCB: City and Hackney Safeguarding Children Partnership Author: Rory McCallum Date of publication: 2021  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.                           Serious Case ReviewChild IJuly 2021Rory McCallum, Senior Professional Advisor, CHSCPContents1. Introduction22. Key Circumstances, Background & Context43. Views of the Family84. Findings & Recommendations1111.Introduction1.1This Serious Case Review (SCR) was commissioned following the death of Child Ifrom natural causes whilst in custody at a Young Offender Institution (YOI). At thetime of his death, Child I was 16 years old and on remand for murder. He had aknown history of carrying weapons and had been arrested several times inpossession of Class A drugs.Over what was a relatively short period of time,Child I’s offending escalated significantly.  It was entrenched, serious and harmful.1.2Exactly how and why Child I became involved in such a spiral of criminal activityremains largely unknown.However, it is reasonable to assume that despitehaving ‘agency’1, he was unlikely to have chosen this path for himself. At variouspoints in his life, there would have been a range of factors at play that ultimatelydetermined the actions he took. It is highly likely that one such factor was criminalexploitation.1.3That said, the SCR neither seeks to excuse Child I’s behaviour nor dilute theimpact it had upon many, not least his victims and without doubt, his own family. Itdoes, however, recognise that for many children, the boundary between ‘victim’and ‘offender’ will often be blurred. Front-line professionals need to recognise thistoo and give sufficient priority to both areas as part of their practice. Put simply,when offending is driven by exploitation, one won’t be addressed without the other.1.4Whilst the SCR noted some positive work that was undertaken with Child I, hisstory reinforces a number of important lessons for practice. The SCR highlightsthe need for practitioners to be alert to a broader range of ‘critical moments’ thatcan arise in the lives of children.It also underscores the need for practice tocapitalise on the strengths of multi-agency partnerships when risk is predictablygoing to increase.1.5The need for ‘early help’ to be explained by professionals in such a way that it isunderstood by families is a simple, yet important, lesson identified by the review.The SCR also points to whether the offer of early help is early enough.Thesignificance of this latter point cannot be overstated.We know that diverting1 the capacity of individuals to act independently and to make their own free choices.2children from criminal activity and protecting them from harm becomes morechallenging the older they get.Once groomed and engaged, the pull-factors forchildren can simply be too overwhelming.Just as Child I was unlikely to havechosen his path, it was equally unlikely he had much choice to leave it.‘Having worked with good and decent young people who have been drawn into atwisted perception of reality by their gang elders – a world of enemies, honour andartificial territorialism that seems utterly alien to those outside the sphere of control– I’ve seen how lost they can become to reason. However hard their parents try totalk sense into them (and I’ve seen them try incredibly hard), gang elders exert farstronger control.’21.6When looking at Child I’s life in the context of criminal activity, serious youthviolence and exploitation, a number of themes are present that are neither uniquenor unknown.In this respect, the SCR has not sought to repeat many of thosefindings that have already been established from a range of comprehensivereviews3 4 5, rather it focuses on a limited number of areas upon which the SCRbelieves the local partnership should apply focus.Finding1:Practitionersnotonlyneedtorecogniseandrespondtowell-established ‘critical moments’, but ‘subtle moments’ too; moments that mightpresent clear opportunities to help and protect a child.Finding 2:We know much about the circumstances in which risk relating toexploitation, criminality and serious youth violence is predictably going to increase.Despite this knowledge, practice does not always accrue the benefits of a coherentmulti-agency approach.Finding 3: Where children are identified as needing early help, it is important thatparents and carers fully understand what this involves in respect of a coordinated,5 Serious Youth Violence – Thematic Serious Case Review – Buckinghamshire Safeguarding Children Partnership4 Vulnerable Adolescents Thematic Review – Croydon Safeguarding Children Board 20193 It was hard to escape – Child Safeguarding Practice Review Panel 20202 Young perpetrators of knife crime are victims too – Anonymous April 2018, The Guardian3multi-agency approach to help and protection.Without this understanding, theymay be hindered in their ability to provide informed consent.1.7The SCR has not considered the circumstances of Child I’s death at the YOI.These have been reviewed by the Prison and Probation Ombudsman (PPO) andwill be reported following the completion of Child I’s Inquest.2.Key Circumstances, Background & Context2.1Child I was a Black child who lived with his mother, father and older sibling. Formuch of his childhood, there were no known concerns and his primary schoolyears appeared largely uneventful.This changed following Child I’s transfer tosecondary school. After a year of being relatively settled, a number of difficultiesrapidly emerged.2.2In 2015, Child I (aged 13) came to the attention of Children’s Social Care (CSC)when he was reported to have stolen around £2k from his father. Throughout thisyear and later into 2016, there was a noted deterioration in Child I’s behaviour atboth home and school.There were serious incidents where Child I would bullyother pupils for money, many of whom were vulnerable.2.3As a consequence, Child I received a number of exclusions.In an attempt toaddress his worsening behaviour, the school provided weekly sessions ofindividual and group support via the Pastoral Team. Believing more was needed,attempts were made to engage Child I’s family in early help services.Recordsindicate that this offer was not taken accepted by Child I’s parents and that theyfelt the existing support in place was sufficient. Child I’s parents, however, recall adifferent version of events.They state that they never withheld their consent forhelp and given the difficulties they were experiencing with their son, they wouldhave willingly accepted any additional support being offered.2.4In early 2017, an incident took place at home during which Child I damaged hismother’s hearing aid. The Police were called, and Child I was arrested. Whilst incustody, Child I’s mother informed the Police that she had found a large knife in a4bag at home. Child I was bailed to return to the Police station with conditions notto contact his parents.He was placed in foster care and subsequently chargedwith common assault and criminal damage.2.5Child I returned home in late March 2017. Case records from the time show thatmother felt uncomfortable and sometimes fearful when Child I was at home. Shesaid that her son was very rude to her and had no respect. She described him aswanting to do as he pleased and not responding to any rules or boundaries.2.6Both parents were extremely worried for their son’s welfare and his peerassociations.They believed he would be best placed in secure accommodationfor his own safety.2.7In February 2017, Child I was permanently excluded (PEX) following six previousexclusions for disruptive behaviour. Child I was subsequently engaged at a localPupil Referral Unit (PRU), where he remained from early February 2017 until July2017.2.8In May 2017, Child I went missing during the school half-term. Nine days later, hereturned in the early hours of the morning with no explanation as to where he hadbeen.When spoken to, Child I said he went missing as he believed his motherwould lock him in the house over the holiday period. His mother believed he wasrunning ‘county lines’. Around the same time, the PRU reported similar concernsto the Police that Child I was involved in gang activity.2.9In June 2017, Child I was arrested on suspicion of Grievous Bodily Harm (GBH)relating to an incident which had occurred in April 2017. Neither his parents norother family members felt able to continue to look after Child I and he enteredLocal Authority care under a voluntary section 20 agreement6.2.10After coming into care, Child I remained in his first placement for only three daysand was subsequently missing for several weeks. When located, in Brighton, hewas with a known drug user, with a knife, a large sum of money and crackcocaine. Child I was detained in a YOI on six charges including one of false6 Section 20 Children Act 19895imprisonment.Bail (with conditions) was granted, and Child I was moved to aresidential placement in London.2.11At the time, Child I’s parents thought it would be best for Child I to be placedoutside of London.Records indicate that discussions were held with the familyabout the availability of local support. They also show that CSC staff were alert tothe fact that such action does not always mitigate risk, particularly in the long-term.2.12In October 2017, Child I received a 12-month Referral Order for three of theoffences committed in Brighton.Later that month, staff at his residentialplacement called Police to report that they had found a large knife in Child I’sbedroom. An appointment was made by the Police to attend and seize the knife.Child I was not seen or spoken to by officers.2.13Also in October 2017, Child I was arrested in Reading for Affray and possession ofcannabis. This incident was not progressed to charge after he was held overnightand questioned by the Police.2.14Over a period of ten days in late November 2017, Child I was ‘Absent’7 from hisplacement on five occasions. On 28 November 2017, Child I was again arrestedin Reading. This time he had 80 - 100 wraps of crack cocaine. He was held inPolice custody for two nights and then appeared in court. Child I pleaded guilty.2.15In December 2017, Child I started at a new school. He was described as beingacademically able, although he was not always well focused and was fallingbehind.Initially, Child I was polite to all members of staff.He followedinstructions, cooperated with his peers and had been performing well in lessons.2.16In January 2018, he became subject to an Intensive Supervision and SurveillanceOrder (ISS) and was required to wear an electronic tag.7 Police definitions - A person is ‘absent’ when they are not at a place where they are expected or required to be. A person is ‘missing’ when theirwhereabouts cannot be established and where the circumstances are out of character, or the context suggests the person may be subject ofcrime or at risk of harm to themselves or another. Note:  The Metropolitan Police Service no longer use the definition of ‘absent’ in their responseto missing children.62.17Two months after being at this new school, Child I’s behaviour and attitudechanged.He was reported to respond to male staff members but ignore and bedisrespectful to female staff.There was also a concern about the re-emergenceof his bullying behaviour, with Child I appearing to target one of the quieter pupils.2.18By April 2018, despite work via a Family Learning Intervention Programme, Child I’sfamily didn’t feel he could return home.However, they remained supportive andfully engaged with the range of practitioners trying to keep Child I safe.2.19In June 2018, Child I was arrested at his placement after staff found a whitesubstance on his bedside table which they believed to be Class A drugs.Nofurther action was taken. Child I stated that it was sugar that he had placed thereas a prank. A cannabis grinder was seized from his room.2.20In October 2018, Child I was arrested in the company of another male after he hadbeen seen on CCTV to place a large knife in a bush. He returned to retrieve theknife, unaware that the Police had seized it.He was arrested on suspicion ofpossession of an offensive weapon. He denied any wrongdoing and was releasedunder investigation.  No further action was taken.2.21In January 2019, Child I was arrested again, this time for intent to supply a Class Adrug. He was scheduled to answer bail but did not attend. Child I’s parents informedthe review that this was on the advice of his solicitor. No further action followed.2.22In March 2019, Child I was arrested in relation to an allegation of rape. During asearch of his room, a machete was found underneath his mattress. He was bailedto appear at a London Police station. He did not attend. Again, Child I’s parentstold the review that this was due to the legal advice given to their son.2.23In May 2019, Child I was arrested in relation to suspicion of murder. He was bailedto appear at a London Police station in June 2019. The placement where Child Ihad been for two years served notice due to the significant nature of his recentarrests.72.24As a result, Child I moved to another placement. Here, he did not adhere to hiscurfew, often returning at 1 or 2am in the morning. This was noted as not beingunusual. Whilst Child I reportedly kept in regular contact with placement staff, henever disclosed his whereabouts.2.25In June 2019, Child I was re-interviewed by the Police and charged in relation tothe offence of murder.  He was remanded into a YOI.2.26In late June 2019, Child I became unwell, and he was found unresponsive by YOIstaff on his cell floor. Paramedics were called and took him to hospital, from whichhe was transferred to another hospital for specialist care. Child I did not respondto treatment and subsequently died.3.Views of the Family3.1The independent reviewer met with Child I’s parents to better understand theirexperiences and to capture any views on how well professionals worked with thefamily.The CHSCP is grateful for their input.Both were fully supportive of theSCR, recognising that ‘whilst we can’t go back, we can only change what is aheadfor others’. ●Child I was described by his parents as an intelligent boy, with this beingevident from an early age. His parents also acknowledged that Child I appearedto have two sides to his personality, for example they experienced that Child Icould be very kind but were also aware that he could bully other children. ●Child I had a trusted mentor in secondary school with whom he had a goodrelationship. He was noted by his parents to listen to this mentor and was seento be doing well at this point in his life. However, his mentor left at short notice,and this affected Child I.He was upset and was reported to have helped thementor pack her things when leaving her office. ●Child I was also noted as getting on well with a subsequent mentor, althoughthis was time limited support.Despite attempts by Child I’s mother, she wasunsuccessful in her requests to keep this arrangement continuing.8●As concerns escalated in respect of Child I’s behaviour, his parents tried toemphasise these to professionals.For example, Child I was taking a differentroute home from school and was increasingly staying out later. They feltprofessionals were not thinking about what Child I was doing when he wasgoing missing and that the police did not care. They believe that Child I was justbeing seen as belonging to a group and not as an individual child at potentialrisk. ●Child I’s mother felt she was repeatedly asking professionals to listen to her,saying ‘[Child I] is not showing it but he is scared. Please get [Child I] out ofLondon and get him help. The response was for [Child I] to stay andprofessionals to work with him here. I wanted my son to be safe and get properhelp. They didn't listen to me or Child I’s father’. ●Child I’s parents felt frustration in that they were asking for help for issuesarising outside of their family, but they did not receive this. Child I came from aloving home, and they felt professionals would have intervened sooner had theconcerns come from within the family home. ●When Child I stole money from his father, his parents believed he did this tolook ‘cool’ amongst his peer group. When challenged by his parents about theconsequences of theft, Child I’s response was ambivalent and somewhatdismissive.It was as if experiencing prison would be seen as ‘a badge ofhonour’.●Child I’s parents recall recognising a point in time when the seriousness of therisk their son was facing became starkly apparent. This was when Child I toldhis mother that she couldn’t walk to the shops with him and that she should justmeet him there.Child I’s parents believe this was his way of protecting hismother from a risk of violence that Child I knew he was exposed to.●Whilst Child I’s parents would talk extensively to their son, it was clear to themthat he was telling them what they wanted to hear and that he was beingmanipulated / threatened by gang elders. ●Child I reportedly said that the Police told him to call his parents whenever hewent missing and confirm “he was okay and just late”.This was believed tohave been said as ‘advice’ to Child I so as to lessen the urgency / veracity ofany police response. Child I’s parents said their son used this strategy severaltimes.9●Whilst research shows that removing Child I from the local area may not havebeen effective, his mother queried whether other options to keep Child I safehad been fully explored. For example, some interventions appeared to beworking whilst Child I wore a tag.Child I would hurry to get home and wasactually arriving on time. ●Child I told his father (and another family member) that he left the family homethrough his own choice and had no regrets about doing so3.2Child I’s parents also highlighted some key messages for professionals:●Professionals should see children as individuals rather as a group. What worksfor one child may not fit another.●Listening to parents can help professionals help children as individuals; parentsknow their children best. ●Professionals need to reflect on the language used when engaging parents andexplaining the support that might be available.  Around the time Child I wasbeing reported to the police, if someone had offered help they would have‘grabbed it with both hands’.●Father particularly noted raising concerns and that these issues could havebeen ‘shut down’ earlier.  Both parents were adamant that they never withheldtheir consent for help and support. ●Professionals need to engage parents at the outset to check whether emergingissues align with the parental perception of their child.●Rather than focusing on labelling children, professionals need to focus onfinding out the underlying reasons about why a child is displaying disruptivebehaviours. ●Professionals need to spot early when something is wrong. Child I’s father gavethe analogy of a tooth decay. ‘First, you make sure you’re doing the basics suchas brushing your teeth properly.  If there’s a problem, you see a dentist as soonas possible.  If you wait too long, the tooth will need to be taken out’. ●Professionals need to be aware of the risk that children can be exposed to bysimply going to school by themselves. Criminal gangs are aware of thesechildren and will engage them on route. ●Child I’s mother felt that all children in Year Five and Six should have access totraining around criminal exploitation as part of the curriculum.103.3Whilst no specific recommendations are made in respect of the key messagessuggested by Child I’s parents, all of these issues will be formally considered by theSafeguarding Adolescent Working Groups in operation in both the City of Londonand Hackney. Any actions deemed necessary will form part of the action plans forthese groups respectively.4.Findings & Recommendations4.1In the four years preceding Child I’s death, his life was characterised by a patternof escalating risk, deteriorating behaviour and increased criminal activity. Thiscomplexity and the challenges faced by those trying to help Child I, including hisfamily, are fully recognised by the SCR.4.2Finding 1:Practitioners not only need to recognise and respond towell-established ‘critical moments’, but ‘subtle moments’ too; moments thatmight present clear opportunities to help and protect a child.4.3Much has been written on the concept of ‘critical’ or ‘teachable’ moments. Theseare described as ‘critical moments in children’s lives when a decisive response isnecessary to make a difference to their long-term outcomes.’8They include thepoint at which children are excluded from school, physically injured or when theyare arrested.4.4The thinking behind such moments is that they present opportunities where childrenare more likely to be receptive to help. In Child I’s case, there was limited evidencethat professionals capitalised on these moments or used them to pause and plan inthe context of risk.4.5This can be seen in Child I’s permanent exclusion from school and his entry intocare a few months later. Both were critical moments. In a relatively short period oftime, there was less oversight of Child I by those that knew him well and given his8 It was hard to escape Page 3, CSPRP 202011known history, risk over this period was arguably predictable. Despite these factors,neither event resulted in any focussed work with Child I about the dangers he mightbe facing.  They were missed opportunities.4.6This ultimately meant that there were no real barriers to those who were likely to bemanipulating Child I. A strong hypothesis is that gang elders took full advantage ofhim being ‘less visible’.After his exclusion and entry to care, it was now time forChild I to become a more important part of their ‘family’ and he was quickly taskedwith more criminal activity beyond Hackney’s borders.4.7The arrests that followed Child I’s sharp increase in criminal behaviour were alsocritical moments.Most can similarly be characterised as missed opportunities.Despite the known indicators, there was little evidence that practice by the policewas being driven by a ‘safeguarding first’ philosophy and a need to protect Child I.Actions were largely reactive and based on a criminal justice response to hisoffending.These are seen by the SCR as largely correlating with the concept of‘Adultification’.4.8As described by Davis and Marsh 20209, ‘adultification’ is a term ‘used to describehow preconceptions of children (specifically Black children) may lead to them beingtreated and perceived as being more adult-like (Goff et al, 201410). If Black childrenare seen as less vulnerable and more adult-like, services may overlook their needsand disregard their legal rights to be protected, supported and safeguarded.’ Whilsta relevant learning point, the SCR is aware that Adultification is an acknowledgedissuethattheCHSCPisrespondingtolocally.Assuch,no particularrecommendation is made in this regard.4.9Although Child I’s potential vulnerability was noted as being recognised after hisarrest in Reading, this didn’t appear to result in any escalated response by thepolice. For example, the SCR found no evidence of any disruption activity aimed atidentifying who Child I’s exploiters actually were.10 Goff, P.A., Jackson, M., Di Leone, B., Culotta, C. and Ditomasso, N. (2014) The essence of innocence: consequences of dehumanizing blackchildren, Journal of Personality and Social Psychology, 106(4): 526–545.9 Davis, J. and Marsh, N. (2020) Boys to men: the cost of ‘adultification’ in safeguarding responses to Black boys, Critical and Radical SocialWork, vol 8, no 2, 255–259, DOI: 10.1332/204986020X15945756023543124.10Whilst recognising that a number of local initiatives have been implemented tobetter respond to critical moments (such as specialist youth workers being locatedin hospital Emergency Departments), this is an important aspect of practice toreinforce.A critical moment needs a critical response.Practice in this respectneeds to be timely, systematic and underpinned by a coherent partnershipresponse. This should prioritise safety planning, mitigate risk and create pathwaysfor children to engage.4.11There also needs to be much greater emphasis placed on the disruption of thosewho are exploiting children.Whilst also a role for the wider partnership, the keypowers in this context rest with the police. Without downplaying the complexity ofthis task, such actions should always be a feature within the multi-agency responseto children who are being exploited or at risk of exploitation.This aspect shouldalso form a clear thread of any strategic approach by safeguarding partners, withthe fundamental aim of making it more difficult for exploiters to operate andultimately abuse children.4.12Of equal relevance is the recognition that critical moments won’t necessarily bedefined by a clear set of circumstances or specific events.They might relate towhat a child says or how they act. In this respect, the need for trusted relationshipswith children are essential, as is the need for practitioners to know the children theyare working with.Good relationships and effective communication can make amassive difference to children and their safety.4.13In Child I’s case, one such moment arose whilst in residential care.He told staffthat he didn’t want his electronic tag to be removed. Not much weight was affordedto this comment at the time. In hindsight, this could have been a cry for help or aserious suggestion from Child I about how he might be kept safe. This could havebeen his only excuse not to leave his placement and be criminally exploited. Thiscould have been a strategy to escape his exploiters (even if only temporarily),without being seen as the one making that choice.‘Once a child is part of a county lines gang their loyalty and commitment will betested. The gang will begin to trap the child by making them feel powerless to leave.This might include threats of violence if they leave, making the child feel like they13are betraying their new ‘family’, or telling the child they will get in trouble if they seekhelp because they have committed a criminal offence.’ (Children’s Society, 2019).Recommendation 1:Safeguarding partners should seek reassurance that policy,procedure and practice relating to critical moments (both well established and thoseless obvious) is sufficient robust to ensure effective safety planning.Recommendation 2:Safeguarding partners should seek reassurance from thePolice about the sufficiency or otherwise of local disruption activity targeting thosewho are criminally exploiting children.4.14Finding 2:We know much about the circumstances in which risk relating toexploitation, criminality and serious youth violence is predictably going toincrease.Despite this knowledge, practice does not always accrue thebenefits of a coherent multi-agency approach.4.15The safeguarding sector has a substantial evidence base on which to develop itsresponse to exploitation, criminality and serious youth violence.This has beenamassed through front-line experience, research, the Child Safeguarding PracticeReview Panel and from local safeguarding arrangements that have undertakenreviews concerning vulnerable adolescents.4.16Whilst accepting that intervention in this context is never easy, we do have a goodidea of what the early indicators of risk look like and the circumstances where thethreat of harm is predictably going to increase. One such indicator is wherechildren are displaying signs of challenging behaviour.4.17Whilst acknowledging that there will be numerous reasons why a child’s behaviourcan deteriorate, the SCR believes a much more nuanced approach is needed totackle it. A single agency acting in isolation is unlikely to ever get to grips with theroot causes of such behaviour, and neither will it be capable of mitigating futureconsequences, particularly in the context of risk. This latter point is key. Figurespublished by the Government for 2018-19, show that persistent disruptivebehaviour is the most common reason for both permanent exclusions (35%) and14fixed period exclusions (31%)11.When we know that exclusions (particularlypermanent exclusions) can significantly exacerbate risk for a child, it follows thatpersistent disruptive behaviour should perhaps be better framed as a coresafeguarding issue.4.18This does not mean that all such cases require a statutory social work response,but they do require early coordination of support across a range of differentagencies, and they need to be seen beyond just a disciplinary matter for theschool. A ‘Safeguarding First’ approach should apply, with practice being attunedto reflecting on the past and using this knowledge to focus on future risk. As onepractitioner said at the Child I’s SCR workshop: ‘Due to the numerous incidents,professionals were reviewing what had occurred rather than looking forward’.’4.19In Child I’s case, he made the transition to secondary school without any immediateproblems. One year into his new school, he received his first exclusion. 12 monthslater, he was permanently excluded.Over this period, the response to Child I’sbehaviour was characterised by school staff (and some other professionals) workinghard in collaboration with Child I’s parents.This was positive, but the school wasacting without the full engagement of other agencies that might have been able toprovide additional support. The school recognised this and attempted to facilitate areferral to early help services, but there was no consent from the family to progressthis further (see Finding 3).4.20The overall result was that whilst practice involved more than one agency, it wasn’tmulti-agency.There was limited presence of health services, with information onthe GP records (a conduit for all health-related information) being scant and nosignificant involvement from school nursing.4.21Early intervention with Child I appears to have been largely focused on hisbehaviour at school by the school. Improved coordination of this work with a widerset of agencies (and the family) might have helped more effectively addressed thecauses of Child I’s behaviour.11 Academic Year 2018/19 Permanent and fixed-period exclusions in England. Gov.15Recommendation 3:Safeguarding partners should work with primary andsecondary schools to ensure that they are able to identify children who showpersistent behavioural difficulties.On identification, the partnership’s early helpresponse should be robust and seek to mitigate known or possible safeguardingthreats.Recommendation 4:Safeguarding partners should ensure that a multi-agencyresponse to the persistent disruptive behaviour of children is sufficiently describedin the threshold tools of both Hackney and the City of London.4.22Commenting further on the issue of exclusions, the SCR does not criticise theindividual decisions of Child I’s school in this regard.Based on existingframework, the school acted entirely appropriately, particularly in the context of thesignificant efforts undertaken to help Child I. However, the SCR believes there is awider systems issue that exposes the inherent flaws in how exclusions arecurrently governed.4.23The SCR recognises that discipline is a key issue for schools, as is theirresponsibility to ensure all pupils are safe and have the opportunity to learnwithout disruption. Having said that, permanent exclusion is a known mechanismthat can exacerbate risk. It can inadvertently create more danger for children andas such, this should place this issue firmly under the umbrella of safeguarding.4.24In the opinion of the SCR, the current exclusion process fails to accrue thebenefits of multi-agency working, which as we know, is the most effective way tohelp and protect the young and vulnerable.4.25This does not necessarily mean that the overall accountability for decision makingneeds to change, but the SCR holds a strong view that no child should ever beexcluded without a process that engages the wider partnership.This should bedone for two reasons. Firstly, to leverage the maximum support available to keepchildren within mainstream school and secondly, if this isn’t possible, to begin earlyplanning for mitigating the predictable risk that will arise for some.16Recommendation 5: Operating within the current law and guidance concerningexclusions,SafeguardingPartnersshouldexplorewithbothprimaryandsecondary schools how multi-agency involvement could be improved both prior toand at the point decisions are being made about permanent exclusions.4.26Of equal relevance to this finding are the questions raised about why formal childprotection procedures were never initiated to safeguard Child I.4.27Prior to Child I’s permanent exclusion and entry into care, a number of risk factorswere clearly evident to the professional network. As early as 2016, Child I’s fatherwas reporting that things were deteriorating. He told professionals that Child I hadbeen seen with a knife in Brixton and two knives had been found in his bedroom athome.He was said to be climbing out of his window in the evening to leave thehouse and was not returning from school until very late at night. He had also beentalking on his phone until the early hours. At this time, Child I had also told schoolstaff he had been spending a great deal of time ‘hanging about his local area’ oftenlate into the evening.4.28These incidents, alongside those of Child I stealing from his father in 2015, thebullying for money and his defiant attitude were all potential signs that Child I wasbeing criminally exploited.4.29In this respect, there was a strong argument that Child I was at risk of sufferingsignificantharm.Despitethis,therewasnopartnershipresponse thatunambiguously placed intervention with Child I on a child protection footing. Therewas no strategy discussion, no child protection enquiry and no consideration as towhether a child protection plan was required at any stage of involvement withChild I and his family.4.30Some practitioners believed that had these concerns being dealt with under a childprotection framework, then this might have helped the professional network betterrecognise Child I’s vulnerability and better develop a plan of intervention to makehim safer.174.31The SCR acknowledges the variability that exists across many local areas in theiruse of child protection procedures when responding to extra-familial risk. It is alsoalert to the ongoing debate that is seeking to clarify how this work might better bedefined within relevant legislation and statutory guidance.124.32That said, learning from this SCR is clear.Whatever the source of risk(intra-familial or extra-familial), multi-agency practice should always be undertakenwithin the parameters of clear thresholds and clear procedures. These are key tomaking sure that children receive a service commensurate to their needs and thatthe multi-agency partnership acts as one.As it was, practice involving Child Ilacked this coherence and fell short in developing an agreed multi-agency plan tomitigate risk.4.33Whilst accepting that the existing child protection procedures might not cover thenuances of extra-familial harm, practitioners need to guard against this beinginterpreted that no multi-agency framework is required. In line with the HackneyChild Wellbeing Framework (and depending upon presenting risk), the processessupporting early help, child in need and child protection responses are all availableandshouldbeused.Whilstanimportantissue,theSCRmakesnorecommendation on this issue given it coverage as part of a previous Local ChildSafeguarding Practice Review undertaken by the City & Hackney SafeguardingChildren Partnership.4.34Finding 3:Where children are identified as needing early help, it isimportant that parents and carers fully understand what this involves inrespect of a coordinated, multi-agency approach to help and protection.Without this understanding, they may be hindered in their ability to provideinformed consent.4.35Whilst there is no debate that the school attempted to involve early help services,there are differing opinions as to why the family were never engaged. Some caserecords suggest that a lack of consent stalled the partnership’s ability tomeaningfully engage Child I at a critical moment in his life.The parents’12 The legal and policy framework for Contextual Safeguarding approaches (2020) Firmin and Knowles18recollection is different, and they are categoric in their view they would never haverefused help if offered.4.36The SCR deals with both scenarios as learning points.Firstly, an absence ofconsent for help is not a new issue for safeguarding professionals.There willalways be families who decide that they don’t want professionals involved in theirlives.Depending on the needs of the child and potential risks, some of thesedecisions will be justified, others won’t be. How practitioners react when consentis refused (and the level of professional curiosity and challenge they show) is animportant finding of the SCR.4.37It is established good practice to seek consent from families for help and support,unless doing so might place a child at a risk of significant harm.However, ifrefused, practitioners shouldn’t just end the conversations there. They should beprofessionally curious about the reasons why this is being refused and challengethose reasons where a child’s welfare might be compromised.4.38For any case involving similar issues as seen with Child I, these need to beapproached with a significant degree of rigour.These should be a firm focus onmitigating future risk and robust conversations with parents / carers that explainthe seriousness of what might happen if coordinated support isn’t provided andisn’t provided early.4.39The SCR is already alert to work being undertaken in Hackney to strengthen theapproach of practitioners seeking consent prior to referrals being made toChildren’s Social Care. This work is fully supported by local safeguarding partnersand aligns with statutory guidance. This SCR reinforces the need for the issue ofconsent to be a key focus for the partnership going forward, not only in how this isroutinely sought, but the response by practitioners when consent might not begiven.Recommendation 6:Safeguarding partners should ensure that local thresholdtools, associated guidance and multi-agency training set out clear practiceexpectations about seeking consent. These should include guidance for staff on19how to respond when consent is not given in circumstances where there areconcerns about actual or potential risk.4.40In conversation with Child I’s parents, it was clear that their understanding of whatan early help response might have involved significantly differed to that of theindependent reviewer.Neither parent understood this to involve the level ofmulti-agency coordination that would ideally follow in such circumstances.4.41In this respect, the issue of whether consent was given or not may be somewhatof a red herring.Focussing on this issue alone detracts from a simple learningpoint about how well the offer of early help is set out in Hackney and how this isconveyed to parents and carers. If not done in a way that fully explains how thisworks and motivates the parents or carers to see the difference it can make fortheir child(ren), they may see little point in engaging. To this end, the SCR makesthe following recommendation.Recommendation 7: Safeguarding partners should ensure that the multi-agencyarrangements for early help are underpinned by a defined strategy, clearprocesses and communication material to help practitioners explain the offeravailable to families in Hackney.20