A teenage boy, Jack, was sexually abused over several years from the age of 13, by multiple adult males. He had come out as gay to friends at school. The school had responded appropriately and his parents had sought help from the family GP. He was visiting adult chat rooms, being groomed and meeting individuals who posed a severe risk to him. There was significant multi-agency support for Jack, but services were not effective in keeping him safe from abuse. Good practice identified by the school and GPs. Key learning: a lack of understanding of technology assisted abuse and its effects; restricting a young person's access to technology will not keep them safe; we must educate children, young people, carers and parents in how to keep safe whilst online; child protection procedures were inconsistently applied; a lack of coordinated support for families and young people; absence of leadership and planning. Review was conducted using a Partnership Learning Review model. Recommendations include: the need to investigate technology assisted abuse and consider local responses to protect children and young people; to seek assurance from Police and Children's Social Care that child protection processes are fit for purpose; and that issues relating to practice identified by this case are being dealt with.
      
 Title:  Serious case review overview report: Jack. LSCB: Bradford Safeguarding Children Board Author: Stephen Ashley Date of publication: 2017  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.                                 Bradford Safeguarding Children Board  Serious Case Review Overview Report  Jack              28 June 2017     Report Author Stephen Ashley    2 Copyright of this report remains with the publishing LSCB(s) listed above CONTENTS SECTION ONE – INTRODUCTION 3 1.1 WHAT THIS REVIEW IS ABOUT 3 1.2 WHY THIS REVIEW WAS CONDUCTED 3 1.3 HOW THIS REVIEW WAS CONDUCTED 4 1.4 METHODOLOGY 5 1.5 HOW THIS REPORT HAS BEEN STRUCTURED 7 SECTION TWO – THE STORY OF JACK 8 2.1 INTRODUCTION 8 2.2 WHAT WAS JACK LIKE? 8 2.3 JACK’S STORY 10  SECTION THREE – ANALYSIS OF SIGNIFICANT EVENTS 24  3.1 INTRODUCTION 24 3.2 SIGNIFICANT EVENTS 24 SECTION FOUR – KEY THEMES 37 4.1 A LACK OF UNDERSTANDING OF TECHNOLOGY ASISTED ABUSE AND ITS DEVASTATING EFFECTS 37 4.2 THE LACK OF APPROPRIATE USE AND APPLICATION OF CHILD PROTECTION PROCEDURES 40 4.3 THE QUALITY OF THE INITIAL RESPONSE BY AGENCIES TO JACK AND HIS FAMILY 43 4.4 A LACK OF COORDINATED SUPPORT FOR FAMILIES AND YOUNG PEOPLE 45 4.5 AN ABSENCE OF LEADERSHIP AND PLANNING 48 SECTION FIVE – THE VOICE OF THE CHILD 49 SECTION SIX – GOOD PRACTICE 50 SECTION SEVEN – KEY FINDINGS         50       7.2 INTRODUCTION 50 7.3 KEY FINDINGS                                                                                                                                                                                     50 7.3 OVERALL FINDING 51 SECTION EIGHT – RECOMMENDATIONS 52 8.1 INTRODUCTION 52 8.2 RECOMMENDATIONS 52 SECTION NINE – CONCLUSION 52 APPENDICES 55 APPENDIX A 55 APPENDIX B 55 APPENDIX C 68 GLOSSARY OF TERMS 76    3 Section One – Introduction 1.1 What this review is about This serious case review concerns the case of Jack, a teenage boy living in the Bradford area.  The Bradford Safeguarding Children Board (BSCB) Serious Case Review Panel considered the case of Jack in 2015.  The panel concluded that there was compelling evidence that Jack had been sexually abused by multiple adult males and that this abuse commenced when he was 13 years old. It was apparent that agencies first became aware of the risk of sexual abuse in August 2010.  These events began when Jack informed school friends that he was gay during the course of 2010. Jack’s parents became concerned that he was in contact with adult males on line and that he had been groomed and planned to meet an unidentified male in Portsmouth in early 2011. The parents of Jack reported their concerns to West Yorkshire Police and sought medical assistance for Jack with the family doctor.  Two separate police investigations have been undertaken into sexual offences against Jack. Thirty-six adult male suspects have been identified, twenty of whom have been convicted of various sexual offences and grooming offences against Jack.  Jack has received support from specialist children’s services, voluntary sector organisations and specialist NHS services. His school was active in seeking support services for him.  Whilst there was significant multi-agency support for Jack, services were not effective in keeping him safe from abuse.  Consequently, there is evidence that Jack has experienced serious sexual, physical and emotional harm. 1.2 Why this review was conducted On 13th July 2015 the Independent Chair of Bradford Safeguarding Children Board (BSCB) agreed with a recommendation of the Bradford Serious Case Review Panel that this case should be the subject of a serious case review; under the requirements of the Local Safeguarding Boards Regulations 2006, section 5(1) (e) and (2).  The statutory basis for conducting a serious case review (SCR) and the role and function of a Local Safeguarding Children Board is set out in law by: The Local Safeguarding Children Board Regulations 2006, Statutory Instrument 2006/90.  Regulation 5 requires the LSCB to undertake a review 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.    4 Guidance for Local Safeguarding Children Boards (LSCBs) conducting a serious case review (SCR) is contained in Chapter 4 of Working Together 2015. This version of Working Together was used when deciding upon the serious case review process, as – having been published in March 2015 – it was the most current at the time decisions were taken about the review process. The purpose of this serious case review is to establish the role of services and their effectiveness in the care of Jack, whether information was fully shared by the professionals involved and child protection procedures were appropriately followed. This process ensures that any deficiencies in services can be identified and lessons learned to minimise the risk to other children or young people.  1.3 How this review was conducted 1.3.1 The Review Panel Prity Patel was appointed by BSCB as an independent chair. Ms Patel has over twenty years’ experience as a senior child protection lawyer in both the private and public sector.  Miss Patel has overseen a substantial number of serious case reviews as an independent safeguarding consultant. She reported directly to the independent chair of the BSCB.   The lead reviewer/author was Stephen Ashley who has extensive experience in the compilation of high level reports into child protection issues, having been a senior police officer for thirty years and worked more recently for Her Majesty’s Inspectorate of Constabulary.  The author reported directly to Prity Patel.   Both parties are independent of Bradford Safeguarding Children Board in accordance with Working Together 2015 chapter 4 (10).   In addition, a review panel was established. Meetings were held at regular intervals; the panel was consulted about the progress of the review and were able to provide further information where appropriate. The panel included a senior manager from each of the following key agencies:  Bradford Children’s Social Care  West Yorkshire Police  NSPCC  Jack’s school  Child and Adolescent Mental Health Services (CAMHS)  The Clinical Commissioning Groups  Bradford Council legal services The panel was supported by the Bradford Safeguarding Children Board (BSCB) business unit. 1.3.2 The Terms of Reference This SCR has been conducted using a Partnership Learning Review model1.  This methodology has been adapted to suit the circumstances of this review and is described in more detail in the next section. The methodology established how well systems have                                                 1 Partnership Learning Review – a model for conducting serious case reviews in accordance with Working Together guidance.   5 worked, and where they can be improved.  It is not a criminal or disciplinary review designed to attach blame to individuals.  The period that the review covers is 1st January 2009 to 31st December 2015. This period was selected following a serious case review panel meeting and is of a sufficient range to include all engagement that Jack had with agencies in Bradford. Although this period was the basis for the review, contextual and relevant information falling outside of it was also included.   The chair of the panel also agreed that the review would consider the support offered to Jack and his family following the court proceedings that arose out of this case. The main subject of this review was Jack who was a young teenager living and attending school in the Bradford area throughout the review period. The review was conducted in a way which:  Recognised the complex circumstances in which professionals work together to safeguard children.  Sought to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did.  Sought to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight.  Was transparent in the way data is collected and analysed.   Made use of relevant research and case evidence to inform the findings. Agencies that are involved in child safeguarding are required to follow the statutory guidance laid down by government. The guidance is called Working Together. It contains all of the processes that agencies are required to follow and has been through a number of iterations.  This review benchmarks against the statutory guidance contained in Working Together 2010. Whilst the period under analysis covers a number of versions of Working Together, the 2010 version seemed to the lead reviewer the most appropriate and most complete document to refer to. This is the version that professionals would be working to during the most critical phases of this case.  In addition, the lead reviewer has referred to Safeguarding Children and Young People from Sexual Exploitation 2009, which provides supplementary statutory guidance to professionals and is an addendum to Working Together. The author took full cognizance of the second annual report of the national panel of independent experts on serious case reviews that was published in November 2015. 1.4 Methodology The methodology agreed by the Bradford Safeguarding Children Board (BSCB) review panel for this review is based on a model consistent with the requirements of Working Together 2015. It ensures that:    A proportionate approach is taken to the SCR.  It is independently led.  Professionals who were directly involved with the case are fully engaged with the review process.   Families are invited to contribute.   6 1.4.1 Chronologies and Management Reports Agencies were asked to compile a report detailing their contacts with the individual involved in this case, resulting in a combined chronology of events. In addition, each agency was asked to highlight areas of concern and good practice.  Where appropriate, an action plan, detailing those areas for improvement and the work being undertaken to address those issues, was included. All of the agencies that were asked for a report provided the information requested. These reports are referred to as Internal Agency Review reports (IARs). In cases where further clarification was required agencies responded in an open and honest way. A list of the agencies providing reports is shown at appendix A.  In some cases, where contact with the subjects was minimal, agencies were only asked to provide a chronology and a covering report. In addition, a number of one to one interviews with front line staff and managers took place. 1.4.2 Learning Events Learning Events with front line practitioners are an essential part of the process. In the first of these front line staff and managers that had had contact with Jack were brought together for discussions around themes that had been identified from the chronologies and reports. This provided a view of their engagement with Jack that enriched the information provided by agencies and ensured that all of the relevant facts were recorded. It was the most effective way of triangulating the evidence and ensuring that an accurate picture of Jack and the traumatic events he has suffered were obtained. This review seeks to determine why events occurred and not just record the facts of what happened. The front-line view is invaluable in achieving this. While the details of discussions that took place were recorded, the comments made by the staff involved were non-attributable and they are not quoted directly in this report. For many front-line practitioners, this was the first opportunity for them to discuss with other professionals their engagement with Jack and his family; it was pivotal to the learning from these traumatic events. The second Learning Event was an opportunity to disseminate learning to a wider audience. 1.4.3 Family Engagement  Jack and his family have been engaged in this process and the lead reviewer has had a number of meetings with Jack and his parents to take account of their views. Jack’s parents have provided much background information and have been supportive of the process. In section two a brief summary of their experience and views has been included.  1.4.4 Parallel investigations Throughout the period covering this review a criminal investigation was being conducted by West Yorkshire Police that resulted in a number of prosecutions and convictions. The Independent Police Complaints Commission (IPCC) has conducted an investigation into a number of police officers following a formal complaint made to them by Jack and his parents2. This investigation is complete and the IPCC recommended a number of                                                 2 The Independent Police Complaints Commission oversees the police complaints system in England and Wales and sets the   7 disciplinary proceedings to be conducted against police officers. The IPCC informed West Yorkshire Police that nine officers should face disciplinary charges. Four of those officers retired before the investigation was concluded, two officers were given ‘management advice’ and three will face a discipline hearing for ‘gross misconduct’ in May 2017.   1.4.5 Timeliness of the report This report was originally commissioned in July 2015. Delays to the process were caused by on-going court proceedings and the IPCC investigation. In addition, another serious case review, covering the same period and many of the same issues, had been commissioned and it was agreed by the board that review would be completed before the same author began work on the review of Jack’s case. The matter was further complicated when there was a change of lead reviewer and consequently work on this review did not get underway until the end of the summer 2016. This delay was unacceptable but should not detract from the value of this review. Many of the issues raised have been dealt with in the intervening period and summaries of the work undertaken are contained at appendix B. Jack and his family have been kept informed of these delays. 1.5 How this report has been structured Following the introduction, section two provides a history of the subject involved in this review and is the story of what happened to him over the time period agreed within the terms of reference. It provides a synopsis and also tries to paint a picture of the type of person Jack is and the circumstances in which he lived during this period. Where an event has proved to be significant, it is highlighted and analysed in greater depth in section three. Section three analyses the significant events exposed in section two and explains WHAT happened and WHY. From this analysis, the key themes are discussed in section four, the voice of the child in section five and areas of good practice in section six. Section seven contains the key findings. The recommendations in section eight have been developed from these findings taking account of the work carried out by agencies since these events occurred. A summary of that work can be found at appendix B.  The conclusion is, in effect, a summary. It is an evidence-based view of the case. This report has been written so that it can be read by the public without redaction. As a result, the names of the main subjects are not used and there are no specific dates that might readily identify Jack or his family. Police officers have been identified by the code number allocated within the police IAR, to avoid confusion. In recognition of the comments made in the national panel annual report it is worth being clear that whilst there is considerable information contained in this report, section six details the specific findings.                                                                                                                                                         standards by which the police should handle complaints. They are independent and make our decisions entirely independently of the police and government.    8 Section Two – The Story of Jack  2.1 Introduction This section follows the story of Jack over the review period. Those events that are of particular significance are highlighted and examined in greater depth in section three. This section begins with a pen picture of Jack which, in order to maintain anonymity, is relatively brief. In addition, Jack’s parents have provided a brief impact statement detailing how these events have affected their family. This section is intended to provide a degree of context around the circumstances in which Jack was living during this period, the environment in which he had grown up and how these events have affected him.  The section then describes what happened to Jack over the period of this review. This section covers four distinct phases:  Phase One – August 2010 to February 2011   Phase Two – February 2011  Phase Three – March 2011 to January 2013   Phase Four – January 2013 to October 2015 2.2 What was Jack like? Jack lived at home with his parents throughout this time and his sibling was at university.  Interviews with the family indicate that Jack lived in a very stable family and his parents provided a warm and loving family home. Jack’s parents were professional people and until Jack reached his early teens there was nothing particularly remarkable about him or the environment in which he grew up. Jack attended the local primary school and at eleven moved to secondary education in a local school that has achieved high Ofsted ratings.  Jack was popular at school and was seen as an intelligent and hardworking boy. One of Jack’s teachers described him as: “in many ways unremarkable….he worked hard, settled in to school and was popular with his classmates.  Jack was the sort of boy who just got on with life, he was kind to others and amusing; he was, in effect, a model student”.  This section deals with what happened to Jack over the remainder of his teen years. The sudden change in his life appears to others to be near instantaneous.  At home his parents struggled to cope with the apparent change to his character and at school his teachers noticed a change that they could virtually time to the day when, out of the blue, he was disruptive in class. His teacher said, “I was teaching him the day things seemed to change……I had to exclude him from class and when I told other teachers no-one could believe it”.  These changes may have been (and at first were) attributed to the changes expected in young people when they move to senior school and begin the difficult process of moving into adulthood. However, Jack had an additional issue to deal with regarding his sexuality. He informed friends that he was gay and at that point it seems his life began to spiral out of control.    Jack’s life – between his realisation that he was gay at the age of 13 and the end of the review period in 2015 – was very difficult and painful. Jack has documented the impact that these experiences had on him: depression; self-harm; stress; extreme anxiety; loss of sleep; nightmares resulting in hysteria; panic attacks; lack of concentration in school; anxiety about his health and particularly in relation to HIV and STDs; ill health as a result of sexual assault   9 and medication which he has been prescribed which produced side effects such as bad headaches; a phobia of being touched on his neck after someone choked him; loss of friends and an inability to make new ones; withdrawal from his hobbies; loss of self-confidence.    Jack has faced a horrendous time and there is no doubt that the impact of those years will be felt by him and his family for the remainder of his life. Three years after the last reported crime against him Jack is still suffering from serious psychological and physical symptoms of his abuse. He has started to re-build his life but there continue to be incidents relating to the criminal justice system that cause considerable distress and further damage. There is however some reason to be hopeful about the future and perhaps the most important thing to say about Jack is the incredible resilience he has shown. Jack is intelligent and has shown amazing fortitude by continuing with his education, albeit he is now a year behind his peer group.  It can only be hoped that he is able to make a full recovery.   Jack’s parents and sister have also been hugely affected by these events and the following statement by Jack’s parents provides an opportunity to understand the devastation these events have caused. The statement is reproduced in unedited format:  “Six years ago, my wife and I were a happy couple with two bright and engaging children, we could not have imagined what the following years had in store for us all.   The enormity and horror of what our son suffered would be any parent’s nightmare; the effect on our family was, and is, truly shocking. The last 6 years have been increasingly horrific as the cruelty of the grooming and sexual abuse became clear and as we realised our son was being failed by the key statutory agencies.    Our lives have been totally trashed; changed beyond recognition. We had many friends and a busy social life but that has gone as, emotionally, we are no longer the people we were.  It’s hard to be with friends, we are just too sad, heartbroken and angry. We now find it very difficult to engage in what we used to regard as normal social relationships. Close family members are aware of the broad situation but we believe it would be unfair to burden them with full knowledge of the awful assaults on our son.    These should have been the happiest days of our son’s life; but he was robbed of his childhood. We still cannot bear to think of what was done to his young and immature mind and equally to his young and immature body. Even now we can’t manage that, it’s just too difficult. We have been through every emotion – disbelief; horror; sadness; guilt; frustration; bereavement; a loss of where and what we were before this nightmare began. Our great fear was that life would become too unbearable for him to go on and a fear such as that never quite goes away.   Much of the happiness and laughter has gone from our home. Although we are as close as we have always been, too often we talk or think of little else than the abuse of our son.   We must also mention our daughter. Our children still have a good and close relationship and our daughter is a strong support for our son. However, she was traumatised by what has happened to her brother and although she received counselling, which helped, she still cannot bear to talk about what happened to him.    We’ve been asked to comment on what we believe could or should have been done to make a difference. That’s not easy to do but we would point to the events in autumn 2010 when a police officer could have prevented all the harm that was suffered by our son.     10 In conclusion, our family has suffered and is still suffering hugely from the effects of these terrible crimes and by the interminable fight for proper support and compensation from the statutory agencies.”  2.3 Jack’s Story 2.3.1 Phase One – August 2010 to February 2011  Prior to the summer of 2010 Jack had not attracted any attention from safeguarding agencies. He had a good school record and was well regarded by his teachers and peers.  Jack had received universal services and apart from an overnight stay in hospital for a minor head injury there was nothing unusual or concerning in Jack’s interactions with services.  In August 2010 ChildLine contacted West Yorkshire Police to refer Jack. The referral was made to the police rather than children’s social care on the basis this was a criminal allegation. The police call handler took details and sought advice. The referral stated that Jack had contacted ChildLine through the ChildLine chat room. Jack disclosed that a male was threatening to place naked photos of him on the internet and there was also concern that Jack was entering chat rooms, not disclosing his age, and men were arranging to meet him for sex. The police recorded an extensive log, but the operator deemed this to be an incident requiring “parental control” and a supervisor stated it was not a ‘critical’3 incident.    Later that day a police officer was deployed to speak to Jack and his parents. There is some dispute over the conversations that took place between the police officer attending and Jack and his parents. The officer did submit a report of the incident, but ultimately the officer took no action and the log was closed. This officer was WYP7 who worked as part of his duties as a liaison officer at Jack’s school and is referred to in later incidents in 2011 and 2013.   This incident was the first indication to agencies that Jack was now in a difficult stage of his life, that he was clearly vulnerable and already at high risk from predatory paedophiles.   At this point Jack’s relationship with his parents deteriorated and he became difficult to deal with at home. At school Jack had declared, while he was on a residential school trip, that he was gay. This had the effect of alienating most of his male friends and his new friendship group were mostly girls. The school immediately put a well-documented process around Jack and the school clearly recognised that it was important that he received good support and was protected from any negative responses by his peers.  In December Jack’s father went to his own general practitioner (GP) to explain his concerns for Jack. The GP saw Jack alone and referred him to the school nursing team for additional support.  Jack saw the school nurse who offered appropriate advice and support. Following the Christmas holidays Jack again saw the school nurse and said things were settling down.  The school nurse completed the appropriate forms to keep the GP informed of the position.                                                  3 A police term.  Every incident recorded by the police receives a grading.  A ‘critical’ incident would initiate a number of pre-set actions and the report would be treated as one of high priority. Significant event one:  The police failed to deal with the referral from ChildLine in August 2010 in a professional way and according to child protection procedures.  The police did not investigate potentially serious criminal offences and an opportunity to prevent harm to Jack was missed at this first stage.   11 At this stage, at the beginning of January, the school, GP and school nurse team had good reason to believe that Jack’s position had improved and he was not particularly vulnerable.  They had demonstrated good support to Jack and his parents, had followed laid down procedures and communicated well.  Unfortunately, January 2011 was a turning point for Jack and the second half of that month saw a sharp decline in his behaviour and an increase in the risks he was exposing himself to. Jack was telling pupils that he was gay; Jack’s father discussed the matter with school and expressed his deep concerns about Jack’s online activity. The school raised their level of concern through their child protection procedures and referred Jack to ‘Hand in Hand’, a specialist sexual support service. They accepted the referral and used the BLAST project run by Men who have Sex with Men, Action in the Community (MESMAC) to provide support to Jack. BLAST is an organisation that specialises in supporting boys who have been subject to child sexual exploitation. Arrangements were made to meet Jack at the end of January.  Jack became more disruptive at home and at school. On visiting the GP for a minor ailment the GP referred Jack to the Child and Adolescent Mental Health Service (CAMHS) and he received an appointment for early February. By the end of January 2011 Jack was in serious trouble and the support put in place had not resolved the issues he was facing; in particular his use of the internet to contact individuals who posed a severe risk to him. Jack’s use of the internet and the lack of effective measures to control his use, despite his parents and others efforts, are a key theme in this review. 2.3.2 Phase Two – February 2011   February 2011 is perhaps the most significant time in this case. At the beginning of February all of the main agencies become involved in Jack’s case. Jack’s parents overheard him making calls that led them to believe that he was going to Portsmouth the following weekend, to meet a 23-year-old male who he had contacted over the internet. Jack’s mother later found that Jack had been sending explicit sexual images of himself to this unknown male.    Jack’s parents phoned the police and got little response and so attended the police station in person. The police recorded details and passed the information to their safeguarding unit, but no immediate response was forthcoming and the police did not treat this information with the degree of seriousness that you might expect. Jack’s parents also contacted the school who separately informed the police. The police added this referral to their log, with little or no further action.   Jack’s parents contacted their GP who correctly made a referral to Bradford Children’s Social Care (BCSC). Children’s social care also made a referral to the police. A meeting was arranged at the school; the police agreed to attend if Jack became disruptive, but were not specifically asked to be at the meeting. The police did however attend the school and seized Jack’s laptop. They also forcibly removed his phone from him. Despite seizing evidence, the police did not record a crime and it does not appear that an investigation commenced at that point. In fact, the police did not take a formal account from Jack until the middle of February.  During this week the school also received information from pupils that Jack had been visiting males in Leeds city centre and engaging in sexual activity with them. In addition, unknown males had contacted other pupils via Facebook in an attempt to find Jack. This had further heightened the school’s safeguarding concerns, given pupils were in contact with potential predatory child sexual abusers. Jack’s father had recovered clothing that appeared to have forensic value.      12 Neither the police nor BCSC responded in a meaningful way to these incidents. Even though there was a prima facie case for a number of crimes none were recorded at this time and child protection procedures were not followed. It was not until 14th February that a trainee detective had been allocated to the case and a video recorded interview (VRI) with Jack was conducted. This marked the beginning of the first police investigation that would continue until August 2013.  At the beginning of February 2011 Bradford Children’s Social Care (BCSC) received referrals regarding Jack from Jack’s General practitioner and the NSPCC (via Jack’s father).  BCSC were clearly in contact with the police in some regard since the police records indicate that a social worker passed further information to the police at the beginning of February 2011.   The referrals were explicit and provided details that were sufficient to consider that Jack was at risk of serious harm. That being the case a strategy meeting should have been conducted.  Paragraph 5.56 of Working Together 2010 states;         “Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children’s social care, the police, health and other bodies as appropriate.”  A strategy meeting was not called at this stage. While BCSC records are not entirely clear there appears to have been a meeting held at Jack’s school, at which there was attendance by a social worker. This was a meeting that the police were only to attend if Jack became disruptive. This meeting could not be regarded as a strategy meeting.  BCSC have records that state they conducted a strategy meeting and initiated a section 47 investigation4 in the second week of February. The strategy meeting took place between a social worker and her team manager. This does not fit within the definition of a strategy meeting under Working Together.  Whatever this meeting consisted of, the only decision made seems to be that Jack would be referred to ‘Hand in Hand’. In fact, this was a decision made by the school who had already referred Jack to them. BCSC records refer to a section 47 investigation being conducted at this stage, but again there are no records to support this and neither the police or health records support the fact that any form of meaningful multi-agency investigation took place.  A decision was made to complete a core assessment5. The core assessment was completed by mid-February, which was within the statutory timescale, and is broken into pre-set sections; all relevant professionals and family members should be interviewed. Whilst there is considerable comment in the assessment that Jack’s sister and aunt were important to him, they were not interviewed.  Nor were Jack’s parents. The BLAST project worker was not interviewed. The document states that Jack had engaged in sexual activity with older men; Jack was explicit in his response to the person completing the form, stating he fully                                                 4 Section 47 investigation – a multi-agency investigation fully described in appendix C 5 Core assessment – a statutory requirement under the Children Act 1989 and statutory guidance provided in Chapter 5 of Working Together 2010. Significant event two:  The police failed to record initial crimes and begin a criminal investigation in February 2011.  Lack of communication with other agencies at this point led to confusion around the role of the police and as a consequence evidence was potentially lost and offenders left to offend.    13 intended to continue his high-risk sexual activity. The core assessment acknowledges the stable and loving support provided by Jack’s parents. The only action it suggests is that a CSE strategy meeting should be called to reach agreement with other professionals on who can best support Jack. The assessment ticks the Section 17 (Child in Need)6 box as the most suitable engagement from BCSC. There is no acknowledgement that Jack is engaged in high-risk sexual activity and is likely to have been the victim of serious sexual offences, or that he is at very high risk of significant harm. It is unclear whether any form of initial assessment was carried out (as required under statutory guidance) or why a decision was made to move straight to a core assessment. This in itself would indicate that social workers knew Jack to be at significant risk of harm.  Following completion of the core assessment and the Children in Need (CIN) plan, Jack’s case was transferred to the Children and Young People’s Team (CYPT) – the long-term social work team. The Child in Need plan lacked detail and had no specific actions to be completed. The plan was a low-level document that failed to appreciate the high risk Jack faced.  It is a document that has pre-set sections most of which were not completed. There are no milestones and no meaningful outcomes are explored. The section that requires the next review dates is blank. The document could have been completed in a very short time.  A second assessment was completed in April and a third assessment three years later, neither of which added anything of significant value nor detailed expected outcomes.    Another Section 47 investigation was conducted by CYPT on 21st February 2011, following an allegation that Jack’s father had inappropriately restrained him. This was a single agency investigation, which concluded that concerns were not substantiated. Jack was appropriately restrained by his father as he felt Jack was going to run away with an alleged groomer who had come from Tyne and Wear to abuse Jack. CYPT agreed that Placement Support Services (PSS) would work with Jack and his parents on “parent and adolescent conflict issues” and all professionals would continue to support the family on CSE issues.  It is notable and concerning that a section 47 investigation was instigated when Jack’s father prevented him leaving the house to meet an offender, but that no action or consideration was given in respect of the high risk Jack faced from the male he had arranged to meet.      The referral to ‘Hand in Hand’ had resulted in the BLAST project becoming engaged with Jack; as were CAMHS who had each undertaken an initial assessment. Jack stated a preference to work with the BLAST project and CAMHS focussed their efforts on supporting Jack’s parents supported by the general practitioner.                                                 6 Section 17 – a Child in Need (CIN) plan is a multi-agency plan to support the child and their family more detailed legislation is contained at appendix C Significant event three:  Children’s social care had received referrals in February 2011 but did not follow child protection procedures.  No agency took responsibility for the case and the first ‘strategy’ meeting did not follow statutory guidance.  The lack of leadership and failure to follow child protection processes set the tone for this case and as a result Jack was not protected as he should have been.   14  2.3.3 Phase Three – March 2011 to January 2013   By the beginning of March 2011 decisions had been made that would have a profound effect on the outcome of this case. Over the next four years agencies remained engaged, to varying degrees, with Jack and his family.    Jack’s parents and his school continued to identify that Jack was engaged in high-risk activity. Jack’s behaviour continued to be based around his use of the internet and social media. This period proved to be the peak of his high-risk behaviour and the offending against him. Ultimately, by the time Operation Oakberry (the second police investigation) had concluded, the police had identified that Jack had engaged in activity with older men resulting in 39 serious crimes being recorded against him.  It is likely that the number of crimes was far greater. These crimes ranged from ‘grooming’ offences to rape.  36 offenders were identified and ultimately investigated. Jack would arrange to meet men in a variety of locations and on occasions would be picked up at school, taken away during the lunch hour to engage in sexual activity and be returned to school to continue his lessons.  The use of the internet to find and groom vulnerable children, and the ability of young people to expose themselves to those risks is central to Jack’s case. It is significant that this case centred on Jack’s internet use and the inability to control his use of it. The lack of control over social media sites and of apparent means to control content and prevent use by paedophiles for grooming children, are highly significant at this point. This is discussed as a theme later in the report.  Activity by agencies over this period broadly speaking fell into three categories: the police investigation; the use of child protection procedures; and support to Jack and his family.  Each of these three work streams is examined below.  The police investigation had effectively begun on 14th February 2011 when a video recorded interview (VRI) with Jack provided details of eight potential suspects and information from other people indicated a further three suspects. Following initial confusion, a trainee investigator from the divisional CID took over the investigation. This officer was under the supervision of an experienced tutor as he went through his training period.  However, for personal reasons that tutoring officer had little oversight of the investigation aside from the initial VRI. The trainee detective (referred to as WYP 23) retained the lead role in this case until the commencement of Operation Oakberry in August 2013. He investigated 11 suspects. He had no child protection training and no experience of involvement in multi-agency joint investigations. The level of support and supervision provided to this trainee detective was minimal. In all, 13 suspects were arrested between 25th February 2011 and 8th January 2012.    In April 2012 the former West Yorkshire Police Child and Public Protection Unit (CPPU) and District Adult Safeguarding Unit (SGU) had been merged into the Bradford District Safeguarding Unit (BDSU). This entailed a change in the unit’s remit and child protection officers became responsible for the investigation of a wider range of child sexual offences and were no longer restricted to intra-familial and ‘person in authority’ investigations. At this point that unit conducted any new investigations. In fact, only two new suspects came to light between June 2012 and January 2013.  BDSU investigated an offence in June 2012, which was the last ‘new’ offence to be investigated until the commencement of Operation Oakberry in August 2013. A second offence was recorded but not investigated in January 2013.  That offence was later investigated by Operation Oakberry.      15 Throughout this period suspects who had been identified and arrested were processed and charged and either convicted or acquitted at court. There is no evidence of any preventative or proactive work by the police.  Following specific complaints from Jack and his parents the Independent Police Complaints Commission (IPCC) have conducted an investigation into the way the police managed Jack, from the first reports to the police through to the commencement of Operation Oakberry. At the time of this report that investigation was complete and the IPCC has recommended gross misconduct proceedings take place against three police officers including WYP23.  Four other officers retired and two officers received ‘management advice’. The disciplinary proceedings regarding gross misconduct had not begun at the time this report was written.   In addition to the offences being investigated, Jack was reported as missing to the police on two occasions during this period.   On Monday 20th June 2011, the police received information from pupils at Jack’s school that he had arranged, over the internet, to travel to London with an older man the following Friday and stay with him for the weekend. This was followed the next day by another email to the police and copied in to BCSC in which the pupils accurately gave the police (via the school) the man’s correct name and date of birth. The man was 25 years old and Jack was 14. The police passed the information between officers without agreeing who would deal with the matter and a police sergeant from the neighbourhood policing team thanked the safeguarding lead at the school and in an email said: “Thanks for your note. In relation to the possible meet up on Friday, I am glad you let the parents know. We will continue to monitor it all.”    Despite accurate information about the way in which Jack intended to meet the man the police had taken no action 48 hours later. The police officer who was tasked with dealing with the issue informed colleagues she was on rest days, but in any event she expressed the view that: “as far as I can see it still comes under parental control as to his whereabouts Friday”. The police recorded no further action contemporaneously until calls were received on 25th June reporting that Jack had left with the male to go to London. It was subsequently recorded on the missing person log that WYP23 had visited Jack and his family on the evening of 24th June and advised him against going to London.   A question mark remains over the engagement of other agencies. BCSC were aware of this threat to Jack because of the email sent by the school, yet there is no record of any action or escalation by BCSC or any other agency. In effect the police were the sole agency to engage with the school over this issue. This was a critical incident and as such warranted participation by BCSC, but they did not become involved and allowed the police to deal with the issue as the sole agency.   When Jack was reported missing on 25th June police researchers, using information available on Jack’s Facebook page, correctly identified the address to which Jack had been Significant event four:  The police investigation conducted between February 2011 and April 2012 was poorly managed, cumbersome and lacked supervision.  As a result, opportunities to arrest and convict offenders were missed and Jack and other children were exposed to further risk and offending.  The police failed to consider preventative measures to reduce the risk to Jack and locate and arrest offenders.     16 taken. It took 43 minutes to get this information and action it from the time the original call had been received. The operation to recover Jack after the missing report had been received was conducted thoroughly and in accordance with police policies. Jack was found in London at the house of a man aged 25 who was arrested and later charged and convicted.    Jack was brought back to Yorkshire by his parents and the following day a detective inspector asked to see Jack and his mother at the local police station. There is some dispute over the exact nature of the conversation that took place between the inspector and Jack but Jack’s mother says Jack was given “a dressing down”, accused of facilitating the abduction, and wasting police time and resources. The officer broadly denied this. The officer also said he would have Jack put in a secure unit if things continued.  This had the effect of frightening Jack and his mother who began to fear the police and what they might cause to happen to Jack. The trainee detective dealing with the case, WYP23, told Jack’s mother that there was unlikely to be sufficient evidence to proceed against the man arrested in London. Jack’s mother showed the officer copies of conversations she had retrieved from the internet. This proved to be important evidence and the man was later convicted and received a suspended sentence.    One further missing from home call was received in respect of Jack. This occurred at the beginning of November 2012.  At 7.12am on that day ChildLine called the police saying that they had received a call from Jack indicating that he wished to commit suicide and giving a location for him.  Police called Jack and after a brief conversation during which he indicated he had left the location he hung up. At 7.20am an officer was despatched and went to Jack’s home address. At 8.25am he reported that he had located Jack and that he was now back at home. A ‘safe and well’ interview was conducted with Jack but it is unclear whether the information was fed into the CSE strategy group.    The use of child protection procedures is clearly laid down in statute. They should have been instigated following referrals to Bradford Children’s Social Care and the police. The failure to initiate correct procedures in February 2011 was further compounded by a continued failure to follow agreed process, procedures and statutory guidance from March onwards. Jack was now subject to a Child in Need (CIN) plan and had been allocated a Placement Support Services (PSS) worker.    On 9th March 2011, the first CSE strategy meeting was held. This was two months after the referrals to agencies on 3rd February. This was to be a multi-agency meeting where professionals discussed the case and the intention was to monitor the CIN plan. This would not have been an easy task given the brevity and lack of detail contained in that plan. A CYPT team manager chaired this first meeting. A number of key workers attended, including the police, but the school and Jack’s GP were not invited. It was agreed that this meeting would take place every six weeks and was on occasion referred to as a “Team Around the Child” meeting and a “professionals meeting”, demonstrating confusion around the status of this meeting amongst workers. There was no analysis of the risk faced by Jack. It does not appear that the meeting was a decision-making forum and as it moved forward through the remainder of 2011 and 2012 the status of the meeting is never made clear. On at least one occasion the meeting was hosted by the Bradford Safeguarding Children Board (BSCB) who Significant event five:  The police and children’s social care’s initial response to Jack’s intention to abscond to London with a 25-year-old male was poorly dealt with and lacked a multi-agency response, policy was not followed and as a consequence Jack was exposed to severe risk.     17 had no status as far as statutory meetings are concerned. A Placement Support Service (PSS) worker was allocated to Jack and they presented their assessment and the plan of work to the meeting in March. There appears to have been no cross over to the core assessment being conducted and the section 47 investigation put in place on 21st February.   A Community Resource Worker (CRW), who was not a qualified social worker, was allocated to the case and completed the second core assessment on 11th April 2011.  National best practice at the time states that only qualified staff should complete core assessments. This second core assessment seems to add nothing to the first. However, the CYPT Team Manager who was a qualified social worker approved it. The assessment concluded that the family was getting support from a number of agencies and Jack’s parents were working to safeguard Jack by balancing the risk of Jack going missing and meeting people he had met on the internet.  It stated that BCSC would continue to provide support under Section 17 of the Children Act 1989 (Child in Need status).    The first assessment concluded that BCSC would continue to offer further support around CSE issues. A final assessment was carried out some three years later but added nothing to the approach taken by professionals. It is remarkable that there was a gap of three years between assessments. BCSC decided that the Child In Need (CIN) plan would be monitored through CSE strategy meetings. There is no formal record in minutes of the plan being considered or adapted or any changes to the plan. Jack would remain under the supervision of a CRW rather than a qualified social worker.  A further CSE strategy meeting took place on 12th April 2011. It was the third meeting that had taken place.  The school nurse, police and GP were not invited. It was agreed that Jack was at high risk however the BCSC representative stated they would: “take a back seat as there are a lot of agencies involved”. Given the available evidence at this point and the clear desperation felt by Jack’s parents, this is a surprising conclusion to have reached and set the seal on the approach BCSC would take forthwith.  This was a significant meeting because after two months BCSC had, in effect, passed responsibility to a support worker (not social work trained) and decided that the case, while high risk, could be managed through the CSE strategy group which is of doubtful status, lacked any terms of reference, was sporadically attended by key professionals and was not strongly led. The case was not referred to an initial child protection conference (ICPC). It is of little surprise that Jack’s parents and some professionals felt that BCSC were failing in their responsibilities at this point. None of the other professionals appear to have challenged this position.  Nine CSE strategy meetings took place in 2011 and a further eight in 2012/13/14/15. It is clear from the documents provided that the intention of BCSC was that Jacks status should remain CIN and the CSE strategy meeting was responsible for monitoring progress. The service manager at BCSC had clearly made the decision that contact with Jack would be through a Placement Support Services (PSS) worker who was allocated on 9th March. That worker remained in place throughout 2011 and until January 2012. Her role is described more fully later in this section.   The PSS worker had regular contact with the Community Resource Worker from CYPT but it is unclear how regularly she received formal (or indeed informal) supervision. The PSS worker was heavily engaged with Jack until the end of 2011.   Significant event six:  The failure to conduct an initial child protection conference in March 2011 and the subsequent reliance on the use of CSE strategy meetings to monitor Jack’s progress failed to follow correct process and put Jack at high risk of further significant harm.   18  At the end of June 2011, a telephone conversation took place between the social worker manager and the child protection coordinator at BCSC. They noted that Jack continued to place himself at risk of CSE and that regular CSE strategy meetings were being held. Jack’s parents were fully cooperative and there were no concerns about their parenting. They also noted that they had discussed whether an initial child protection conference (IPCC) should be considered, but they felt that a child protection plan would not protect Jack. This is not commensurate with the seriousness of the offences against Jack and the statutory guidance contained at paragraph 5.81 of Working Together 2010, which states:  “Where the agencies most involved judge that a child may continue to, or be likely to, suffer significant harm local authority children’s social care should convene a child protection conference. The aim of the conference is to enable those professionals most involved with the child and family, and the family themselves, to assess all relevant information and plan how best to safeguard and promote the welfare of the child.”  It is not only BCSC that are statutorily in a position to call a conference; that responsibility could have been taken by a number of agencies. It seems that others were unaware of this fact and this is covered in the key themes.  There were discussions between the police and BCSC outside of the meeting structure to consider the use of secure accommodation7. It is not clear how this plan was to proceed.  However, the police CSE Coordinator contacted the PSS worker and informed her that she had discussed Jack with her manager and agreed that concerns were increasing in respect of Jack and he was a danger to himself. The police felt that Jack should be placed in secure accommodation, which would enable him to get appropriate support away from the alleged perpetrators in his life. It is unclear what discussions may have taken place between agencies or whether this proposal was seriously considered. However, four days later the social work manager emailed the service manager at BCSC to update on the current circumstances in relation to Jack. She pointed out Jack was at “very high risk” of CSE.  She outlined that the agencies working with Jack and his parents were fully participating in planning. The team manager expressed a view that she did not support secure accommodation for Jack, and this was in line with the view of parents and partner agencies.  They took the view that Jack was better placed at home.    It seems that the discussion around secure accommodation arose more out of desperation than a realistic prospect of using this as a realistic option. There was never any prospect of Jack being placed in secure accommodation as he simply did not meet the stringent criteria (see appendix C) but at this point professionals were desperate to find a solution that might work.  Ultimately CSE strategy meetings continued throughout 2012 and 2013 and offending against Jack seemed to reduce towards the end of 2012. It seems that BCSC were content to allow these meetings to continue with little or no further action. Professionals at the meeting have said they became frustrated but did not appreciate the options to escalate the case to a higher level. As Jack remained at very high risk the meetings seemed to be achieving little to lower that risk.  This was compounded because many of the professionals involved had little understanding of child protection procedures and their application outside their own field. The lack of understanding and application of child protection procedures is a key theme discussed later in the report.                                                  7 Secure accommodation – secure accommodation is an option available to the local authority to place a child and the legal position is explained in more detail at appendix C.   19  The fact remains that there was a systemic failure by BCSC to follow statutory guidance and this placed Jack at greater risk of harm.  In terms of support for Jack over this period there is mixed picture. Support for Jack and his family was considerable and provided from a number of sources. Predominantly Jack’s parents were doing everything they could think of to put support in place for Jack and to protect him. ‘Hand in Hand’ had commissioned the BLAST project to work directly with Jack and CAMHS were engaged with both Jack and his parents. The PSS worker also worked closely with Jack. Jack’s school and the school nurse team were proactively engaged throughout, as were Jack’s GP and Sexual Health Support Services. The police lacked understanding of how to support Jack but did allocate a police officer to work with him in some form of mentoring role.   Jack’s health and emotional needs were being addressed through a variety of different resources, including the worker at BLAST, high tier CAMHS input (a psychiatrist), placement support service worker and a ‘mentor’ from West Yorkshire Police. The Sexual Health Advisors spent a good deal of time with Jack, checking on his well-being, listening to his concerns and worries and providing additional support. ChildLine was regularly used by Jack to express his feelings in a ‘safe’ environment.  The Sexual Health Service was not directly involved in any strategy discussion or protection planning for Jack, except for general safety advice given to Jack during consultations in the clinic.  There is good evidence throughout the sexual health records that Jack was given several opportunities to discuss how he was feeling, what was happening at home and to check on the support he was receiving. In March 2011, the Sexual Health Advisor documents a “supportive discussion” during which Jack says that he was still arguing with his parents due to their restriction of his access to social networks.   From the point of view of sexual health, improved multi-agency information sharing could have been beneficial and an invitation to attend strategy meetings would also have been helpful. Nonetheless the Sexual Health Service provided consistently high levels of clinical and welfare support.  Jack’s family general practitioner (GP) was the first to raise a referral to BCSC. There was excellent continuity of care from the same two GPs during the timeframe of this review. This was instrumental in Jack and his family accessing support appropriately, especially around Jack’s mental and emotional wellbeing. Jack and his family found the GPs and the practice approachable and accessible.  The GPs were proactive in arranging reviews and monitoring Jack and his treatment. It is apparent that the GPs were aware of the harm to Jack, not only physically but emotionally. When concerns were raised by Jack’s parents about his emotional wellbeing when he first ‘came out’ as gay, the GPs took this seriously and arranged a prompt review of Jack. It was clear that the GP was keen to hear from Jack, rather than just to listen to his parents.  The GPs made a prompt and appropriate referral to the school nursing team to provide further support and assessment to Jack and his family. When the risk of grooming and CSE was raised, the GP made a prompt and appropriate referral to children’s social care.   The GPs triangulated information and supported both Jack and his parents during this period. This helped to gain a broad understanding of the situation over time from the perspective of both Jack and his parents and also provided holistic support to the family.   20  There is evidence of some initial good information sharing from the school nursing team to the GPs when they were seeing Jack about the family tension that had resulted from his use of social media and the internet. Despite the two teams using different systems for recording information, the school nursing team sent a paper update to the GPs.  There was evidence of prompt and appropriate two-way sharing of information between GPs and CAMHS by telephone and letters. These letters included information about the involvement of BLAST.  This case was regularly discussed at practice meetings during this timeframe to ensure that all clinicians providing input to the family were aware of the case, and to allow for reflection and peer support to the GPs who were involved in the case.  The GPs and school nursing team exhibited high levels of competence and clear knowledge and application of safeguarding best practice.  The Child and Adolescent Mental Health Service (CAMHS) received a referral at an early stage. They provided an early appointment and Jack was allocated a psychiatrist.  CAMHS stayed engaged with Jack and his family throughout the period of this review. They shared information and after consultation engaged with Jack’s parents who clearly needed support.  The PSS worker allocated by BCSC quickly established a good relationship with Jack and the family. This worker devoted a huge amount of time to Jack. She told Jack and his parents that she would be available to him until he was 18. In fact, placements were normally for 12 weeks. The worker provided valuable support until the end of 2011. There was no evidence provided about the relationship between the PSS worker and her supervisors. However, there were issues between her and her employer. In interviews with Jack’s parents and evidence provided by BCSC, Jack became part of a dispute between the worker and her employer. This was unprofessional and unhelpful. The timing of the worker’s withdrawal from Jack’s case could not have been worse (just before court proceedings commenced) and the dispute that took place to extend the worker’s attachment added to the distrust Jack and his family felt at this point for professionals.  Jack also contacted ChildLine on numerous occasions. In fact, he spoke with ChildLine counsellors on 20 occasions between March 2011 and April 2012. Jack made use of the ChildLine chatrooms and engaged in one to one engagement with ChildLine counsellors.  This provided an opportunity to talk freely about his feelings, his fears and frustrations. It appears that he accessed the online chat at times of increased stress.    ChildLine counsellors were available and open to listening to whatever concern Jack brought. From the transcripts, which include their questions/comments, they undertook risk assessments whilst the chat was on-going, asking pertinent questions to reduce the risk to Jack. They also challenged him when they felt he was thinking of behaving dangerously.  The breaches of his confidentiality (reports to the police and BCSC) were made appropriately, and the counsellor followed ChildLine procedures and made the referral to the appropriate agency for an urgent check to be made on his wellbeing.  The counsellors could have explored the support available to Jack, given he made several contacts, and there was little sense of a planned co-ordinated response to him. One counsellor was aware of the wider investigation, and counsellors were aware that support was being provided to Jack by psychiatrists and counsellors from other organisations. It is unclear what procedures ChildLine have in place to ensure they are part of the wider picture of support and protection for a child.      21 The police decided to engage an officer to liaise with Jack and act as a ‘mentor’ to him. An officer (referred to as WYP115) volunteered to act as a contact point with Jack and to provide support. The impetus for this appears to have been to make Jack aware of the danger he was placed in by engaging with men on the internet, and stop him doing this, rather than to give him an outlet to express his feelings about his life within his family or community. There is nothing explicit as to why it was agreed this officer was suitable for the role; it was not a coincidence that the officer was a member of the West Yorkshire Police Gay Police Association. However well-meaning this may have been, it was an insensitive and poorly thought through approach. Other professionals warned the police that this was an ill-advised course of action but their views were ignored. Jack formed an attachment to the officer and sent him a large number of texts. The transfer of the officer to another force brought further significant stress to Jack, who felt again that he had been abandoned and let down by professionals.  Whilst this is not a case in which the police would be expected to engage a Family Liaison Officer (FLO) it may have been useful at certain stages of the case, in particular when Jack was abducted and taken to London. At that time, Jack’s parents were left alone and an FLO may have proved useful if it had been practical to engage a specialist officer at this point.      Finally, the support shown by Jack’s parents and immediate family cannot be overlooked.  Jack’s parents have been through hell. They have fought for their son, supported him and tried to do everything they could to protect him. At one point, Jack’s mother told the CSE strategy group that she believed they were effectively engaging in palliative care for Jack, and she no longer knew what to do. There were some criticisms of Jack’s parents and their pro-active approach; it is fair to say that many professionals would not have experience of parents who were so pro-active and clear in their expectations. As parents, they could not have done more. At the first learning event professionals were very positive about the engagement of Jack’s parents and the way they engaged with professionals.  A number of individuals and organisations worked with Jack and there is clear evidence they were well intentioned. However, over two years their work failed to protect Jack or significantly alter his high-risk behaviour and did not prevent him suffering prolonged and serious abuse.     A more coordinated approach would have been more effective and this is discussed as a key theme later. 2.3.4. Phase Four – January 2013 to October 2015  By 2013 the offending against Jack had declined and Jack’s mother felt he was better protected, and they could keep him safe. However, on 17th January 2013 a teacher (the safeguarding lead) at Jack’s school was informed that Jack had left school with a female pupil, to meet a male in his car across the road. This caused alarm since it was now known that Jack had previously left school in his lunch hour and met and been assaulted by an older man on the moors. It transpired this man had been harassing Jack and as a result he took a friend with him to offer support.  Two police officers were flagged down by the teacher who explained the circumstances.  The officers found the man identified by the teacher. The man said that he had not realised Jack’s age and when he saw Jack he told him he wasn’t interested in meeting with him. The officers conducted a voluntary search of the man’s car and conducted a police national computer check. They took no further action and told the teacher there was nothing more they could do. At the request of trainee detective WYP23 the officers later submitted an intelligence report. Operation Oakberry later investigated the case and the male was arrested and convicted. In fact, when the male’s computers were seized, it transpired he had   22 also groomed a 15 year old boy on Merseyside. This is particularly worrying given that one of the officers was the officer that had attended Jack’s house in August 2010 and was a school liaison officer at Jack’s school. Consequently, he must have known the history of Jack’s behaviour and the high risk he faced.   In March 2013 Jack attended the emergency department at Airedale NHS Foundation Trust hospital with his father. Jack reported that he had injured his right testicle, having caught it in his trousers. Records available ensured that medical staff knew Jack had previously been the subject of grooming and was engaged with BCSC. They did not complete a paediatric liaison form or share the information regarding a potentially significant injury. In fact, Jack had attended hospital on a number of occasions over the period of the review with relatively minor ailments, of which this was the most significant. The management of Jack at the emergency department attendances were incomplete in regard to information gathering, and also inconsistent with regards information sharing. Staff did not always follow safeguarding procedures. It is unlikely that these omissions affected Jack in a significant way but it did represent a missed opportunity to raise child safeguarding concerns.  In April 2013 Jack and his parents spoke publicly at a learning event run by the BLAST project. A member of the Police and Crime Commissioner’s (PCC) staff was present and asked if they would consider talking to the PCC about what had happened to Jack. Jack’s parents were reluctant, but did speak to the PCC and in July they agreed to meet the Chief Constable.  Following a meeting between the Chief Constable of West Yorkshire Police and Jack’s parents a step change took place in the investigation of offences against Jack.  The chief constable instigated a review and put in place an investigative team to deal with those that had offended against Jack. The team and investigation was called Operation Oakberry. The fact that the investigation was given an operation name demonstrates how seriously the investigation was now being taken. The operation did not prove to be ‘too little too late’ and resulted in numerous convictions.  In August 2013, the first Operation Oakberry meeting was held. A further 20 review meetings were held in under a year. The Senior Investigating Officer (SIO) or his deputy chaired all of the meetings. These meetings reviewed the investigative plan, planned further actions and developed new lines of enquiry. The head of the force’s Safeguarding Central Governance Unit (SCGU) attended many of those meetings. Operation Oakberry was to re-investigate cases that had been identified in the first investigation.  Witnesses were interviewed or re-interviewed and evidence that had been seized was sent for further analysis. Jack and his family were allocated two trained family liaison officers to assist them (especially through the court process). Trained officers began to attend the CSE strategy meetings.  The investigative team had a mixture of experienced detectives, specialist child protection investigators and officers specialising in CSE. A risk assessment using a nationally Significant event seven:  The incident in January 2013 when Jack met an offender outside his school was badly dealt with.  Despite one officer being entirely aware of the risk Jack was exposed to, his lack of action and poor levels of legal knowledge increased Jack’s risk and meant evidence gathering opportunities were lost.      23 acknowledged risk assessment tool was used to assess risk and this was reviewed at the regular Operation Oakberry meetings.  This contrasts with the nature of supervisory oversight during the earlier part of the investigation. In fact, when interviewed, detective WYP23 commented on the fact that he was amazed at what this team were able to achieve.  The final phase, from March 2014, saw the processing and trial of those suspects, concluding in October 2015 with the conviction of the final suspect. Enquiries were also made in relation to a number of potential suspects who were not identified.  36 males were investigated.  23 were placed before the court, two were found not guilty and two received community orders. 16 men were convicted of serious sexual offences and sentenced to imprisonment of between 16 and 44 months; a total of over 34 years imprisonment for the offences they committed against Jack.    In November 2014, a formal complaint was made by Jack’s parents about the force's management of investigations between February 2011 and September 2013. The complaint was referred by West Yorkshire Police to the Independent Police Complaints Commission (IPCC) on 25th November 2014. An IPCC investigation was commenced on 1st of December 2014. 14 officers were interviewed between 11th June 2015 and 12th January 2016.  The IPCC final report submitted to the force is dated 11th April 2016. The report recommended that gross misconduct and misconduct proceedings should take place against five serving West Yorkshire police officers. Hearing dates have not yet been agreed but are expected to take place in May 2017. Two further officers who now serve in other forces are to receive ‘management action’.  By October 2015 Jack was reporting to support workers that he felt settled.  He was gaining confidence and understood how to keep himself safe. No further incidents have been recorded involving Jack.  It is worth commenting on the issues that continued to cause stress to Jack’s family following the conviction of offenders. It is perhaps to be expected that the workings of the criminal justice system can be stressful for victims and their families. Much progress has been made around the treatment of witnesses and the way in which they are treated during court proceedings.  The Independent Police Complaints Commission (IPCC) have conducted a thorough investigation and sent their report to the Chief Constable of West Yorkshire Police. This report may have serious consequences for a number of police officers. It is to be expected that the force will take time to consider the report before deciding on what disciplinary action is or is not taken. However, Jack and his family have felt that this discussion has been poorly handled and this has made them suspicious of the process.    The Crown Prosecution Service (CPS) appears to have carried out its role properly.  However, it has often been a slow process and again this has caused stress to Jack and his family. When an investigation of this nature begins CPS wait until the full investigation is complete before any proceedings begin. This builds very long delays in to the system and causes further stress for victims.  The Criminal Injuries Compensation Authority (CICA) has taken considerable time to investigate Jack’s claims and have reached conclusions that are difficult for the family to understand. The claims made by Jack to the CICA are still under review and have been appealed. This is a further example of large organisations engaged within the criminal justice system appearing to have little sympathy for victims.   24  This is the only section of this review that is reflective rather than based on information and evidence that have been reviewed.  It seems appropriate that the feelings of Jack and his family should be properly reflected and expressed.   The bureaucracy within the criminal justice system can deter victims and continue to cause severe stress even once cases have been finalised. Section Three – Analysis of Significant Events   3.1 Introduction This section examines in more detail the significant events highlighted in Jack’s story. From that analysis the key findings, themes and recommendations are developed.   3.2 Significant events 3.2.1 Significant event one  The police failed to deal with the referral from ChildLine in August 2010 in a professional way and according to child protection procedures. The police did not investigate potentially serious criminal offences and an opportunity to prevent harm to Jack was missed at this first stage.  The initial police response – to the information that Jack was in contact with men on the internet and had sent an indecent image of himself – was dealt with by one officer and finalised shortly after the officer had attended Jack’s home. There is dispute about what the attending officer was told. The officer subsequently stated to the IPCC enquiry that he was told that no images were sent by Jack, and the person he was in contact with was of a similar age. This contradicts other available information contained in the police control room log and in a telephone conversation with another officer. There is evidence the officer endorsed the log with a report but it is unclear how this report was progressed.    This initial contact by the police offered an opportunity to explore the information provided, including Jack’s use of websites and the nature of his on line conversations. Jack’s meeting with one offender was at about this time, although it has not been established whether this took place before or after the visit by the officer. This report to the police by Jack’s parents was an opportunity to intervene at an early stage and possibly prevent further offending.  This opportunity was not taken and an investigation was not initiated.    The circumstances as outlined on the log should have at least generated the creation of a child protection report and a referral of the circumstances to Bradford Children’s Social Care (BCSC). This would have been the case irrespective of whether Jack had sent someone an indecent image of himself or not. In fact, the police log indicates that Jack was entering adult chat rooms and that strangers were attempting to arrange meetings with him for sex. It seems to have been routine practice at this time for officers to submit a minute sheet report or an email to the Child and Public Protection Unit (CPPU) rather than create a VIVID (Vulnerable Individual Victims Database) report themselves. The officer then relied upon the CPPU to make the referral to children’s services. There is no record that any report was submitted to the CPPU (and the log finalisation indicates that there was no intention to do so) and consequently there was no onward referral to BCSC. The officer did endorse the log to the effect that he intended to speak with Jack’s school re bullying issues, but it is not   25 recorded on police systems whether or not this discussion took place and there is nothing recorded by the school, who have maintained excellent records.  If a referral had been made to BCSC, this should have generated a strategy discussion between a CPPU officer and BCSC with some form of further action. The attending officer viewed the incident as one of cyber bullying, which he felt was appropriate to finalise by way of advice, so the officer made no referral to BCSC, and no interagency strategy discussion took place. Compliance with child protection procedures would have resulted in greater scrutiny of the circumstances, both within the police and between other agencies. A referral would have incurred minimal extra work for the officer. There is no explanation as to why the officer failed to follow established procedures. An early investigation at this stage may potentially have prevented the escalation of Jack’s contact with predatory men and some of the offending that took place against him. In light of the fact that events spiralled so quickly out of control at the beginning of 2011 this represented the best opportunity to put in place interventions and prevent Jack becoming a victim of serious sexual offences. Officer WYP7 was a local officer and had responsibilities for liaison with Jack’s school. The same officer was also involved in an incident in 2011 when Jack was abducted and 2013 when he failed to take appropriate action against an offender. Lack of training and understanding of procedures can only go so far in mitigating unprofessional conduct. The officer has retired and will face no disciplinary action.  This incident, and the way in which it was handled, is an example of a repeated theme throughout this review. It has not been possible to interview the police officer involved (police officers who were under investigation by the IPCC declined to be separately interviewed) and so it is not possible to be definitive about why this officer failed to follow procedures.  However, the officer singularly failed to appreciate the potential seriousness of the offences reported to him, and seems not to have understood that these were criminal offences. This first contact between Jack, his family and the police demonstrates one of the key themes of the review. That is: front line professionals often failed to understand the law around internet based offending, and in particular grooming. As the case progressed this officer and other professionals failed to appreciate that these offences can lead to a downward spiral for children and young people, who lose control and are drawn into a world over which they have little control and are unable to escape. The failure of professionals to be positive and proactive at the earliest possible stage can have devastating effects.  The work that has been undertaken to change the perceptions of front line staff and raise the awareness of those staff is dealt with in appendix C.  3.2.2 Significant event two  The police failed to record initial crimes and begin a criminal investigation in February 2011. Lack of communication with other agencies at this point led to confusion around the role of the police and as a consequence evidence was potentially lost and offenders left to offend.  On 2nd February 2011 Jack’s school contacted the police with information in respect of Jack’s contact with a suspect subsequently identified as an offender. An email between officers made it clear they understood the family had referred these incidents to the BLAST project and Barnardo’s. It does not indicate that police had made a referral to BCSC or that a strategy meeting had been held. No VIVID8 report had been created in respect of this earlier                                                 8 VIVID - this was a standalone database designed ‘in house’ and adopted about 2002.  Vivid recorded all child protection, domestic abuse, forced marriage and hate crime incidents. It has been gradually phased and replaced with Niche (a single Force information and intelligence system now in place).   26 information. A further email at around the same time between officers indicated that Jack’s parents had been to the police station that day to report their concerns. Neither officer involved recorded a VIVID report or referred the matter to BCSC. No crime reports were completed.  When interviewed one of the officers stated she believed that she had spoken with Jack’s father on one occasion on the telephone. She believed that this was in relation to advice in relation to Jack being missing from home. She has no recollection of making referrals to the BLAST project or Barnardo’s.    Later that day police attended Jack’s house after his parents had again reported the same concerns. Two officers (WYP10 and WYP11) attended and as result WYP11 submitted an email report to the Safeguarding Unit (SGU) in the early hours of 3rd February.  The officers were on night duty but were aware that Jack’s parents had already spoken with the SGU. It is reasonable that they believed the SGU were dealing the matter. They had been informed by Jack’s parents that a referral had already been made on 2nd February by Jack’s GP to BCSC. It was reasonable that they made no direct referral to the duty social care staff there and then.   WYP11’s email contains a detailed explanation of the circumstances and concludes “For your urgent attention”. As a result of this email it is apparent that SGU supervisor WYP14, became aware of the report the following morning.   At 11.02am on 2nd February a social worker contacted the police with further information about material found on Jack’s computer, and a meeting was to be held that day at Jack’s school to speak with him about the concerns that had been raised. The call appears to have been interpreted as a request for police assistance in the event that Jack should try to abscond from the meeting.   A police supervisor should have held a strategy discussion with BCSC and agreed whether police should attend that meeting and, if not (given that school staff and BCSC were going to speak with Jack it would clearly not be desirable to have an unnecessary number of professionals present), should have agreed to hold a further discussion after the meeting, to decide how the information from the meeting would be progressed. However, when WYP16 attended the school later that day it was in response to concerns that Jack might abscond or use his phone to alert the offender.   WYP16 reported the circumstances by email to another officer (WYP750, copying in WYP14 and WYP20). On 4th of February there was communication between WYP14 and BCSC and an account of the school meeting was forwarded to the SGU and pasted onto the VIVID report.  However, at no point is there an indication that the SGU requested or took part in a strategy discussion with BCSC to jointly plan an investigation, and agree the matters described in Working Together. No crime reports were completed at this point and as a result an investigation did not begin.  If procedures had been followed and crime reports completed as per police policy an investigation would have begun on 3rd February at the latest. This would have provided early opportunities to secure evidence and obtain a first account from Jack. The criminal investigation did not begin until 14th February by which time the police were aware that Jack: had – as recently as 2nd February – planned to travel to meet a man from Portsmouth; had had sexual contact with four men (including travelling to York with one of them, going to a hotel with another, and two others travelling to his home town); met another man who had travelled to see him; was in internet contact with at least six other men; and that this engagement with men he met on the internet had begun six months earlier in August 2010.  It is unfortunate that the explanations by officers as to their actions are vague. The IPCC have interviewed all of the officers involved in this incident who in effect dispute the facts   27 provided by others. For example, the officers taking the report from Jack’s parents said they were vague about what exactly had been said to Jack and they refused to allow him to seize Jack’s devices.  The officer stated he had no evidence to suspect any offences. The officers at the police station that spoke to Jack’s parents cannot recall speaking to them.  This whole episode is shrouded with claim and counter claim and there are doubts as to the veracity of some officers’ view of events. This has made it difficult to draw conclusions about why an investigation did not begin. The conclusion reached by this review is that the officers involved failed to see the significance of the information they received, possibly through lack of training and awareness of CSE issues, and no officer took responsibility to liaise with other agencies to initiate an investigation.   In common with other police forces at this time West Yorkshire Police were using different criteria when recording crime in 2011 than they have done more recently. Police recording practices nationally have come under scrutiny and there has been considerable criticism of the approach taken by most forces, including West Yorkshire. The situation has changed as a result of this criticism, and police expectations around sanction detection rates. In 2011, there was an attitude that a crime should not be formally recorded until there was absolute certainty that it had been committed, and this often only occurred once an offender had been located and arrested. At this time, if there was any doubt, then the presumption was that the matter would not be ‘crimed’. The opposite is now true and police forces nationally record crime as soon as it is reported to them whether there is certainty around it or not. This was particularly relevant in the case of sexual offences and grooming where physical evidence was often not available. National increases in the number of serious sexual offences are in part attributable to these changes in recording practices.  It is reasonable to assume that the officers in February 2011 would not have been encouraged to record these crimes at an early stage and may well have received internal criticism if they had.  3.2.3 Significant event three  Children’s social care had received referrals in February 2011 but did not follow child protection procedures. No agency took responsibility for the case and the first ‘strategy’ meeting did not follow statutory guidance. The lack of leadership and failure to follow child protection processes set the tone for this case and as a result Jack was not protected as he should have been.  On 3rd February 2011 Bradford Children’s Social Care (BCSC) received referrals regarding Jack from his General Practitioner and the NSPCC (via Jack’s father) and they appear to have had some form of contact from the police. These related to Jack’s use of the internet and the fact that he was intending to travel and meet older men he had met on line. It would seem reasonable that this meant that Jack was at risk of ‘significant harm’ and consequently – in line with paragraph 5.56 of Working Together 2010 – a strategy meeting should have been held. It was not held at this point, but a meeting took place at the school, which the police only attended when Jack became disruptive. Following the meeting a referral was made to ‘Hand in Hand’, although in fact the school had already carried out this action.  On 9th February a meeting took place between a social worker and a team manager which they regarded as a section 47 investigation meeting as defined by Working Together. No other agencies were involved.  The meeting agreed that a core assessment should be completed. When interviewed the social worker was of the view that the police had been consulted by telephone although no record exists of this call. The social worker understood that Jack was at risk of significant harm and that the meeting held by the single agency and   28 the initiation of a core assessment was the first step. While this is a reasonable explanation, it fails to understand the effect this had on other agencies. A section 47 investigation strategy meeting involving the police would probably have had the effect of getting specialist officers engaged in Jack’s case and coordinating support at an early stage. Most significantly it would have launched a meaningful joint investigation.    The BCSC record on 9th February states: “Joint agency Section 47 Investigation completed. Outcome of the investigation was that concerns in respect of Jack were substantiated and he continued to be at risk of significant harm. However, due to a number of protective factors and proactive parents, a decision was made to continue with core assessment.”  On 16th February BCSC records show state: “A number of agencies working with Jack and his parents were cooperative and proactive in accessing resources in order to safeguard Jack. Police investigation on going in respect of online grooming and CSE. Decision was made to continue supporting Jack and his family under Section 17 (Child in Need) of the Children Act 1989.”  In the first instance, a multi-agency strategy meeting did not take place and the CYPT team manager responsible for overseeing the case is adamant that discussions with the police did take place, but were not recorded. There is no evidence in police files of this discussion.  Once it had been agreed at the single agency strategy meeting between the social worker and the team manager that a core assessment should be completed, this was carried out by a community resource worker (CRW) and not a qualified social worker. At this time it was policy at BCSC for CRWs to complete core assessments; this has now changed. There is no record of why an initial assessment was not carried out, which would be usual practice, and would then (depending on its conclusions) trigger the core assessment.  These early decisions were made at a time when crimes of this type were only just beginning to be understood and that may have influenced the social worker’s thought process. The early stages of the BCSC involvement were dealt with too informally. It seems the social worker saw that the parents were proactive and almost took a view that there was no need for BCSC to respond. Further, the basic child protection work was being done and in effect BCSC would monitor the position while completing a core assessment. This approach may not have had any lasting effect on what was to follow, but the failure to take a strong lead and follow child protection procedures more rigidly set a tone that was to be followed by both BCSC and the police when it came to the application of child protection procedures. The support offered by Jack’s parents led social care professionals to underestimate the degree of risk Jack faced.    At the learning event professionals were of the view that the high demands placed on this team and the lack of qualified social workers severely impacted on the nature of support that team were able to offer. They were also of the view that recording systems and computer programmes were not of a good standard. The social care manager was inexperienced and new to her role and that also affected the way in which she recorded actions and supervised staff.  A combination of high workloads and inexperienced staff impacted on the ability of social care professionals to follow procedures laid down in Working Together and the supplementary guidance relating specifically to sexual exploitation. These documents are statutory in nature and should have been followed. Failure to do so affected the outcomes for Jack.  There is also some question about the allocation of resources by BCSC during this period.  Jack was considered as a Child in Need (CIN) and so it was considered suitable to allocate a CRW rather than a social worker to Jack and his family. The manager stated that she was   29 new to the team at this time and she did not have sufficient qualified social workers to allocate one to Jack’s case. In addition, the CRW she allocated was the office CSE ‘champion’ and she had seen other CRWs allocated to CSE cases. The manager acknowledged that the increase in resources around CSE means that this would no longer occur. In any event the case was effectively passed to the placement support services (PSS) worker who maintained the vast majority of contact with Jack and his parents. This was also against BCSC policy as the CRW should have been the lead officer in CIN cases.  This was common practice at that time as evidenced by the same issue arising in the ‘Autumn’ serious case review published by BSCB in December 2016 in which a similar set of circumstances occurred.   The manager acknowledged this, but was clear that it was a conscious decision to use the PSS worker rather than the nominated CRW. The CSE strategy group agreed with this decision because the relationship between the CRW and Jack’s parents was “not positive” and the PSS worker and the BLAST project worker had a good relationship and were regularly engaged with the family. As previously described the relationship between the family and the PSS worker also had some issues that the manager either failed to understand or was not aware of. The team manager from CYPT felt that she had considerable oversight of the case and was “actively involved with the parents” and that she regularly reviewed the case.  It is fair to say that, at an early stage, the team manager had lost the trust of Jack’s parents who felt too little was being done by BCSC to support Jack.  Whilst the use of the PSS worker and the CRW may have had some legitimate use, especially given the lack of resources, far closer supervision should have taken place and Jack’s parents should have been kept fully apprised of the rationale for why specific individuals were selected.   3.2.4 Significant event four  The police investigation conducted between February 2011 and April 2012 was poorly managed, cumbersome and lacked supervision. As a result, opportunities to arrest and convict offenders were missed and Jack and other children were exposed to further risk and offending. The police failed to consider preventative measures to reduce the risk to Jack and locate and arrest offenders.  When concerns were again raised in February 2011 a VIVID (Vulnerable Individual Victims Database) and subsequently a crime report were recorded and allocated to a trainee detective WYP23. Only one interview was conducted with Jack at this time. This lasted one hour and 32 minutes. While valuable in gaining an overview of the abuse Jack had suffered, further interviews should have been conducted in more detail and with closer questioning.  WYP23 discussed the information known following this VRI with a detective inspector, WYP29. This resulted in him being given tactical advice in respect of fast track actions. It did not generate a consideration of the potential scale of the required investigation. The fact that there was the potential for a networked child abuse ring, with other possible and unknown victims was not considered. In fact only two of the offenders were discovered to have acted together and only two other victims were discovered. However, this was not known at the time and could only become known through the process of investigation. There is no evidence that this possibility was considered and no formal policy decision was taken in respect of a coordinated and properly resourced investigation. There was no senior management overview of the circumstances.  This was not assisted by WYP23’s failure to record crime reports for all the matters reported, partly explained by the ‘criming’ policy in place at that time (see above).    30 Similarly, WYP23 stated to the IPCC that he made a decision to prioritise contact sexual offences over non-contact offences.  In fact, ten of the eleven suspects arrested by WYP23 were for contact offences, the eleventh being a male who had travelled and met Jack, although no sexual acts had taken place. This indicates that the decision to prioritise contact offences was in effect a decision not to investigate non-contact ones. This decision was poor, regrettable and meant that potential child abusers were not pursued, exposing other children to risk of harm. This is illustrated by the events of June 2011. Jack gave a VRI in which he disclosed meeting a male in May 2011 and receiving the gift of a phone. This incident was not recorded on a crime report although some enquiries were made regarding the phone. In August 2011, the same male committed a sexual offence against a 14 year-old boy who he had met on the internet. A further opportunity to identify and arrest this offender arose in January 2012 when his conviction for this offence was publicised in the press.  Jack’s father (having seen the case in the newspaper) passed details of the case to WYP23 but he did not act on the information.   It was an acting sergeant who initially allocated the case to WYP23. Sergeant WYP36 said that he thought this a reasonable decision and that it had been partly taken because WYP23’s tutor constable, detective WYP45, had extensive CPPU experience (having served in that unit for ten years) and would ensure that the investigation was properly managed. In fact, WYP45’s only involvement in the case appears to be the video interview she conducted with Jack on 26th June 2011. WYP45 was on sick leave for the whole of February 2011. In March, she was sick for a further four days and in April she was present at work on five days and only three days in May, only returning to normal duties in June. She was not therefore in a position to adequately oversee WYP23’s management of the case or give him the benefit of her expertise in the crucial initial stages of the investigation.  Given the seriousness of the case, this raises a question about the standard and frequency of supervision of trainee detective WYP23. WYP23 should have had a tutor as part of his training and the case should have had managerial oversight.  There are no supervisory investigation plans entered on either the initial crime report created by WYP18 or the crime reports later created by WYP23. This contrasts with an investigation conducted by a child protection officer in April 2012 when her supervisor wrote an initial investigation plan and she herself added an additional plan when the report was allocated to her. This failure to carry out a process laid down in a number of West Yorkshire Police and national procedures may be partly as a result of WYP23’s practice of recording crimes when required for administrative purposes, often related to an arrest, rather than at the time of receiving the information that a crime had occurred. This is in contravention of national procedure for crime recording but was common practice in police forces at this time. It was obviously not possible for supervisors to review reports that had not been created.   Despite there being limited evidence of senior supervisory involvement being documented, senior managers were involved in both April and June 2011. Firstly, when a chief inspector attended a CSE strategy meeting, which she stated to the IPCC was in respect of safeguarding concerns for other children connected to Jack, and not Jack himself. This was correct. Her role as the partnerships lead gave her no involvement in the actual investigation. The second occasion occurred after Jack was abducted to London. A detective superintendent overseeing the enquiries to recover him requested a full report regarding Jack’s circumstances, but following the return of Jack to Yorkshire the superintendent returned to other duties and was not further involved. It is not clear whether the superintendent ever received a briefing from trainee detective WYP23 and was aware of the number of potential suspects. It appears from the IPCC file that he had not, and was not aware of the potential size of the enquiry. At this point the divisional crime manager also became aware of the case, but was assured that the case was being progressed appropriately. It seems this was not followed up.   31  There were a number of areas where the investigation over this period failed. For example, there are four examples where forensic examinations were not conducted in a timely fashion: an offender’s flat in York was never forensically examined, despite sexual contact offences having taken place there; a forensic examination of an offender’s workplace was not conducted until Operation Oakberry began, by which time it was some years after the offence and furniture had been replaced; the car of another offender in which sexual contact took place was not examined, despite its being seized by Greater Manchester Police; on 8th September 2011 Jack disclosed to a police officer that earlier that day he had engaged in sex, but no forensic medical examination was conducted and in fact there appears to have been no investigative actions until Jack was interviewed about the circumstances on 25th September 2011; the search of an offenders flat proved negative in terms of retrieval of evidence, but under Operation Oakberry the flat was searched again and important evidence was found.  In addition, when trainee detective WYP23 sent computers for analysis his status meant they were not prioritised for examination and under-resourcing in the high tech crime unit built in long and unacceptable delays.  The reason why these failures occurred can be examined under a number of key areas.  Trainee detective WYP23 made critical errors that call his competence in to question.  However, there were broader issues that also resulted in a failed investigation.  The first of these concerns the resourcing of the investigation. There is an inherent risk of a failed investigation taking place in respect of any complex crime, if that investigation is allocated to one inexperienced and untrained officer who is also allocated additional investigations, placed on shifts and who is required to respond to real time incidents.     As the only officer allocated to investigate this complex series of crimes any absence by WYP23 prevented the progress of enquires. WYP23 was absent from normal duties from:      9 August to 7 September 2011;     20 October to 7 November 2011;     2 December 2011 to 6 January 2012;     4 April to 14 May 2012;     31 July to 4th September 2012.  During these periods, he was not available to the family and could not progress the investigation.  At other times he worked a shift system, which included regular late shifts. He was also required to investigate other crimes and attend incidents. This impacted on his ability to progress the investigation and attend CSE strategy meetings.   A dedicated investigation team was required which had the capacity to speedily progress investigations and service the requirements of multi-agency working, such as attendance at strategy meetings. It is not necessarily the case that this should have been a fully co-located multi-agency team, but this should have been at least a virtual team with real-time sharing of new information and strategy meetings held on a more regular basis than the six-weekly meetings which were held. This would have enabled such a team to have more focused day-to-day engagement with Jack. Officers could have identified roles such as digital communications examination; arrest and case preparation; interagency liaison. The existence of a team would have ensured that the absence of one officer did not effectively delay the investigation until their return. This is more or less what later occurred when Operation Oakberry was instigated.    32 Secondly, there were questions about leadership. The investigative team should have been overseen by a senior investigating officer (SIO) who would give direction; allocate additional resources if required; liaise appropriately with senior managers in other agencies; and establish a policy framework for the investigation.    The establishment of the policy framework and an investigative plan is vital for the coherent functioning of the operation.  They could ensure that basic decisions about who in the force should be responsible for the investigation (for example SGU staff, the then HMET or divisional staff) would be made by an officer of the appropriate rank. It could also have supported other important policy decisions, such as FLO responsibilities; suspect prioritisation; forensic issues; CPS liaison; information sharing with the family; recording of the investigation (e.g. whether the Home Office Large Major Enquiry System (HOLMES) should have been used); and management of subsequent publicity and other matters as they arose for the investigation. These could and should have been taken by an SIO who would record such policy decisions in a policy log.    Finally, the investigation lacked any proactive approach. The initial investigation was primarily reactive and followed the disclosures made by Jack. Trainee detective WYP23 made a personal decision to only investigate contact offences. This resulted in the large number of suspects and potential suspects who were later identified by Operation Oakberry and who had been available to investigate before it began, but who had not been seen. Oakberry itself was an ‘historic’ investigation which commenced after Jack’s sixteenth birthday. At no point prior to Operation Oakberry was there proactive monitoring of Jack’s use of computers. There could have been some covert monitoring of Jack’s internet use.  This would require authorisation under the Regulation of Investigatory Powers Act 2000 and the Police Act 1997. The police would have to show that such surveillance was necessary, proportional and justifiable. This is by no means a simple process and there is no knowing whether, on the information available at the time, such a request would have been successful, but it is a tactical option which should have been considered at some time in the continuum of Jack’s abuse. This is commensurate with the initial police response, which was not subject to a process of review by a senior officer, and the decision by the sole investigating officer to focus on contact sex offences to the exclusion of other cyber based crime.   3.2.5 Significant event five  The police and children’s social care’s initial response to Jack’s intention to abscond to London with a 25-year-old male was poorly dealt with and lacked a multi-agency response, policy was not followed and as a consequence Jack was exposed to severe risk.  This incident in June 2011 was the first occasion on which Jack was reported as a missing person. Information was received by police and BCSC prior to the incident that Jack intended to travel to London with an older man and had arranged this with him over the internet. The first record of this in police documents is on 20th June when the safeguarding lead at Jack’s school sent an email to a police officer with information – which he had received from pupils at his school – that Jack intended going to London with this male. This email was copied in to Jack’s social worker at BCSC. The information named the suspect and gave his correct date of birth. The officer copied in the lead investigator WYP23 and officer WYP7 (who had school liaison responsibilities and was involved in dealing with the first incident in August 2010). WYP16 replied on 21st June noting that the police would monitor the situation and forwarded the email to another officer (WYP165). Later that day further information was emailed by the school to WYP16. This was also forwarded by WYP16 to WYP165, copying in WYP23 and WYP7.  WYP16 noted that she was about to   33 commence rest days and the email effectively referred the information to WYP165 for consideration of further action. WYP16 expressed the view that: “as far as I can see it still comes under parental control as to his whereabouts Friday’”. It was subsequently recorded on the missing person log on that date that WYP23 had visited Jack and his family on the evening of 24th June and advised him against going to London. These officers did nothing proactive or of value to prevent Jack leaving with an offender. Again WYP7 was involved; his previous omissions had resulted in a failure to protect Jack. It is not possible to explain why this officer behaved in the way that he did.  BCSC were aware of the intelligence surrounding Jack and had been contacted by the police and should have called a strategy meeting, or at least asked the police to do so. In fact they took no action and the police dealt with the matter alone.  The police recorded no further action contemporaneously, until calls were received on 25th June reporting that Jack had left with the named male to go to London. Jack had been taken to a karate lesson by his father who waited outside for him. Jack exited the building through a toilet window and was driven away by the waiting offender. The response at this point contrasts with the response from officers earlier that week. The operation to recover Jack after the missing report had been received was conducted thoroughly and in accordance with policy. The log was initially created as a medium risk missing person report but the supervisor making this decision entered a rationale for this grading on the log, indicating that it was provisional on a series of actions he identified and listed on the log. These enquiries were commenced, units were tasked with attending Jack’s home address and that of another caller, and the supervisor liaised with a senior manager. At 12.30 the supervisor re-graded the incident as a high risk missing person report. Further work continued to try and intercept the offender and Jack and at 5.28pm Metropolitan officers attended at the offender’s address, found Jack there and arrested the offender.  There was therefore an opportunity to prevent this episode occurring if a more proactive action had been taken by the police and BCSC, upon receipt of the initial information. This was clearly not information about a “parenting issue”, but the disclosure about a potentially serious and dangerous offender when a number of serious offences had already been committed.    When Jack was officially reported missing on 25th June police researchers, using information available on Jack’s Facebook page, correctly identified the offender’s home address within 43 minutes of the original call being received. This highlights the relative ease with which officers could have resolved the issue before Jack left for London. Police officers did nothing for four days and waited until Jack had gone missing before they took any action.    The reactive response to this ‘missing from home’ report was in accordance with policy and had a successful outcome. Proactive action by the police when the information first came to light may have prevented it occurring.  On return from London an Inspector spoke to Jack and his mother and, according to Jack’s mother, gave Jack a “dressing down” which included threatening that Jack would be removed to a “secure unit”.  As a direct result of this meeting Jack and his mother feared the police and felt there was no hope left for them. The meeting served only to further alienate the police from Jack and his family.   So why did these events occur in this way and why was there no proactive approach? It is difficult to be definitive about the answer. Put simply, the officers involved did not see the information they received as important. They did not understand the risk to Jack and they did not understand the law relating to sexual offences and grooming. The information was passed around and no one was prepared to take responsibility. It is important that this report   34 assesses actions, understanding that they are being looked at in isolation and in hindsight.   It must consider the ‘why’ around poor decision-making.    There is no justification that the lead reviewer can determine for these officers’ failings.  While the officers may not have been trained in specific offences, or understand the difficulties around child sexual exploitation, the facts speak for themselves. These officers were told that a 14 year-old boy was going to be picked up by a 25 year-old man he had met on the internet, and taken to London. They were given the man’s details including his date of birth. A police officer should not need training in specific offences to understand that this was criminality and that the child was at extreme risk. This review finds that these officers showed a high degree of incompetence and a failure to take responsibility. This was not system failure.  There is simply no record of any action being taken by BCSC. This is inexplicable. The email they were copied into also referred to Jack self-harming and while the police could and should have called a strategy meeting, in the event that they didn’t, BCSC should have done. Given that Jack was at risk of significant harm in two different ways this demonstrates a failure to follow statutory guidance and a failure to safeguard a vulnerable child.  3.2.6 Significant event six  The failure to conduct an initial child protection conference in March 2011 and the subsequent reliance on the use of CSE strategy meetings to monitor Jack’s progress failed to follow correct process and put Jack at high risk of further significant harm.   The first CSE strategy meeting took place on 9th March 2011.  These meetings took place every 6 weeks throughout 2011 and through to July 2014.  These meetings were the only multi-agency child protection meetings that took place. There are no terms of reference for these meetings and it is not clear who called them or who was responsible for their management. The first two sets of meeting minutes were recorded on Bradford Metropolitan District Council (BMDC) headed paper and the remainder are on paper headed with the Bradford Safeguarding Children Board (BSCB) logo. The minutes do not always reflect who chaired the meetings, although it seems that a BCSC team manager was most likely the chair at the majority of meetings. It is unclear what status these meetings had.  Some professionals felt that these meetings could best be described as “Team Around the Child” meetings and others described them as “professionals’ meetings”.  It seems they were predominantly for information sharing and case discussion.  This would make sense given that in a single agency meeting it was agreed that Jack would be treated as a ‘Child in Need’ under section 17 of the Children Act.    At the first meeting the minutes reflect that “… the purpose of the meeting to ascertain level of risk [Jack] is at regarding CSE.  To clarify roles and responsibilities of each agency.  To formulate a plan of support”.  This did not happen.  Given that this was the first formal strategy meeting attended by police it may have been appropriate for a police supervisor to attend, particularly given the attendance at this meeting of Jack’s parents. This is not usual practice at strategy meetings (although parents are invited to participate in initial and review case conferences). Strategy meetings usually take place without family members as their presence can inhibit discussion, the exchange of confidential information and cause professionals to be defensive and non-committal. It would, for example, be appropriate to inform a child’s parents that a suspect had been arrested and in general terms what enquiries were being undertaken and the likely timescales of those enquiries. However, it would be entirely inappropriate to share with a   35 victim’s parents any personal information about a suspect, who at that point had not been convicted of any offence. Such information could include the private domestic arrangements, occupation or previous offending history of a suspect, which would normally be shared with partners as part of the joint investigation planning and review process. Working Together makes no comment on the role of parents in strategy meetings, perhaps because it did not anticipate this happening. It does state:  ‘in all cases where the police are involved, the decision about when to inform the parent or caregiver will have a bearing on the conduct of police investigations and the strategy discussion should decide on the most appropriate timing of parental participation’ (para. 5.67).  There is no indication in police records of any discussion with police about the role of Jack’s parents in strategy meetings. At the learning event, professionals that attended these meetings felt that Jack’s parents were very positive and proactive and all of the professionals welcomed their attendance and felt it added to the information supplied.  No professional expressed a view that the attendance of Jack’s parents inhibited progress, in fact quite the reverse. This further demonstrates that the meeting was not a formal strategy meeting.  A formal risk assessment tool was not used. While the risk assessment toolkits for child sexual exploitation have only become available in the last two years, there was no informal assessment and no recorded, risk specific, discussion in the minutes.  The minutes of meetings seem to reflect a series of updates given by various agencies and little substantive planning. On speaking to professionals they express a great deal of concern about the lack of police attendance. Their presence was sporadic and rarely did police supervisors attend the meetings. Little account seems to be taken of the unavailable dates of an officer who was on shifts, though other police officers could have been nominated to attend.  These meetings provided the backbone of multi-agency working in this case. The fact is they lacked leadership and whilst professionals that attended felt they were valuable in terms of an exchange of information they accepted that no plan was formulated or referred to, and there was little in terms of a coordinated approach. The meetings had no formal status.  Jack’s parents, who often provided an input, attended the meetings. Given these seem to be the only times professionals met, it is questionable whether it was appropriate to have Jack’s parents at every meeting. In addition, a decision was made to allow an academic ‘expert’ to attend meetings and again this raises questions about the purpose of the meeting.  Whilst engaging a national expert showed an imaginative approach there is no evidence of what was actually achieved or if advice was followed. This is also particularly questionable given that some professionals (notably the GP and school nursing team) were not invited.  The decision to use this meeting as the mainstay of the multi-agency response stems from the relaxed approach to child protection procedures taken by the social worker and team leader in the first instance. The fact that no change to Jack’s status as a ‘Child in Need’ took place is because no initial child protection conference (ICPC) occurred. Whilst any agency could have requested an ICPC, BCSC were the lead agency and should have convened an ICPC. In July 2011, a social worker and the team manager discussed the case and decided that an ICPC was not required as there was no evidence this would provide any further protection to Jack. This is debatable given the serious nature of the offending against Jack and the fact that this reduced the options open to BCSC and partner agencies. When interviewed, the team manager was clear that she had consulted other professionals and senior managers before making the decision. Most of these interactions were not recorded, as ICT systems at this time were said to be unreliable. The manager also acknowledged that   36 at that time she was reluctant to record too much information on a child’s file, that this was a mistake and she now recorded more information.   It seems that BCSC were satisfied that the CSE strategy meetings, and the use of a placement support services worker, would meet Jack’s needs. It did not.    Professionals allowed these meetings to continue because they did not seem to grasp the connection between CSE and child protection procedures. At this time CSE was just coming to the forefront of professional thinking and the connection between CSE and child sexual abuse was not always clearly understood and often not seen as being on the same spectrum of abuse.  In this case professionals treated CSE as a ‘stand-alone’ form of abuse and consequently used different systems than they would have ordinarily have done, and these fell outside of statutory guidance. In addition, there seems to have been little managerial oversight or support. Professionals did not understand escalation procedures or that it would be possible to step Jack up and consider a child protection plan. When questioned as to why no one escalated these concerns, there was again a lack of understanding of process. One professional said that, given this meeting was run by the Bradford Safeguarding Children Board (BSCB), he didn’t see where else it could be taken.  This misunderstanding of structures undoubtedly impacted the ability of non-BCSC professionals to change the status of Jack and indeed the meeting.  3.2.7 Significant event seven  The incident in January 2013 when Jack met an offender outside his school was badly dealt with. Despite one officer being entirely aware of the risk Jack was exposed to, his lack of action and poor levels of legal knowledge increased Jack’s risk and meant evidence gathering opportunities were lost.  This incident is of particular concern given that by this stage Jack’s case was well understood by local officers and it was already the case that 12 men had been arrested and a number were awaiting trial. In their interviews with the IPCC both the officers said they were aware of Jack and had received briefings explaining Jack was vulnerable and had been meeting men for sexual activity.    One of the officers, WYP7, was not only a police liaison officer at Jack’s school, but was the officer who had attended Jack’s home in August 2010 and failed to take appropriate action and had been informed of the threat of Jack being abducted to London in 2011 and taken no action. This officer has retired and will therefore not face disciplinary action.    While the officers did search the man’s car they did not arrest him; did not seize his phone; did not interview witnesses or take witness statements; and did not speak to Jack.  At the request of detective WYP23 they submitted an intelligence report. These officers had a huge gap in their knowledge and lacked professional curiosity.    This male, following an investigation by Operation Oakberry, was later interviewed and charged although the case was dropped because of some difficulties with Jack’s account.  The two officers at the scene lost an opportunity to gather evidence and arrest the offender.  The man was convicted of offences against a 15 year old boy in Manchester and received a 27 month custodial sentence. It will never be known whether the two officers could have prevented those offences. The failure to take action, in particular by WYP7, was not explained and this incident was another example of a failure to apply professional curiosity and make a meaningful intervention.       37 Detective WYP23 believes the actions of the officers was reasonable given there was no physical contact between Jack and the man. It is remarkable that an officer who had been investigating offences against Jack for nearly two years did not understand that criminal offences had been committed and that they should have taken further action.   Section Four - Key themes 4.1 A lack of understanding of technology assisted abuse and its devastating effects This case has centred on Jack’s use of the internet and social media to make contact with men who groomed him in order to commit serious sexual offences against him. The use of technology facilitated and made possible the abuse he suffered. Jack’s parents had realised this at an early stage and discovered he had been sending images to men and later discovered he had been entering chat rooms.  Jack’s initial access to the internet was through his phone, laptop and iPad. When these were removed, he accessed the web by using the phones of his friends. Given the ubiquity of phones with internet access amongst teenagers, he must have had many opportunities to do this. These young people were then contacted by offenders seeking Jack and clearly there was the potential for the grooming process to begin on them, though there is no evidence that associated grooming occurred.  His parents took steps to restrict his access to internet enabled devices, for example by turning off their router at times they were not able to physically monitor his usage. However, he circumvented this by finding an unprotected Wi-Fi and logging onto that.   His parents sought to monitor his use of the internet and sought advice from providers such as O2, which they acted on. This monitoring was ultimately unsuccessful and Jack was able to circumvent their measures.  Stopping Jack using devices continued to be a cause of stress between Jack and his parents. In fact, when a police officer removed Jack’s phone for evidential purposes, he had to do so forcefully. At various points devices were taken from Jack but it seems they were replaced or Jack found other means of access.  The police did not at any stage monitor his usage, nor did they seek to do so. An officer stated on one occasion that he did view Jack’s open Facebook page, but although this was available for anyone to view, it did not give access to all the messaging that took place on it.  Operation Oakberry officers were best equipped to conduct a monitoring exercise but it was a reactive investigation reviewing ‘historic’ offences. By the time it commenced Jack was16.  It would have been difficult to justify any covert measures to monitor his internet usage when any contact or exchange of sexual messaging would not amount to an offence.  There is no indication in records that other agencies monitored Jack’s internet use other than the Facebook research conducted by the BLAST project worker after he had been alerted to alleged offending.         Technology moves on at an incredible pace. Internet based companies and those responsible for managing social media sites have increased their knowledge in this area and have become more engaged with agencies. However, much more needs to be done to protect young people and prevent offending. This is a national issue highlighted by this case and as the recent Home Affairs select committee reported, technology companies need to do more.   38  Recent research concerning on-line grooming summarises the problem. In December 2016 Barnardo’s published  ‘Digital dangers - The impact of technology on the sexual abuse and exploitation of children and young people’   This was written by Tink Palmer and it says:  “Research conducted with a number of Barnardo’s services, both specialist child sexual exploitation and educational services, has revealed how integral new technology has become in the sexual abuse and exploitation of children. The internet and new technologies have allowed potential victims to be accessible and available to perpetrators, who may be anonymous, quickly and freely in ways that would otherwise not be possible. Children and young people are now able to communicate more easily with people they would otherwise not usually interact with.  Children and young people at risk of harm online may not have any previous vulnerabilities that are often associated with being victims of sexual abuse and exploitation, such as being in care; from families facing adversities or having a history of sexual abuse. This means that they are less likely to be identified, as they might not be known to the authorities. Also because of the nature of online activity the currently accepted indicators of possible sexual exploitation, such as going missing or school absence, may not be displayed, and the first parents may know that their child has been a victim of sexual exploitation is when the police contact the family.”  It goes on to say that:  “Certain groups of children and young people, such as young people with learning difficulties, those with mental health problems and lesbian, gay bi-sexual, transgender and questioning young people, appear to be particularly vulnerable to online harm. All professionals interviewed for the research believed that the development of new technology over the last eleven years has changed the way they have to work with young people and the methods of providing support.  The report highlights the need for:  •  Easier access to existing prevention resources and advice, including age-appropriate healthy relationships and sex education through schools • Training for all professionals working with children and young people so that they feel confident in identifying those at risk of harm online • Assessments to be carried out by support services to include abuse that relates to online harm only  Assessment of products, such as games and apps, both those currently in use and those in development, to make sure they have safeguards in place to prevent children being harmed online.”  Recent research by the NSPCC throws further weight behind the fact that technology assisted abuse is a problem that agencies have yet to fully appreciate or understand. The research had not been published at the time the report was written, but a summary of the work was provided to the review by the NSPCC.  The researchers undertook work with a number of young people who had suffered technology assisted abuse. It found that technology assisted abuse caused extra complications not previously experienced. The work is entitled “Everyone deserves to be   39 happy and safe” and is a mixed methods study exploring how online and offline child sexual abuse impact young people and how professionals respond to it, written by Hamilton- Giachritsis,  Hanson, Whittle & Beech, 2017.  The complications it identifies are:   Difficulties recognising the abuse.  The speed of occurrence.  Use of technology to initiate, escalate and maintain the abuse.  Outcome (control of image, permanence, re-victimisation).  Perception by self and others of their ‘active’ role in the abuse (including fear of criminal justice system).  Professionals and services viewing it as less serious. In addition, the research found that:   Online abuse is sometimes perceived as less impactful and of less immediate concern than offline abuse by professionals.  TA-CSA (Technology assisted child sexual abuse) abuse has the same degree of impact as offline sexual abuse.  Technology provides additional routes both to access young people to abuse and to manipulate and silence them.  With TA-CSA there are additional elements for young people to contend with, related to control, permanence, blackmail, re-victimisation and self-blame.  Some professionals noted that victims are more often ‘blamed’, seen as participating in the abuse or do not see it as abuse when it is online.  Both pieces of research highlight the problems faced by Jack, his parents and the agencies trying to protect him.  They are not alone. Sunderland Safeguarding Children Board have recently published a thematic review into two young people (Young Persons I and K) that highlight the role technology played in two tragic cases, and particularly the lack of understanding that agencies had around the use of social media by these young people. This review can be found on the Sunderland SCB website and the link is:   http://www.sunderlandscb.com/user_controlled_lcms_area/uploaded_files/Thematic%20Report%20YP%20final%20120916.pdf  That review further highlights the difficulties being experienced nationally, and provides another set of tragic circumstances where technology has played a huge role.  The police seized Jack’s devices; his parent’s restricted access.  At no point in three years did this prevent Jack contacting men over the internet and social media.  The key must lie in how we educate children, young people, carers and parents.  Restrictions on use and age limits on access to sites have minimal effect. A more imaginative way needs to be found. An analogy that helps in understanding this is: you do not take a child to the beach and show them children having fun in the sea and then leave them alone with a warning that they shouldn’t go in the water, or if they do it can only be to their ankles.  Instead, you teach them to swim and explain the dangers and to some extent you then rely on trust. This case could form part of the impetus to open a real debate on how we move forward in this area.   40  At this time, professionals from all agencies completely failed to understand or develop tactics that could reduce Jack’s risk. Removing devices from an individual or blocking access is a temporary fix at best. There needs to be a real debate on this subject and it needs to include children, carers, parents, service providers, and third sector organisations, as well as the safeguarding agencies.  This is a national issue and there needs to be a concerted effort by government and safeguarding agencies to provide impetus to a new approach for on-line safety for children and young people. There are a number of areas where more work is required. Technology companies appeared before the Home Affairs select committee on 14th March 2017 and the chair of the committee, the Rt Hon Yvette Cooper MP, said:   "We've seen too many cases of vile online hate crimes, harassment or threats where social media companies have failed to act.  It cannot be beyond the wit and means of multi-billion dollar social media companies like Twitter, Facebook, and Google to develop ways to better protect users from hatred and abuse. They have a duty to do so. We will be asking the companies about specific cases, why they didn't act, and what they intend to do about it now."  In addition, this review has shown that the police were potentially powerless to monitor Jack’s use of the internet because of current law and regulation.  There must be questions around whether legislation is keeping up with technology and the risks it poses to children and young people.  4.2 The lack of appropriate use and application of child protection procedures  Throughout this review there has been an inconsistent approach to the application of child protection procedures. Working Together 2010 was not followed and at times the lack of understanding of the legal aspects of child protection was gravely concerning. Given this case was related to CSE the supplementary guidance published in 2009 was also highly relevant and should have been referred to.  Police officers, children’s social services and some health professionals failed to follow their own safeguarding processes and often lacked the most basic understanding of referral procedures. The ‘Autumn’ serious case review, published by BSCB in December 2016 and covering the same period, highlighted the same issues.  Those individuals and agencies responsible for safeguarding children in Bradford should consider how they are ensuring front line staff are properly trained and how the outcomes from training courses are being evaluated.  The failure to conduct an Initial Child Protection Conference or follow correct procedure for an initial strategy meeting and section 47 investigation set the tone for BCSC engagement; it was not well judged. In addition, the process of the CSE strategy meeting provided an opportunity for information sharing but lacked leadership and inconsistent attendance, especially by the police, put its status in doubt. Other than the information sharing opportunity, these meetings were ineffectual and little more than a sounding board for professionals. No formal risk assessments took place and a formal plan was not developed or managed.    41 A core assessment was completed as was a Child in Need plan. Neither had the depth of detail you might expect, and did not contain a full range of multi-agency options with clear milestones and anticipated outcomes.  One of the more concerning aspects around the use of child protection measures was the discussion that took place, over a number of months, where the use of section 25 of the Children Act was considered. The question of whether Jack should have been placed in secure accommodation has caused considerable angst. Jack’s parents were totally opposed and felt this was a police initiated response potentially motivated by the fact that Jack’s parents had made a complaint against the police handling of the case  In fact, the evidence suggests that BCSC were the first to consider this as an option. Whether a secure placement for Jack may have helped him is a matter of debate. However, it was an issue that was considered by police and BCSC and when presented, dismissed by other professionals and Jack’s parents.    The use of secure accommodation by local authorities is dealt with by Section 25 of the Children Act 1989 and the Children (Secure Accommodation) Regulations 1991. The full legal position is contained in appendix C. The fact that Jack was not a ‘looked after child’ and did not have a long history of running away precluded any chance of section 25 being used.  The professionals discussing this as an option did not appear to be aware of the process of consultation required before an application. The CYPT manager did consider section 25 and initially suggested it as an option. The manager says that following consultation it was not considered the right option at that time.    The two main agencies charged with the protection of children considered using section 25 procedures. This was considered despite the following: Jack was living at home with supportive and responsible parents; hiss case had not been considered serious enough for a case conference to be initiated; and BCSC provided a support worker rather than a qualified social worker. This demonstrates a concerning lack of understanding of child protection procedures.   It is surprising that no legal advice was ever sought from local authority lawyers who are experts in this area. It is standard practice for social workers to refer a case to their legal advisors when any sort of court proceedings are being considered. Social care lawyers could have provided relevant advice and consideration may have been given to invoking care proceedings, given that Jack was prima facie “beyond parental control”.  Appendix C provides a legal synopsis. It is not possible to determine whether a legal response to Jack’s case would have been appropriate, or proportionate, and most importantly whether it would have reduced the risks to him. The matter was never referred for legal advice and it should have been.  Health professionals including the family GP, the Child and Adolescent Mental Health Service (CAMHS) and Sexual Health Services, complied well with child protection procedures, in particular communication with other agencies and the referral process. This was not true of front line staff at the emergency department (Airedale NHS Foundation Trust).  When Jack attended the emergency department in March 2013 with an injury to his testicle, staff understood that he had been a victim of sexual exploitation and grooming but failed to follow their own safeguarding procedures. In fact, Jack had attended the emergency department on a number of occasions with relatively minor injuries and ailments, that did not cause alarm, but full safeguarding procedures were not adhered to at any of those visits. On each of the occasions in his teenage years staff had records indicating Jack was known to BCSC and had been the subject of grooming and child sexual exploitation.     42 At none of the emergency department attendances was there any apparent consideration of signs of child abuse or an alternative diagnosis of abuse or exploitation made. Despite staff having knowledge regarding Jack’s history of exploitation, there was no involvement of a Consultant Paediatrician or Named Doctor for safeguarding children. Reference is made to a history of sexual exploitation; however, staff did not appear to recognise there could have been a current risk of further exploitation and abuse. There is no reference in the documentation to the staff talking to Jack’s parents regarding any change in his behaviour or how he was managing. There is a lack of documentation of staff talking to Jack and finding out what his life was like.  At no time was it recorded whether Jack was spoken to alone.  There is no explanation as to why procedures were not followed, though Jack always attended with at least one parent who was articulate and able to explain what had occurred.  It seems that staff took each case individually on its merit and dealt with the facts as put before them, rather than considering the whole child protection picture. At the time of Jack’s attendances to the emergency department between 2009 and 2015, the paediatric liaison nurse only reviewed the emergency department cards that were left out for her. Since July 2016, the paediatric liaison nurse has begun to review all children’s cards. This has enabled a process of quality assurance to ensure required actions are completed, and is considered good practice. There is no evidence to suggest lapses in child safeguarding procedures at the hospital had any negative impact on the outcomes for Jack.  So why weren’t child protection policies followed in the way that might have been expected?  It is difficult to be exact. The core assessment and child in need plan provides the basis for the low level this case retained on the child protection spectrum.  Nationally, front line children social care staff spend the vast majority of their time dealing with neglect and emotional abuse issues, which are the basis of 70% of child protection plans. Only 5% of such cases relate directly to sexual abuse. It is not even possible to establish from official national statistics how many boys suffered from child sexual exploitation and were referred. In addition, many of the compounding factors around those children referred to children’s social care concern drug and alcohol misuse, domestic abuse, family dysfunction, and high levels of social deprivation.  It means that social care professionals found themselves in a very different situation when dealing with Jack. All social care documents, and indeed the interviews with staff, go to great lengths to comment on the stable family background Jack has and the support his parents are willing and able to give him. Social care staff along with all the other professionals could find no ‘easy’ explanation for Jack’s behaviour. The family had no previous records with the agencies and there was no evidence of drug/alcohol abuse, domestic violence, physical neglect, emotional neglect, intra-familial abuse, and no social deprivation. Social care services were not dealing with a situation they were trained for or expected. We do not know whether professionals found dealing with Jack’s parents – who are intelligent, articulate and inquisitive – intimidating but Jack’s parents were considered capable of, and expected to, prevent harm to Jack. Professionals did not feel, given the support of Jack’s parents, that moving this case to an initial child protection case conference was appropriate given the support the parents were providing.  It is fair to say that in the majority of cases dealt with by BCSC the child is being protected from its parents or carers. This response though rather assumes that child protection is just about poor parenting and if parents are supportive a child cannot face serious risk of harm.  While it is impossible to be sure whether this was the issue, for many of the professionals Jack and his parents were not a typical child protection case and this may have affected their thought processes.      43 In conversations with front line staff and at the learning event the issue around resourcing was raised. There were strong feelings that the resources were not available to put in to this case and that the actions of senior managers restricted the options available. This was particularly apparent in the case of BCSC. There are examples of resourcing being a concern, such as the allocation of one trainee detective to Jack’s case. When the referral was made to BCSC in February 2011 the BCSC team that were allocated the case had no available social workers and three staff who were newly qualified. In effect using a CRW who was a CSE champion seemed the reasonable option. It was also clear that front line staff were of the view that following Working Together to the letter would have overwhelmed the service and consequently cases had to be prioritised.    One of the lessons from serious case reviews across the country is that children’s protective services are at full stretch and consequently cases are prioritised. While there must be considerable sympathy for front line staff and managers who are required to juggle these limited resources there can be no deviation from keeping children safe. Statutory guidance is often difficult to adhere to, but if as a professional you choose to step outside that guidance you must be able to justify those actions and demonstrate that the course of action was taken in the best interests of the child. It might be easier said than done, but if, as a professional, policy decisions by senior managers force you to work outside the guidance then that should be properly recorded and concerns appropriately raised.    4.3 The quality of the initial response by agencies to Jack and his family  This theme concerns the initial responses made by agencies when they were made aware of Jack and the significant risk of harm he faced. There were three agencies that failed to respond quickly and effectively when referrals were made to them.  Until Jack’s parents spoke to the Police and Crime Commissioner and the Chief Constable of West Yorkshire Police (at the request of those officers) the service provided by West Yorkshire Police to Jack and his family was poor. This review has highlighted the failure by officers to understand the seriousness of offences committed against Jack in 2010; the slow and inept investigation that took place between February 2011 and April 2012; the way in which officers dealt with the intelligence around Jack’s abduction to London in June 2011; the manner in which senior officers spoke to Jack and his parents following that incident; the response by officers when Jack met a male outside his school; the lack of understanding of child protection procedures; the lack of understanding of CSE and its impact; and all of this amounts to a lack of professional conduct. This has been the subject of an IPCC investigation.  While individual errors of judgement occurred, and these have been detailed throughout the review, it was the view of an experienced officer who completed the police internal agency review report (IAR), that to a large extent individual staff acted very much in line with the working practices and expectations current at the time. A key area of this is the profile of safeguarding, child abuse investigations and CSE in particular. There is evidence to suggest that the work they undertook did not have the same importance or difficulty as acquisitive or violent crime investigation. This was partially supported by the organisation’s own performance framework and the targets that district commanders were held to account for by the force command team, and which they in turn communicated to their staff as priority areas.    The operational performance pack for the policing district where WYP23 worked for November 2011 has been reviewed. This was an information pack forwarded by Headquarters to the Divisional Commander prior to a review of divisional performance by a member of the Chief Officer Team with that officer. It detailed the areas of performance to be   44 reviewed and how the division had fared. These areas represent the force’s own priorities.  Some of these relate purely to management functions including budget statements, financial briefing, savings delivery plan, efficiency, vehicle fleet and overtime. Sickness absence levels are also reviewed. The ‘Local Policing’ section includes trends in recorded and detected crime and features burglary in a dwelling and metal theft. Protection of the public from serious harm features the domestic abuse sanction detection rate and serious sexual offences. There is a focus on sanction detection rates as the key indicator of performance.  Demand reduction in relation to the use of custody services and the number of incidents that can be resolved without officer despatch are also featured. The key crime types are burglary, robbery, vehicle crime violent crime and criminal damage. Burglary is the most featured of these.    In relation to protecting the public from serious harm the targets are: “Continue to tackle the level of serious violent crime; stabilise the sanction detection rate for domestic violence and; stabilise the sanction detection rate for serious sexual offences”. Although sexual assault on a female aged 13 and over is included in this list, sexual assault on a boy aged 13 and over is not, and most of the offences committed against Jack are not included in the diagnostic.  There is no mention in the document of CSE or wider child protection issues. This document is supported by the account of WYP29, a detective inspector in the division at this time who described burglary figures as the being most important diagnostic for all staff.  Jack’s case came to the fore at a time when the police service nationally was beginning to go through major change. In terms of child protection, forces nationally, including West Yorkshire Police (WYP), were realising that child protection was an area that had seen little development and that the concentration on performance indicators had detracted from their ability to provide high quality protective services to vulnerable persons.    Appendix B provides details of the work that has been undertaken by WYP to improve their response to CSE. This does not detract from the fact that police officers on a significant number of occasions failed to appreciate the incidents being reported to them represented a child that was at high risk of harm, and who was already a victim of serious criminal offences.  While it is true that police training and resourcing was not where it should have been, it is not mitigation for police officers who seemed to lack compassion and professional curiosity. There needs to be a process undertaken to assure the public that the message of this and similar serious case reviews have been understood and acted upon by WYP.  In terms of children’s social care previous sections have highlighted the failure to deal with referrals in a way that complied with statutory guidance. The level of resourcing in BCSC at that time is a cause for concern. There were issues around consistent managerial oversight and information sharing with other agencies. ICT systems made recording information more difficult and inexperience amongst both team leaders and social workers affected decision-making.  These are all mitigating factors that have credence. However, children’s social care is the most important agency in terms of child protection. BCSC hold the statutory powers and their front-line staff should understand their role in keeping a child safe. The fact is that when they received referrals they did not respond quickly enough and with the degree of strong leadership and grip that was required. In interviews and at the learning events it was obvious that front line staff in other agencies did not have the knowledge of child protection procedures you might expect.  BCSC should have filled that gap.  Finally, the Emergency Department failed as previously described to undertake any action following Jack’s attendance and this seems to be because staff were happy with the facts reported to them. This showed a degree of naivety and a lack of professional curiosity.    45 While in some cases the use of ‘agency’ staff was cited as mitigation the Trust should ensure that any of the staff they employ have the appropriate training.  This case has highlighted the importance of the initial response by agencies when they are made aware that a child is at risk of harm. There is clear statutory guidance to follow when a child at risk is identified. It is not a voluntary scheme. All professionals that are involved or come in to contact with vulnerable children should understand that guidance. In the case of those involved in education and health, and to some degree the police, there needs to be a proactive response. An individual’s professional curiosity should identifying circumstances that indicate a child is at risk and that child care services need to become involved. In the case of child care services this is a reactive process, acting upon the referrals and information received from other agencies. These are not easy judgements to make and with limited resources the level of required support can be difficult to put in place. It requires a multi-agency approach with professional risk assessment, a plan with milestones and intended outcomes overseen by strong leadership.  In Jack’s case, too many professionals could not or did not see this as a serious case when the initial facts were reported. The failure to treat these initial reports as seriously as they should, and to engage other professionals at an early stage, put Jack in further danger.   4.4 A lack of coordinated support for families and young people Jack was provided with a huge amount of support from individuals and agencies. However, there was no overall strategy to co-ordinate support and establish how effective it was in protecting Jack.  Jack’s parents and school were the first to provide support to Jack. Jack’s parents spoke to the school and their general practitioner (GP) for advice, to coordinate a response and to put a protective package in place around Jack.  Jack’s school has excellent safeguarding procedures and a deputy head teacher (school safeguarding lead) who is committed and knowledgeable about the role the school should take. A member of staff attended 90% of CSE strategy meetings and was proactive at meetings and in contacting the police.  The first time it became apparent that Jack was in difficulties was at a school residential outing. The school were aware that he had declared to his peers that he was gay. The school offered him support. Most of Jack’s male friends took a step backwards and a female friendship group filled this void. While they were supportive of him, it became clear as Jack became at higher risk, that some of this group unwittingly assisted Jack to maintain contact with older men by lending him their mobile phones, escorting him on trips to Leeds where he would meet men, and provided him with alibis as to his whereabouts.  The school dealt with this issue very sensitively arranging to brief parents to help prevent such occurrences. This worked to a large extent and it should be clear that Jack’s friendship group provided significant support throughout his darkest times. The school referred Jack to ‘Hand in Hand’ a third sector support organisation. In turn they referred Jack to the BLAST project whose engagement is described below.   The school worked closely with Jack’s parents, as you might expect, but they dealt with Jack in a professional and even handed manner. The school put in place as many practical measures as they could to protect Jack while he was at school and ensured other agencies were kept informed about any relevant events involving Jack.      46 The school followed safeguarding procedures and the school safeguarding lead took a close and personal interest. The level of commitment shown by the safeguarding lead was exemplary. The school appears to have been a beacon of good practice in this case.  In February 2011, when Jack was 13, he was referred to the BLAST Project.  The project is part of Yorkshire MESMAC, a sexual health organisation.  The BLAST project specifically works with young men and boys involved in, or at risk of, becoming involved in sexual exploitation.  The BLAST project provided one to one support for Jack from 2011, until it formally stopped in late 2015 when Jack’s CSE risk had lowered and he was able to deal with the consequences of his abuse.  The BLAST Project offered regular, on-going and consistent support. The support Jack required was long-term in nature and developing trust is not an easy or quick position to achieve. As events unfolded for Jack the BLAST worker provided a constant that was lacking from some of the other individuals. A video has been recorded by Jack where he describes his circumstances and says how BLAST was a big help, and stresses how important the consistency element of support is. Jack credits much of the improvement in his position to the understanding and support he received through BLAST.  The BLAST project worker saw Jack on a regular basis and part of the role was to act as an advocate for Jack, who shared his views, thoughts and comments with the BLAST project worker. These views, thoughts and comments were shared at the CSE strategy meetings.   Jack received support from Sexual Health Services, which were being provided by Bradford Teaching Hospitals Foundation Trust (BTHFT) throughout the review period. The first contact between Jack and Sexual Health Services was in February 2011 and Sexual Health Services knew him from then until January 2015, although contacts predominantly took place in the period from February 2011 to September 2012.  The Sexual Health Service includes Sexual Health Advisors (SHA) and Sexual Health Nurses. The SHA role is to support patients, inform about the testing process and how they will get results, to counsel about safe sex practice, contraception etc. and ensure that appropriate follow-up arrangements are made. They are also involved in partner notification.  Jack was aged 14 years when he first attended the clinic.   Jack had 16 appointments with the Sexual Health Service during the three year period from February 2011 to February 2014. Six of these were new appointments and all were self-referrals, the first being suggested by West Yorkshire Police. The remaining ten appointments were for planned follow-up reviews, investigations or vaccinations. It can appear as though a large number of staff were involved in the care of Jack over that time, but in practice the majority of contacts were with two SHAs and a doctor.   There is no information in any of the paper or electronic records to suggest that Jack ever underwent a child protection medical or forensic medical assessment.   The numerous contacts with ChildLine counsellors provided further evidence of support and advice being offered to Jack. In fact, Jack had one to one advice on over 20 occasions in 2011 and 2012. Whilst this helped Jack and in fact the prompt referrals by ChildLine were an effort to reduce the risks to him, the efforts of these counsellors were never coordinated with the others that were providing help and support.   Jack received considerable support from a number of sources over a protracted period to increase his understanding of the risks he faced and address his perception of the nature of   47 the relationship between himself and the men he was in contact with. This included the role of a police officer, WYP115. Officer WYP115 volunteered to act in a ‘mentoring’ role for Jack but had no ‘brief’ in respect of his role or what was expected of him. He had no training as a Family Liaison Officer (FLO) or experience of working with children generally or CSE specifically. He had no ‘de-brief’ structure and once it had been agreed he should have contact with Jack it appears he was essentially left to his own devices about how this would proceed. The concept of having a dedicated point of contact within the police to support the family and hopefully develop a relationship with Jack was valid (and this happened under Operation Oakberry in the form of two family liaison officers (FLOs)) but the way this was done were not appropriate and it is not known how effective the involvement of WYP115 was. He attended only one of the CSE strategy meetings. A more directed use of either this or another officer to form a positive relationship with Jack, which was not focused around investigative matters, may have assisted Jack to achieve a better understanding of the risks he was exposed to and the true character of his relationship with the men who abused him.  The decision to use WYP115 in this role appears to have been based on nothing more than the fact that he volunteered and that he was a member of WYP Gay Police Association. At a CSE strategy meeting a number of professionals counselled against this approach believing there was an inherent risk to the officer and his involvement was unlikely to help Jack in the long term. Both these concerns became a reality. The decision to use WYP115 was ill thought through and served to make a number of professionals believe the police had a stereotypical image of gay men.  The Placement Support Services worker appointed to Jack and his family by BCSC started in a positive way. She built a good relationship with Jack and the family. The worker told them she would remain with Jack’s case until he was 18 years old. This was disingenuous as these placements have a three month timescale. We do not know why this worker chose to tell the family that this was the case. Nonetheless the officer remained in place for over 12 months. She provided considerable support to Jack and would attend appointments with him. It seems she had little supervision. The social worker overseeing the case did not build a good relationship with Jack’s parents (mainly because she missed a number of appointments) and it seems the team manager was happy to allow the PSS worker to take the lead.  Whatever good was done by the PSS worker was eroded when, in late 2011, Jack and his family were told the PSS worker was to be withdrawn. This was unfortunate and insensitive timing given that a number of court cases were due to start at this time. It is unclear what the position was. Ultimately there was a phased withdrawal but there was some form of dispute between the PSS worker and her employer. This confusion was indefensible given the position the family were in at this time. It undoubtedly removed any trust or respect the family had for BCSC. Jack’s parents complained about the withdrawal of the PSS worker but this made little difference.  Many of the people involved were committed and determined to do their best to support and protect Jack. No matter what support was put in place Jack continued to be at high risk and continued to be offended against.  The CSE strategy meetings certainly provided a forum to discuss on-going work and exchange information. Although discussion took place, there was a lack of leadership when it came to a coordinated approach to Jack and his family.  There were individuals who were sympathetic and listened to Jack’s concerns. The BLAST project worker in particular built up a good relationship, as did the PSS worker in the first months of her contact. The school provided an excellent pastoral service. The police   48 nominated an officer to act as a “mentor” and again Jack built up a good relationship with him.  The only constants were the school and the BLAST project and to some extent the counsellors at ChildLine. The PSS worker became involved in a dispute with her manager over Jack and eventually was withdrawn, and a similar situation occurred when the police officer acting as a mentor transferred to another police force. This added to a feeling by Jack that officials kept letting him down. This may not always have been justified but there is no doubt that the position of the PSS worker and the police officer as a mentor were not well thought through, and ultimately failed to recognise Jack’s level of need.  It is also the case that many of those engaged with Jack had little experience of dealing with CSE of this type and scale, and in particular CSE involving a boy  This meant that most of the professionals were ill-equipped and lacked experience in this area.   There was a lack of a thought around a multi-agency holistic plan for Jack. Instead individuals took the action they thought appropriate and Jack received mixed, conflicting messages and information from services. This seems to have added to his anxiety, mistrust and unwillingness to engage.  It must also be said that there were no simple solutions. Jack pushed support away from him and could be manipulative and not entirely truthful with those trying to help him. This is to be expected and professionals must understand this and develop tactics to deal with it.  To examine why this programme of support was unable to reduce Jack’s high-risk behaviour is a difficult task. The lack of leadership was a key factor. It is not possible to identify an individual or agency that was responsible for forming a multi-agency and holistic plan of support and this was a major factor. In addition, the lack of understanding of Jack and the failure to take a child centred approach had some bearing, as did the inexperience of most professionals around male CSE cases. 4.5 An absence of leadership and planning This case lacked leadership and direction from either of the two main agencies that should have been protecting Jack, West Yorkshire Police and Bradford Children’s Social Care.  There was no effective plan or coordination. They failed to prevent offending or protect Jack.  The most useful forum for planning and coordinating work was the CSE strategy meetings.  In fact, at the outset the chair of the meeting stated this as a clear aim of the meeting. It was never the case that this meeting was the environment in which a plan for Jack was formalised. These meetings were an opportunity to provide updates and share information.  Even on that level the meeting did not succeed. Key individuals and agencies were often not invited or failed to attend. At best the information shared was relevant but incomplete. For example, the school nursing service, sexual health advisor and GP were not invited and police attendance was sporadic.  In the vast majority of child protection cases either the police or children’s social care take the lead role. In this case the police, as you would expect, took the lead on the investigation of offences. The lead police officer acted largely in isolation from other agencies. The police did not engage in the majority of CSE strategy meetings and in terms of support prior to 2013 their only contribution was the suggestion of placing Jack in secure accommodation and appointing an officer in an unsuitable role as a ‘mentor’.    49 Children’s social care should ultimately have taken the lead in implementing child protection procedures around Jack. However, there was no clarity around roles and responsibilities for front line BCSC staff. A community resource worker and a placement support worker were responsible for Jack. They lacked the qualifications and seniority to really implement meaningful plans and did not appear to receive formal or informal supervision. A decision was made to classify the case as a Child in Need. This set the tone for the way Jack’s case would be regarded. Even then procedures were not followed, as they should have been.  When Jack’s school informed both the police and BCSC that he was at risk of being abducted no one from these agencies thought to take the lead or indeed any responsibility for preventing Jack being exposed to extremely high risk. This demonstrated a complete absence of leadership by those agencies when Jack, his parents and the school needed it most.  It is clear that many agencies worked hard to support Jack but the lack of coordination caused by the lack of leadership and a plan meant that individuals and agencies acted without being given clear aims and timelines.  At the start of the process around Jack a comment is made by a BCSC manager that they would take a back seat because of the number of agencies involved; in doing so they signalled an intention not to take a lead. It was never clear who they thought might take that role.  This case is notable for its lack of leadership; the absence of a formal SMART plan; the lack of formal risk assessment. In short no one person or agency ever got a grip and directed and coordinated activity to protect Jack.  Section Five – Voice of the child Many people were listening to Jack and trying to help and support him. There is evidence of systematic approaches to ensure that the voice of the child was heard. In particular, Jack’s school devoted time and resource to supporting him. Jack’s GP supported by the school nurse team, CAMHS and sexual services provide very good support and there was evidence that Jack’s voice was listened to.  The police response to Jack was based on a clearly perceived idea that he was, to some extent, the author of his own misfortune and was placing himself in situations of danger of his own choice. This was to an extent true given the way in which he had been groomed but the failure to understand Jack, and the action he was taking, is indicative of a service failing to listen to the victim. There were a number of examples of police officers failing to listen or understand him. The police inspector that spoke to Jack on his return from London in June 2011 is one example. When Jack came forward in August 2010 and spoke to police he was ignored.  That destroyed his trust in the police. There seems to have been no understanding or indeed sympathy for the position Jack was in, and no acknowledgement of the courage it had taken to talk to a police officer; in short no compassion was shown.  The fact that that no social worker or CRW was able to build a relationship with Jack or his family must also be of concern. The workload of social workers makes it difficult to build a relationship but this is the main part of their role. Professionals at the learning event expressed the view that the allocated social worker was too busy to devote more time to Jack and the family. A less qualified worker, who had time to devote to the family in order to develop a relationship, provided a good option to fill the gap, but ultimately the qualified social worker should have been the primary focus. There is still a requirement to supervise   50 and lead and it is not clear that the social worker and team leader understood the needs and views of Jack.  The trust and expectation that agencies placed on Jack’s parents to protect him demonstrated a failure to listen to Jack’s views. There are few teenagers who prefer their parents to represent them than being able to speak for themselves. While the school, BLAST and the PSS worker were engaged directly with Jack, the CSE meeting excluded him completely.  Who does listen to the voice of a young gay boy? There is a lack of support for boys who are struggling to come to terms with their sexuality. Jack’s mother gave a very good example of the amount of work that needs to be undertaken to change attitudes. She said, “It would be unthinkable to have children’s story books in which black or disabled children were specifically excluded, and yet you do not find books for children or young people in which there are young, gay people”.  Although there are some exceptions this does sum up a societal attitude that caused so much angst to Jack. We have to ask questions about who is listening to the voice of children who feel isolated and what support is currently available in Bradford to support these children.   Section Six - Good Practice This report has largely focussed on the areas of practice that have failed or required significant improvement. However, there were individuals and agencies that did demonstrate exemplary practice.  The work of Jack’s school deserves particular mention.  This is not limited to the individual that took the lead for safeguarding, who provided support far beyond that which might be expected, but the school as a whole.  Strong safeguarding policies have been followed and more importantly engendered an attitude that encourages young people to express themselves. They provided safe space to Jack and did everything they could to protect him.  The general practitioners also deserve to be highlighted for their approach.  They exhibited excellent awareness of safeguarding issues and maintained a significant interest in the family and good continuity throughout. The GPs shared appropriate information and made timely referrals to appropriate agencies.    A number of agencies provided consistent levels of support and whilst it might be argued that their actions do not amount to good practice per se it is certainly worth acknowledging that the following services should at least feel they fulfilled their statutory roles:    Child and Adolescent Mental Health Services remained engaged and shared information. They acknowledged the seriousness of Jack’s case.   ChildLine provided a unique service and were always available to Jack.   Sexual support services provided excellent care for Jack and liaised well with other health providers.   The school nursing service responded swiftly and liaised well with medical and educational services.    51  The emergency department were able to access accurate records showing Jack was engaged with services and although they failed to respond to that information. It is promising that the information was at least readily available.   The BLAST project provided a consistently good service to Jack and his family.   It is to the credit of the Chief Constable of West Yorkshire Police that, when he was briefed by Jack’s parents, he put in place an effective response.  Section Seven – Key Findings 7.1 Introduction This section summarises the key findings and provides an overall finding.    It is essential that this report is read in conjunction with the ‘Autumn’ serious case review published by the Bradford Safeguarding Children Board in December 2016.  Although there are huge differences in the circumstances of this case and that of Autumn, many of the issues found here were repeated in that case. More specifically the time frames are similar.   This section does not provide detail on the evidence behind key findings but rather it summarises them.  In 7.2 there is a summary of those findings that lead to the overall finding in 7.3. 7.2 Key findings Jack suffered abuse at the hands of a large number of perpetrators over at least three years from August 2010 to some point in 2013. All the key child safeguarding agencies were aware that Jack was facing significant risk of harm from February 2011.  The key points on which the overall finding is based are:   The failure by the police officer in August 2010 to make a referral to children’s social care resulted in a lost opportunity to protect Jack and prevent the series of offending that took place against him over the next three years.   The failures in February 2011 to follow process, record crimes and instigate an investigation resulted in the loss of key evidence and the failure to apprehend offenders.   The initial failure to follow child protection procedures by Bradford Children’s Social Care, following initial referrals in February 2011, was in contravention of Working Together statutory guidance and represented a systemic failure of child safeguarding processes.   Attempts made to restrict Jack’s use of the internet and social media by restrictions on him or removal of his devices failed.  A new approach to protecting children and young people from significant harm caused by those who prey on them through this medium needs to be found.    52  The police investigation conducted between February 2011 and April 2012 was at times inept, lacked management oversight and was poorly resourced.  This resulted in missed opportunities to arrest and deter offenders and resulted in further harm to Jack and potentially other young people.   The failure by both the police and Bradford Children’s Social Care to respond to the intelligence regarding Jack’s possible abduction to London in June 2011 was negligent and their lack of action placed Jack in an extremely high-risk position.   The model of using CSE strategy meetings to manage Jack’s case was flawed and together with a lack of a formal risk assessment process was a major contributory factor to Jack’s continued and heightened risk.   A failure by professionals to use and apply statutory child protection procedures resulted in a lack of management and mitigation of the risks to which Jack was exposed.   There were a number of examples of support to Jack, but a lack of leadership in developing a multi-agency, coordinated support programme had a severe impact on protection of Jack from harm.   The failure by police officers in January 2013 to properly investigate offences reported by Jack’s teacher showed a poor level of professional knowledge and curiosity. In this incident one police officer, who had several previous contacts with Jack, was grossly incompetent. This led to the loss of evidence gathering opportunities and a chance to prevent offending against Jack and other young boys.  7.3 Overall findings This review finds that:  1. West Yorkshire Police and Bradford Children’s Social Care failed in their statutory duty to protect Jack in that:   there was a poor response by police to reports of Jack’s contact with an offender in August 2010,    there was a failure of the police and Bradford Children’s Social Care to initiate a multi-agency strategy meeting and conduct a joint section 47 investigation, following referrals to them in in February 2011,     the police and Bradford Children’s Social Care failed to respond to reports of a planned abduction in June 2011   Bradford Children’s Social Care failed to put in place effective protective measures for a child at significant risk of harm and failed to follow statutory guidance    the police investigation that lasted until April 2012 was inept, badly managed and under resourced.    Managerial oversight and leadership was lacking and failed to challenge practice, provide supervision and positive, effective support to front line workers.  This contributed to Jack remaining at high risk of serious harm and being repeatedly offended against for three years.      53 2. The use of technology exposes children and young people to high risk through contact with child sex abusers.  No individual or agency in this case were able to prevent this. There is a dearth of knowledge and information on how to prevent children and young people from exposing themselves to high risk through these mediums.  There needs to be a national response to provide the tools and information to prevent harm to children and deter and apprehend offenders. Section Eight – Recommendations 8.1 Introduction The period of this review covers a similar period of that dealt with in the serious case review about Autumn, published by the safeguarding board in December 2016. The findings in that review crossover significantly with those in this review and consequently the recommendations are likely to be similar. This lead reviewer took cognisance of the recommendations in the Autumn review when compiling these recommendations so as not to complicate issues moving forward. 8.2 Recommendations 1. Bradford Safeguarding Children Board should take steps to look at technology assisted abuse and consider local responses to protect children and young people.  2. Bradford Safeguarding Children Board should seek assurance from West Yorkshire Police and Bradford Children’s Social Care that child protection processes that are fit for purpose and child protection procedures, as set out in Working Together, are being applied.  3. Bradford Safeguarding Children Board should seek assurance from the Director of Children’s Services that a review is being conducted into this case and the issues relating to practice are being dealt with. Section Nine – Conclusion Jack was brought up by parents who provided loving and constant support to him.   The family would be regarded by many as a typically ‘middle class family’. Jack’s parents were professional people and he attended a school that was rated highly by Ofsted. He was not raised on the margins of society or born into any circumstance that pre-disposed him to be a likely victim of abuse. As an intelligent and educated teenager, with the technical means at his disposal, he used the internet to explore his emerging sexuality and his own identity.  This led him into contact with men who despite full knowledge of his age and vulnerability used him for purely sexual purposes and gratification. They cleverly groomed Jack and were able to deceive him through false love and empathy. They offered Jack false hope of helping him define himself, through a shared experience of growing up as a gay person. Jack’s naivety, youth and need for contact with, and understanding from, other gay people, made him an easy target for abusers. This was a classic case of grooming.     54 The frustration shown by professionals, who could not understand why he put himself at risk, showed a lack of understanding around that grooming process and the level of conditioning that Jack had suffered. It meant that Jack was not only happy with the contact of his abusers but actively sought it out. Unlike other high profile CSE cases Jack’s abusers were not a networked group of individuals operating in concert within a locality that could be definitively identified, disrupted and prosecuted. Based on the experience of this case there were potentially dozens of hitherto unknown, unrelated and nationally distributed offenders willing and able to travel the country to meet Jack and abuse him, following contact through social media and the internet. Professionals, who were only just beginning to understand the concept of child sexual exploitation, treated this as a different entity from child sexual abuse, and worked outside statutory guidelines to deal with it. They failed to treat Jack’s abuse in the way they dealt with other forms of abuse in which they had more experience and understanding. It seems that professionals failed to grasp that the technology assisted abuse against Jack should have been dealt with by the same statutory child protection procedures as any other abuse.  They assumed that parents of Jack would resolve the issue because they had the means to do so, but when it became obvious that they were unable to prevent their son putting himself at high risk these agencies failed to step up their commitment and involvement. Jack’s determination to continue contacting and meeting older men over social media and the internet caused frustration and exacerbation from everyone that was involved with him.  It is difficult to know what more could have been done to stop him putting himself at risk.  The lead reviewer has not heard one person involved in this case provide a solution. There are significant difficulties once a child has been groomed; at that point prevention becomes far more difficult.  Current work underway in Bradford using a mentoring system certainly seems to offer a possible, or at least partial, solution.   The internet and social media provide abusers with new opportunities. Most significant is the speed at which grooming can be successfully undertaken. Many professionals are still of an era where non-familial abuse required the abuser to be out in the open. The grooming of a child required one to one physical contact by a person who had normally acquired a position of trust. The development of the grooming process carried far greater risk and interventions were easier to put in place. We have entered a new age of non-familial abuse of children through the use of technology; there needs to be a national response. At least part of the solution is accepting that as a society we have not yet fully developed our understanding of how children who are coming to terms with their sexual orientation are supported. The lack of obvious support networks for Jack led him to the internet, which is now the first place many turn to for answers and support. It is not possible to control the internet so we must prepare children so they are able to keep themselves safe and find the support they need. Since 2010 West Yorkshire Police and Bradford Children’s Social Care have undergone significant change to improve the standard of help and protection they provide (as detailed in appendix B).   In conclusion, this review has found that Jack’s use of the internet and social media put him at high risk and caused him to suffer serious harm. We do not know what could have been done to prevent this. An opportunity in 2010 was potentially the only time when an intervention may have been effective. However, when Jack and his parents turned to the agencies they thought best placed to protect him, they found the system failed them. They talked to police officers who lacked compassion, basic legal knowledge and any sense of professional curiosity. They watched a poorly resourced and ineptly managed police   55 investigation make laborious progress. They saw their son abducted despite warnings.  Children’s social care failed to get a grip of Jack’s case and failed to follow child protection guidance. There was no multi-agency strategy meeting or multi-agency section 47 investigation. No formal legal advice was sought. The decision not to use a formal child protection meeting structure and rely on informal CSE strategy meetings was wrong. It resulted in a failure to develop a strong Child in Need plan with any form of governance. In the early part of 2011 a child protection conference should have been conducted and this would have resulted in the development of a child protection plan with the associated actions this would have triggered. Children’s social care should have taken a lead. Instead they allowed Jack’s case to drift and as a result he remained at risk of significant harm for over three years. Ultimately, the police and children’s social care should have done more to protect Jack.                                       56 Appendices Appendix A Internal Agency Review reports  These reports were completed by the following agencies:   West Yorkshire Police  Bradford Children’s Social Care  Jack’s school  Airedale NHS Foundation Trust  Bradford Teaching Hospitals NHS Foundation Trust  MESMEC  Airedale, Wharfedale & Craven, Bradford City and Bradford Districts Clinical Commissioning Group  Bradford District Care NHS Trust (CAMHS)  National Society for the Prevention of Cruelty to Children Appendix B There is a considerable amount of work that has been undertaken since 2010.  The work is summarised below.  This information has been provided by the agency and has not been tested as part of this review.  West Yorkshire Police  Since 2010 the Force has progressed massively in its management and approach to CSE. This progress is recorded below with a summary of the current CSE investigation provision in Bradford and some remaining issues for the Force.  (a) CSE specific training.   Two rounds of training were issued by the Force to be delivered in District.   A training package was written in the latter part of 2011 to be delivered by District training officers to all West Yorkshire Police staff during February and March 2012, including front line uniform and specialist staff and staff in other roles such as communications operators. This took place on rostered training days which all front line staff were obliged to attend. Attendance by staff in specialist units was less guaranteed as these days were not scheduled into their rotas. The material included detailed guidance on how to identify young people at risk of or experiencing sexual exploitation by describing the warning signs outlined in the 2009 DCSF document: Safeguarding Children and Young People from Sexual Exploitation. It included guidance on how to protect children, covering legal powers and action to take when encountering children who may be at risk under the heading ‘What is my role’. A case study based on the actual experience of a West Yorkshire victim and presented in two parts with an accompanying work book explored these indicators, the effect of abuse on victims and on families and how officers should respond, focusing on the need to identify the child as a victim and not an offender in circumstances where they were involved in minor crime. It identified that CSE affected boys and girls. It identified three common forms that the ‘finding’ stage of grooming might take – ‘on street’ grooming, internet grooming and   57 introduction through another victim. It described the five stages of grooming. One section of the training material looked specifically at factors in relation to boys and young men.        In September 2012 a multi-agency event was held at the Force Training School which was specifically targeted at Safer Schools officers and other agency staff who worked in schools to publicise the Friend or Foe resource for use in schools with children. This was presented by staff from a South Yorkshire child protection charity who had successfully used the resource in Sheffield.  In addition to attending the event copies of the resource were sent to Safer Schools officers along with the My Dangerous Lover Boy DVD and training notes.        In April 2013 four events were held at the Force Training School which were a presentation by the psycho-therapist Zoe Lodderick. Other agencies were invited and over 650 people attended the sessions. These provided information on the psychological effects of abuse on child victims and guidance on interviewing and supporting victims.      The training delivered in 2012 was reinforced during a round of refresher training conducted with all front line officers from May to July 2013. This training was delivered by staff from local Safeguarding Units and focused on the reality of child sexual exploitation in their particular districts, using a successful West Yorkshire CSE investigation where two offenders received lengthy sentences as a case study (Operation Gardia which both WYP58 and WYP59 had been attached to prior to secondment to Operation Oakberry and which resulted in lengthy sentences for two men engaged in street grooming and subsequent child sex offences). It included briefing officers on local ‘hot spot’ areas, ongoing local operations, repeat perpetrators and high risk victims, so that the theoretical knowledge conveyed in the first round of training could be refreshed in a practical way relevant to the officers day to day duties and setting that knowledge in context. All staff were issued with aide memoir cards as part of the training which was linked to the Know the Signs campaign detailed below.         Between June and September 2013 the Force ran six Missing From Home Master Classes which were held for Sergeants and Inspectors from across the Force. These covered a wide range of aspects in relation to missing from homes but included a presentation by the Senior Investigating Officer and Deputy Investigating Officer on the Force’s major CSE investigation Operation Kellerabbey. This outlined the lessons which had been learnt in the course of this investigation about the investigation of CSE crimes and the investigation of missing children cases. This was supported by a presentation from the Safeguarding Detective Inspector responsible for managing CSE investigations in the Bradford area which discussed identifying and taking account of CSE risk when responding to reports of missing children. Operation Kellerabbey referred to the abuse of one victim by multiple suspects (on the 8th of February 2016 twelve suspects received custodial sentences totalling 140 years at Bradford Crown Court as a result of Operation Kellerabbey and other convictions also resulted from the investigation. Kellerabbey has itself been subject of a Bradford Serious Case Review).        In 2014 NCALT CSE e learning (part of the Public Protection – Missing Daughter module published in December 2013) was advertised to the Force for access by officers.            As a result of a training needs analysis in January 2015 the Force Training School revised the Safeguarding Everyone’s Business course. This was a five day course run for 8 staff, initially to be taken from the Force’s Safeguarding Units. The Force ran this course through 2015 and it covered all aspects of safeguarding including CSE. Additionally all new recruits in Constable, Special Constable and PCSO roles receive a specific input on CSE and Safeguarding and the new three week SIO course has a case study based on a missing young girl linked to CSE.        CSE is now a key part of the following crime courses:    58 • Initial Crime Investigation • Initial Management of crime • Detective Inspectors Development Programme. • Specialist Child Abuse Investigator Development Programme        West Yorkshire are therefore confident that its staff are now skilled and competent to recognise and respond appropriately to CSE and have the training and awareness to do so.  (b)  Awareness Raising.      In addition to specific training inputs the Force has invested in internal and external awareness raising of CSE.         In conjunction with this refresher round of training in 2013 the Force launched its Know the Signs campaign which was directed both at the general public and internal staff. This has run since 2013 and has featured communication of CSE information via a number of media:       Internally:   A CSE video briefing by then ACC Lee placed on the intranet page;  CSE Aide memoires issued to all officers;   Posters displayed within all police premises;  Screensavers carrying CSE messaging;  The circulation of an internal magazine;  This campaign has been the basis of subsequent refresher material to the Force, for             example in screen savers highlighting the need to recognise forensic opportunities               when dealing with CSE cases.  Externally:   A dedicated page on the Force web site;  Posters distributed in public area;  Z card information leaflets for the public;  Press releases - including material placed on the Aljazeera web site;  Radio adverts;  Social media messaging (e.g. twitter)  The release on You tube of dramatized accounts of CSE scenarios recounted to              police by victims they had worked with and made by students at local colleges and                other videos such as a ‘talking head’ video;  Facebook advertising;  During July and August 2013, police and partners ran a number of road shows              visiting towns and cities across West Yorkshire, which included a video played on a              big screen, as well as officers talking to the public.    Training was also delivered by local policing staff to workers at shopping centres,              bowling alleys and train stations;  Live web chats by senior managers;  The release of a video involving the parents of child victims of CSE talking about              their experiences. The Force worked in partnership with local organisation PACE                 (Parents Against Child Sexual Exploitation) to record their experiences and raise               awareness of the issues;  On line guides: a series of simple step-by-step guides produced to help parents set              privacy settings on popular apps and games consoles used by young people;  Guides released prior to Christmas to encourage parents to make gadgets safe              before giving them as presents;    59  The campaign was used to support the first National CSE Awareness Day involving             internal intranet headlines & video, screensavers, press releases, public video             messaging, social media messages and joining a national ‘thunderclap’;  The campaign’s graphics were displayed on the big screen at the Rugby Union            World Cup Fanzone on Millennium Square, Leeds from 10th September – 18th             October 2015.  Following the success of the Know the Signs campaign, a CSE Communications Group was formed, made up of communications representatives from West Yorkshire Police, the Office of the Police and Crime Commissioner, Local Authorities and Crimestoppers, in order to develop the campaign in the future. This agreed to specifically address on line grooming and in July 2014 the ‘Who are U Really talking To? campaign was launched. This was aimed at raising awareness of online grooming amongst young people and was launched during the school summer holidays. Materials were produced in consultation with a Leeds youth group. The campaign was delivered with animated graphics mainly via digital or online channels such as websites, social media updates, Facebook advertising, and big screens in city centres. A video was released to show the full story behind the animation and a video released on YouTube and via social media. This campaign was itself followed by the ‘Think before you send’ campaign which began in July 2015 and highlighted the dangers of sexting using similar communication avenues as above, principally relying on social media and other areas most accessed by young people.  In addition to the above there has been routine use of the Force’s primary internal communication medium, its intranet, to publish briefing items and inform staff of developments in the Forces tactical management of CSE. The following are examples:   31/01/2011: The creation of the child at risk of CSE flag and CSE management occurrence;  08/02/2012: The creation of a Niche warning flag: Involved: suspected CSE perpetrator;  09/11/2012: Publication of links to a CEOP training film re CSE;  24/05/2013: Publication of the Force’s CSE policy guidelines;  18/07/2013: The ability to now flag niche crimes as CSE related through a new ‘stats classification tab’;  02/10/2013: Information re the creation of the Niche occurrence type:  Child Sexual Exploitation (CSE) Problem Solving. This was introduced to allow local managers to action CSE ‘hotspot’ locations by creating occurrences to record action plans and progress made re those areas;  03/03/2014: Information publicising West Yorkshire Police’s membership of the National Working Group Network and how to access material from the Group’s website;  11/06/2014: Guidance on flagging CSE suspected CSE perpetrators on PNC;  08/10/2014: Briefing re the provisions Section 116 of the Anti-Social Behaviour, Crime and Policing Act 2014 grants new powers to the police in respect of hotels;  05/12/2014: Creation of a ‘Location of interest’ Niche flag to be used to flag locations subject to CSE intelligence;  06/03/2015: Information re the use of civil Injunctions in cases of CSE following the use of these by Birmingham City Council;  27/07/2015: Information re Section 136 of the Sexual Offences Act 2003 (Closure Orders in relation to CSE);  13/10/2015: Information on new recording standards for CSE.  In short, the Force has invested considerable resource since 2012 in raising awareness amongst the public at large and amongst West Yorkshire Police employees to ensure that   60 CSE is understood, recognised and properly responded to and has steadily developed its flagging and recording processes to highlight children at risk, risky individuals and locations where CSE may occur.  (c)  Policy development.  At the beginning of the investigations into Jack’s abuse West Yorkshire   Police had a child protection but no CSE specific policy. A child prostitution policy existed (adopted in 2004) which was primarily to guide staff who encountered children (i.e. under eighteen years of age) engaged in on street soliciting, instructing that they were to be responded to as victims and become subject of multi-agency intervention. A CSE policy was not formally adopted until May 2013. The writing of this policy followed a lengthy process of discussion between the five West Yorkshire LSCBs to agree an updated version of the West Yorkshire Consortium’s 2008 CSE policy to incorporate the content of the 2009 DCSF guidance Safeguarding Children and Young People from Sexual Exploitation. During the latter part of 2011 West Yorkshire Police had worked closely with Leeds City Council to write procedures for Leeds. As a result of that work the police submitted a draft update of the 2008 document to partners for consultation at the beginning of 2012. By that date Bradford had also developed its own procedures to reflect the 2009 guidance. Discussions subsequently centred around the format of the risk assessment process and agreement was not reached on a single policy for West Yorkshire until January 2013 when the new policy was adopted. The police took the view that it was undesirable for their staff to work to different guidance in different areas in line with local partnership agreements and preferable to have one Force guidance and consistent multi-agency procedures in all local authority areas. As a result the development and adoption of a Force policy was delayed pending this countywide agreement. Once this was agreed a Force policy was written, consulted on internally and with partners and adopted at the beginning of May 2013. This was then incorporated into the second round of Force training which commenced in May 2013.  Since that date the West Yorkshire Consortium procedures have themselves been updated and the Force has revised its own CSE policy as its experience of managing CSE has developed and to meet changes in legislation and national policy. This has included a change in the definition of CSE. Current Force policy follows national guidance and defines this as:  ‘Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ as a result of them performing, and/or another or others performing on them, sexual activities. CSE can occur through the use of technology without the child’s immediate recognition, e.g. being persuaded to post sexual images on the internet/mobile 'phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability’.  The policy adopted in 2013 restricted the scope of the policy to:  ‘those cases where abuse is conducted in a group or gang context where a number of perpetrators are acting in concert to abuse one or more victims.  This may be commercially motivated, i.e. for financial or other gain, or be committed for the sexual gratification of the perpetrators.  It includes the exploitation of children who are   61 abused in ‘on street’ contexts and in premises where adults may be exchanging sex for payment.’  This was done because the national definition contained in the 2009 guidance was considered to be too wide. It fitted the majority of cases reported to police which involved any form of grooming, particularly intra- familial cases where there was evidence of gifts, however small, being given. It was believed that this wide definition would diminish the focus of personnel on dealing with the type of networked abuse the Force was trying to identify and address, for example by flagging so many cases that the flags became meaningless to operational staff.  The current policy also places a caveat on its remit, excluding:   Offences within an intra-familial or domestic setting and there is nothing to suggest a wider organisation and/or a commercial purpose;  sexual experimentation between children aged under 18, where the relationship is age appropriate and there are no identified exploitative concerns; or  “sexting,” i.e. an exchange of images of a sexual nature via use of technology between children under 18, where the relationship is age appropriate and there are no exploitative concerns.  The original policy excluded most of the incidents of abuse suffered by Jack as there was no evidence of networked activity between the perpetrators. The new policy would bring his cases within its scope.  The current policy is extensive. It details police powers (for example under the Anti-Social Behaviour, Crime and Policing Act 2014) and the local procedures for implementing these, human trafficking procedures (applicable in Jack’s case), provisions about creating action plans on documents called Misper 18s directing how to respond to reports that a CSE high risk child is missing (which had it been in place would have been applicable to the reports of Jack’s impending abduction to London in June 2011) and guidance on multi-agency working.  The policy also addresses the resourcing of CSE investigations and states that these should be in accordance with the Force’s Serious Sexual offences policy. This defines a serious sexual offence as:  all rapes, all sexual activity involving a child under 13, sexual activity without consent or sexual activity with a person with a mental disorder, abuse of children though prostitution and trafficking for sexual exploitation.   The policy states that offences of rape, serious sexual offences (other than rape) and other sexual offences should be investigated by District Safeguarding Units (SGUs) or other District staff. Only intra-familial child rape must be investigated by the SGU.  In addition to guidance in respect of tactical options to address CSE the CSE policy includes detailed process instructions for the management of information that a child may be subject to CSE. These are described as Minimum Recording Standards and a flow chart showing these is attached at Appendix Six.  (d) Organisational structure.  The Force’s internal structure and partnership arrangements have   developed significantly in respect of CSE since 2010. WYP20 joined the then Vulnerable Victims Unit (VVU) in the Division in 2008 and assumed the role of Missing Persons and CSE Coordinator. This was obviously a large workload and at his time she was a part time member of staff working   62 twenty hours a week. One of her roles was to attend Multi-Agency Against Child Sexual Exploitation (MAACSE) meetings in Bradford. These were six weekly panels attended by representatives from a number of agencies who met to review potential new CSE cases, share information and agree appropriate actions. There were however no investigative staff allocated to progress this information and WYP20s role was limited to attending the meetings and passing on any information to local CID colleagues for development. At some point WYP18, a police staff employee, was assigned to assist WYP20 and came to take the lead on CSE while WYP20 took responsibility for the management of missing from home reports. This arrangement continued when the Bradford North and South SGUs merged into one unit at Eccleshill police station in April 2011 and WYP18 and WYP20 remained the only personnel responsible for implementing the District’s operational response until April 2012 when the former CPPU and Districts SGU were merged to form a new District SGU combining adult and child safeguarding. At about this period additional resources were allocated to provide a dedicated CSE investigative resource and a multi-agency CSE team began to develop. These developments have continued through to 2016 and the current Bradford CSE arrangements are described below.  Bradford currently has a dedicated Detective Inspector led multi-agency CSE team co-located in CSC premises. This unit has been in place for approximately eighteen months although has only recently moved to its current CSC premises.  As noted elsewhere this DI has previously led a District CPPU team and also has extensive experience in other multi-agency work (drug rehabilitation services), District reactive CID and held a DI operational role in the Force’s Protective Services Crime major crime investigation unit. He leads a team of 12 officers including a sergeant of whom seven are allocated investigator roles and the remainder form part of the joint CSE Hub team, three officers working with CSC colleagues to undertake joint visits to victims and make initial enquiries into concerns etc., one to undertake offender management and problem solving and one to manage interagency information sharing and coordination. The CSE Hub are forwarded any referrals received by the Multi-Agency Safeguarding Hub (MASH), which triages all child protection referrals, which indicate that they are CSE cases. This includes offence reports, intelligence and reports of general concern. These are recorded on a daily action report and each case is reviewed at a morning meeting of the CSE Hub members chaired the DI. These comprise statuary agencies such as health, the Youth Offending Team, Placement Support and CSC and third sector agencies such as Hand in hand, BLAST and Turnaround. Not all physically attend the meeting in person but there is daily communication with each partner to identify actions in each case. The daily meeting identifies what actions are required (for example Section 47 enquiry, crime investigation, joint visit and so on) and each referral is recorded on a Niche occurrence and the content of the discussion and actions arising recorded on it. This allows the referrals to be reviewed by the Hub’s managers. This process includes deciding when an offence is identified who will investigate it and this may be the CSE team investigators, the SGU child protection staff or other District resources, with a presumption that the most serious cases will be held by the CSE team. Should a referral disclose that a complex multi suspect investigation may be required the DI may escalate this to the Bradford District Detective Superintendent to discuss investigation planning and resourcing and possible further escalation to Force level and the use of additional resources, for example from the Force’s Protective Services Crime department. Similar teams now exist in the five West Yorkshire Districts.  In addition to these ‘live time’ teams West Yorkshire Police have recruited approximately thirty police staff, largely from retired officers, to investigate non-recent cases of CSE, that is potential crimes which may not have been reported at the time they were committed. Potential victims have been identified in each District using an algorithm which has extracted risk indicators which indicate they may have victims of CSE from police databases. These have been prioritised and staff are currently visiting these potential victims to identify if they now wish to disclose that they were victims of abuse and if so to initiate investigations which   63 will result in their abusers being prosecuted and by doing so protect future victims from harm.  Strategically, CSE has been overseen by the Force Strategic Safeguarding Board. This meeting is attended by Superintendent leads from each of the Districts and other relevant departments such as the Force Safeguarding Central Governance Unit (SCGU) and is Chaired by the Assistant Chief Constable lead for safeguarding. This forum is responsible for all policy and strategic decisions relating to the Force’s response to CSE. Additionally, in 2012 West Yorkshire Police convened a county wide CSE strategy Meeting which was initially led and coordinated by the Force and which was attended by LSCB leads to agree joint approaches to CSE. This function subsequently transferred to the OPCC’s office and the Force is also represented at the quarterly West Yorkshire CSE Strategy Meeting convened by the OPPC’s office. This is responsible for coordinating the county’s joint multi-agency CSE response. It is attended by senior police leads for CSE from each of the five Districts and the SCGU, LSCB business managers and Heads of Service as appropriate. It is coordinated by an OPCC employee who was appointed in the role of county CSE coordinator and is responsible for ensuring that there is consistency of service level and quality across the Districts.  (e) Summary  West Yorkshire Police are therefore in a much stronger position to   respond to and mange CSE related investigations than it was in 2010 and 2011. Training and awareness raising has taken place over a number of years and the skill levels and understanding of front line staff is much greater. The Force has restructured and dedicated specialist multi-agency units with investigatory capacity now exist to assess and action CSE reports. Staff operate within a comprehensive policy framework with senior strategic governance at a Force and multi-agency level.   A remaining challenge which the Force is addressing is the training of child protection staff. Safeguarding the vulnerable is now the Force’s key strategic priority and as a result there has been an increase of staff in safeguarding work (at a time when staffing in other areas was falling). As of August 2016 and Force wide there were 594 officers and staff engaged in District Safeguarding Units. This includes warranted and unwarranted staff and a small number whose functions are primarily clerical.185 are in the Bradford District. These officers and staff cover a variety of functions from ‘live’ adult at risk, rape and domestic abuse investigations to non-recent CSE work. In the Bradford District there were 63 police officers engaged in child protection work, excluding the non-recent CSE staff (most of whom are police staff).The unit had additional non-police officer members. However, not all staff who are engaged in child protection work are Specialist Child Abuse Investigator Development Programme (SCAIDP) and Initial Crime Investigators Development Programme (ICIDP) (PIP2) trained. This means that the Force is still not compliant with national guidance that all child protection investigations should be completed by fully trained officers. The CSE Hub team illustrate this point. Of the twelve officers currently seconded to it four have completed their ICIDP course (PIP 2 trained); four have completed a SCAIDP course (only one has completed both); seven officers are ABE video interview trained; seven are Tier Two interview trained and one Tier Three; one officer is ‘Cellbrite’ trained (this allows staff to interrogate mobile phones without having to submit them for specialist examination). This is indicative of the current training requirement to meet this standard. To achieve this the Force has undertaken detailed work to identify its training requirements and has produced models to show the staffing requirements and time spans required to achieve the objective of training all child protection officers to the required standard. This work is ongoing.    64 Bradford Children Social Care  Since 2012 when the offences against Jack were committed, Bradford Children’s Social Care has undertaken a number of actions which have considerably strengthened the approach to identifying, appropriately assessing and tackling CSE. This has included:   Strengthened Strategic Response and Governance;  Quality Assurance and External audit of CSE cases;  Setting up the CSE hub;  Review of the hub;  CSE training;  Awareness raising- CSE and on line grooming;  Referral to the Jay Enquiry.   Strategic Response and Governance  Senior leaders and politicians have taken an active role in assurance following the issues arising in the Jack and Autumn SCRs.  The new DCS put in place a monthly meeting with the Leader of the Council, Lead Member, and Chief Executive.  An Interim AD was put in place to review and address social care practice and performance issues including CSE and Children Missing from Home. As a result of this, social care put in place a range of quality assurance activity including an external audit of CSE cases, regular reporting and case file audit. The monthly meeting complements the twice yearly Corporate Safeguarding Accountability meeting which is chaired by the Leader of the Council and includes the Chairs of both the children’s and adults safeguarding Board and the DCS.  The Management team in children’s services was restructured to include both a Deputy Director for Social Care and an AD for Performance to increase the focus on performance.  The AD for Performance has responsibility for the Safeguarding Children Board to formalise the separation of the board from Social care.   Bradford Safeguarding Children Board (BSCB) has developed a partnership 9 Point Strategic Response to CSE which identifies the priorities agreed by all partner organisations working with children and families in the Bradford District. These priorities are:   Our partnership response to CSE is child, young person and victim focused;  Partners will develop and resource a multi-agency co-located team which will work together to reduce the risk to victims and bring offenders to justice;  A training plan will be developed for all professionals and leaders regarding CSE, in particular training and support for schools to identify to pupils and teachers the signs of being groomed for CSE;  Communities will be assisted to deal with the impact of CSE;  Support networks will be supported focusing on women and mothers;  A specific direct work plan will be developed aimed at boys between 14 and 17 years to tackle any unacceptable attitudes regarding the sexual abuse of any person;  Partners will work together to develop responses and resources to address the impact of CSE in its varied manifestations across the District’s communities;  A partnership response will be developed to reduce the opportunities for perpetrators of CSE to traffic and abuse children and young people through the use of all regulatory functions of the Council and its partners;  Our partnership response includes undertaking multi-agency historic investigations into CSE.    65 Organisations develop specific plans, consistent with their statutory responsibilities and local needs analyses, for recognising and responding to the impact of CSE. The 9 Point Strategic Response is periodically reviewed and the BSCB CSE and Missing Children Sub Group directly monitors those plans that are the responsibility of BSCB and holds partners to account for the progress of their individual agency plans for tackling CSE. A report was provided in September 2016 to Council Executive regarding the 9 Point Strategic Response to CSE.  Key decisions made by the Council have demonstrated a strong commitment by elected members to ensuring that they and council officers make a full contribution to the District’s 9 Point Strategic Response. At the Full Council Meeting of 12th July 2016, members accepted the recommendation of the Governance and Audit Committee to amend the Members’ Code of Conduct to require all Members and Co-opted Members of Council to complete CSE training. BSCB is seeking assurance from the Council’s Member Development Manager who is charged with ensuring that all Members are able to fulfil this requirement.             Since the period of time that the Jack SCR relates to, reports on CSE have been to Children’s and Corporate Overview and Scrutiny Committees twice yearly, and to all area committees.  Quality Assurance- External Audit and QA Framework  In response to the issues raised in the two SCRs, the DCS wanted to seek assurance about current practice within social care in relation to CSE.  As a result of this, an independent file audit was commissioned in December 2015 of 73 medium and high risk CSE cases. As a result of this an action plan was developed and fully implemented by June 2016.    In 2016 a QA framework was developed to bring together all of the quality assurance activity undertaken within children’s social care, to enable leaders to be assured of practice and outcomes.   Activity within the framework relating to CSE assurance includes:  1. Data: A range of numerical indicators of performance and activity is gathered and relevant officers provide analysis and interpretation of the figures; 2. Regular monthly case file audit is undertaken by all managers; 3. Supervision, training & appraisal of Staff; 4. Multi-Agency  Challenge Panels are run by the Bradford Safeguarding Children’s Board (BSCB); 5. Local Learning Reviews and SCRs: BSCB leads local learning reviews and commission Serious Case Reviews.  The action plans for these are monitored through the SCR sub group of the BSCB.  The actions relating to social care are actioned through the Social Care SLT and monitored through the CCSPG; 6. IRO Challenge;  7. User feedback; 8. Children in Care Council:  the Children in Care Council have a role in ensuring that the voices of children in care are heard by council officers and elected members and that this is used to inform the development of services; 9. Feedback from CP Chairs; 10. Learning from Complaints and Compliments; 11. External inspections of children’s services provision – including residential units – by Ofsted; 12. Political challenge and scrutiny.  Setting up the CSE hub    66 The partnership response the issues raised in the SCR was the setting up of a new approach to tackling CSE and supporting victims, through the establishment of a CSE Hub The CSE Hub was initially set up in September 2012 with a social worker  working alongside police and Turnaround based at Javelin House. The initial role set about gathering information in relation to CSE concerns in relation to children and sharing of information. Daily meetings were established with the CSE Risk Assessment Tool referring concerns into the CSE HUB.  The HUB has significantly increased in capacity over the last three years. Currently the HUB has   Local Authority: Children’s Services team manager and two social workers, an Intelligence Officer and administrative support;  West Yorkshire Police: 12 officers, including specialist missing persons officers, detectives and a CSE Problem Solving Officer;  Barnardo’s Turnaround Service including a Service Manager, social workers, outreach workers, a “Night Time Economy” worker and administrative support;  A Nurse Practitioner to strengthen information sharing and operational links with Health Trusts.  Children’s Social Care (CSC) is the lead statutory agency for assessing a child’s safety under S47 and S17 Children Act 1989 and will:   Ensure information is shared in  a timely manner to inform decision making and professional judgment in respect of vulnerable children;  Fulfil their statutory responsibilities by identifying and assessing children under S47 and S17 CA 1989;   Facilitate strategy discussions and meetings as set out under Working Together guidance. undertake S47 on that case with a named police officer and jointly with Allocated SW;  Work in partnership with statutory and non-statutory agencies to ensure a holistic approach to the safeguarding of children at risk of CSE;  Hold responsibility for a case deemed high risk, providing consistency to the case;  Undertake Child and family assessment for new cases;  Attend daily morning meetings and complete social work review on each new case;  Support and  assist in the completion of CSE risk management plan on all cases;  Track each case open to CSC in term of quality assurance re visits, and that CSE issues are being addressed;  Identify and implement opportunities to involve the Voice of the Child in designing services for children at risk of CSE;  Assist and advise all professionals in terms of CSE;  Input data when necessary onto the CSE work space, ICS system;  Attend planning meetings, Strategy meeting, LAC reviews, and CP conference where necessary;  Undertake quality assurance audits on open cases to CSC;  Ensure that CSE hub performance indicators are met in partnership with colleague’s in the hub;  Develop working relationships with other parts of the service and other authorities;  Ensure that YP out of authority have a risk management plan;  Escalate any issues regarding standards of practice in line with the escalation plan;  Actively contribute to all aspects of the LSCB 9 point CSE strategy;  Review High Risk CSE cases monthly and Risk Management plans;  Review medium /High Risk cases every three months.   The CSE Team are part of Bradford’s Multi-agency Safeguarding Hub (MASH). The MASH includes over 100 staff from a range of agencies including social care, the police, health and   67 the VCS all working together.    There are also other partners such as Hand in Hand, Blast, placement support, youth services, youth offending team that meet weekly.  Multi-Agency Review of the CSE Hub:  In 2015, the BSCB and DCS were keen to ensure that the Hub arrangements were effective in relation to tackling CSE.  Beginning in December 2015, BSCB undertook a partnership review of the working of the CSE Hub. This was led by the interim Assistant Director for Childrens’ Services. The multi-agency group leading the review of the Hub met eleven times between 8th December 2015 and 9th June 2016. It included eight agencies who considered the following issues:   Current policies and procedures including pathways to services and the West Yorkshire risk assessment tool;  Staffing levels, roles and responsibilities;  The interface between children missing from home or care, CSE and the work of the Integrated Assessment Team;  The interface between the local authority children’s services long–term social work teams and the CSE Hub;  Support for victims;  Support for staff;  Recording systems;  Data analysis;  Quality of practice;  Work with communities.  The final report of the review of the Hub was accepted by BSCB in July 2016. The report resulted in the development of a detailed framework for professionals working with children who experience or are at risk of sexual exploitation. This is underpinned by revised detailed practice guidance for all agencies located in and working closely with the Hub. A detailed plan containing 18 actions to be delivered by specific services has been developed. Named agencies are accountable to BSCB, through the CSE and Missing Sub Group for the delivery of these actions and are required to provide evidence of impact. This impact will be tested through the BSCB programme of audit and challenge panels.  The review provides evidence of the necessity for clearer pathways into therapeutic services for children and adults who have experienced sexual exploitation. This is an issue highlighted in national reports as well as local work. A specific multi-agency group has been identified to map current therapeutic provision, to identify priorities for commissioning and to provide a future report for the Health and Well Being Board.  The review demonstrated the importance of ensuring that all partners provide a high quality and prompt response to all incidents of children going missing from home or from care. Children who go missing may be vulnerable to a range of crimes and other forms of harm. However, there is strong evidence from national research that a very significant risk for such children is of CSE. There has been significant progress by the partnership to improve responses to children who go missing from home or care and it is recommended that the Children’s Services Overview & Scrutiny Committee receive a report about this work.  CSE Specific Training  The Jack SCR demonstrated the need to ensure that all professionals working with children are aware of the risks of CSE and in particular ensuring they understand the risks to boys.  Training has been delivered across the partnership.  Specific examples include training for Youth Workers  who now support low level CSE cases; Families First workers who support   68 Low Level cases; foster carers completed in relation to raising awareness Training in relation to Cyber awareness to schools by the Cyber team. Social workers and other agencies have completed CSE online training. Voluntary agencies have delivered CSE training in schools this includes Safeguarding Board/PCC funding a play, Somebody's Daughter, Somebody’s Sister, targeted at high schools across the district.   Currently a play targeted at CSE / Health relations in primary school “Mr Shapeshifter” is being rolled out to primary schools.  CSE awareness training completed with Licensing Taxi, hotels etc. by police and Turnarounds Nigh Watch worker.  Awareness raising- CSE and on line grooming   For the past three years significant CSE Awareness events have been held in both Keighley and Bradford City Park. These have been multi-agency events highlighting to children and members of the public in relation to CSE, Missing and Trafficking.  Activity includes handing out leaflets, talking to public; the Cyber team also attend the events promoting Cyber awareness.  Voluntary agencies Hand in Hand, Turnaround and Blast continue to raise awareness within their day to day work.  Bradford Safeguarding Website raises Awareness to CSE and Missing with information, training and useful websites.  Keighley community group held a week of CSE Awareness in 2016 targeting stalls in Keighley college , local events etc in which the CSE HUB were part of this.  Other events held in the local colleges to raise awareness to the young people,   Since the publication of the Jack SCR, there has been training offered to schools in the district along with a play, Mr Shapeshifter which has toured primary schools in the district.  A bid has gone the Community safety partnership to develop a Bradford based social media campaign highlighting the danger of on line abuse, which will also include running a partnership conference.    Referral to the Jay enquiry  On July 29th 2016, the Chief Executive of Bradford Council wrote to Dame Justice Lowell Goddard, the then chair of the Inquiry. The letter is attached to this report as appendix 2. The Chief Executive drew the chair’s attention to the call for an independent inquiry into CSE in the Bradford area by Ms Angela Sinfield, who is the mother of one of the local victims of child sexual exploitation. The letter goes on to invite “robust scrutiny” of Bradford’s record and arrangements.  Summary  Since 2012 children social care response to CSE has developed in line with national best practice, in response to serious case reviews (Autumn and Jack)   Bradford uses the West Yorkshire risk assessment tool, cases are reviewed on a regular basis, and all cases of high risk are considered for an ICPC.  All cases that have children social care involvement have an allocated social worker.  Social workers work to the agreed standards of practice, have mandatory training, the guidance for practitioners.  All cases are overseen by the CSE hub. Bradford Safeguarding Children Board  Bradford Safeguarding Children Board agreed a seven point strategic response to CSE in July 2013. This was replaced by a nine point strategic response agreed in December 2014. The strands describe statutory safeguarding activity to be undertaken by statutory and   69 voluntary sector partners, awareness and training activity and community activities informed by specific knowledge of the incidence of CSE in the Bradford District.  The overall aims of these strands were to:    Safeguard and promote the welfare and children and young people who have been, or may be sexually exploited.   Successfully prosecute those who perpetrate or facilitate CSE.  Limit the opportunities for potential perpetrators to abuse children and young people in this way.   Support families and communities who are dealing with the consequences of CSE.   Develop preventative services which raise awareness of CSE among children and young people, parents and the communities of the district.  Develop community resilience to the potential divisive and damaging impact of CSE on the Bradford District and its constituent communities.    Offer support and therapeutic services to survivors of CSE.   Ensure that identified perpetrators receive a treatment programme in order to minimise the chances of reoffending.   Ensure that arrangements are in place to undertake any necessary investigations into historic cases of CSE.   The nine point response included the following:    A partnership response to CSE which is child, young person and victim focused.   A multi-agency co-located team which will work together to reduce the risk to victims and bring offenders to justice.  A training plan for all professionals and leaders regarding CSE. In particular a bespoke training programme will be developed for Schools to identify to pupils and teachers, the signs of being groomed for CSE.   A plan will be developed for all faith and community leaders to support communities through the damage caused by CSE.   A support network focusing on women and mothers of perpetrators.   A specific direct work plan aimed at boys between 14 and 17 years to tackle any unacceptable attitudes regarding the sexual abuse of any person.   A specific product for the Pakistani origin community which addresses CSE and explores the harm that this offence can cause to individuals and families.  A partnership response to reduce the opportunities for perpetrators of CSE to traffic and abuse children and young people, through the use of all regulatory functions of the Council and its Partners.   A partnership response to include undertaking multi agency historic investigations into CSE.  Further BSCB developments of scrutiny and challenge   The introduction of CSE challenge panels.  The development of a CSE improvement plan  The introduction of CSE case audits  The review of the CSE Hub   70 Appendix C The Legal Position  Children Act 1989 Section 17 -  Provision of services for children in need, their families and others. (1)It shall be the general duty of every local authority (in addition to the other duties imposed on them by this Part) — . (a) to safeguard and promote the welfare of children within their area who are in need; and . (b )so far as is consistent with that duty, to promote the upbringing of such children by their families,  by providing a range and level of services appropriate to those children’s needs. (2) For the purpose principally of facilitating the discharge of their general duty under this section, every local authority shall have the specific duties and powers set out in Part 1 of Schedule 2. . (3) Any service provided by an authority in the exercise of functions conferred on them by this section may be provided for the family of a particular child in need or for any member of his family, if it is provided with a view to safeguarding or promoting the child’s welfare.  (4)The [Secretary of State] may by order amend any provision of Part I of Schedule 2 or add any further duty or power to those for the time being mentioned there.  [(4A)Before determining what (if any) services to provide for a particular child in need in the exercise of functions conferred on them by this section, a local authority shall, so far as is reasonably practicable and consistent with the child’s welfare— . (a) ascertain the child’s wishes and feelings regarding the provision of those services; and . (b) give due consideration (having regard to his age and understanding) to such wishes and feelings of the child as they have been able to ascertain.] . (5)Every local authority — . (a)shall facilitate the provision by others (including in particular voluntary organisations) of services which [it is a function of the authority] to provide by virtue of this section, or section 18, 20, [22A to 22C], 23B to 23D, 24A or 24B]; and . (b)may make such arrangements as they see fit for any person to act on their behalf in the provision of any such service. . (6)The services provided by a local authority in the exercise of functions conferred on them by this section may include [providing accommodation and] giving assistance in kind or in cash. .   71 (7)Assistance may be unconditional or subject to conditions as to the repayment of the assistance or of its value (in whole or in part). . (8)Before giving any assistance or imposing any conditions, a local authority shall have regard to the means of the child concerned and of each of his parents. . (9)No person shall be liable to make any repayment of assistance or of its value at any time when he is in receipt [of universal credit (except in such circumstances as may be prescribed),] of income support [under][F10 Part VII of the Social Security Contributions and Benefits Act 1992,][ of any element of child tax credit other than the family element, of working tax credit][of an income-based jobseeker's allowance or of an income-related employment and support allowance]. . (10)For the purposes of this Part a child shall be taken to be in need if— . (a)he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority under this Part; . (b)his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or . (c)he is disabled, . and “family”, in relation to such a child, includes any person who has parental responsibility for the child and any other person with whom he has been living.  (11)For the purposes of this Part, a child is disabled if he is blind, deaf or dumb or suffers from mental disorder of any kind or is substantially and permanently handicapped by illness, injury or congenital deformity or such other disability as may be prescribed; and in this Part— . “development” means physical, intellectual, emotional, social or behavioural development; and  “health” means physical or mental health.  (12)The Treasury may by regulations prescribe circumstances in which a person is to be treated for the purposes of this Part (or for such of those purposes as are prescribed) as in receipt of any element of child tax credit other than the family element or of working tax credit.] . (13)The duties imposed on a local authority by virtue of this section do not apply in relation to a child in the authority’s area who is being looked after by a local authority in Wales in accordance with Part 6 of the Social Services and Well-being (Wales) Act 2014.] Section 20 -  Provision of accommodation for children: general  (1)Every local authority shall provide accommodation for any child in need within their area who appears to them to require accommodation as a result of— . (a)there being no person who has parental responsibility for him; . (b)his being lost or having been abandoned; or .   72 (c)the person who has been caring for him being prevented (whether or not permanently, and for whatever reason) from providing him with suitable accommodation or care. . (2)Where a local authority provide accommodation under subsection (1) for a child who is ordinarily resident in the area of another local authority, that other local authority may take over the provision of accommodation for the child within— . (a)three months of being notified in writing that the child is being provided with accommodation; or . (b)such other longer period as may be prescribed [in regulations made by the Secretary of State]. . (2A) Where a local authority in Wales provide accommodation under section 76(1) of the Social Services and Well-being (Wales) Act 2014 (accommodation for children without parents or who are lost or abandoned etc. ) for a child who is ordinarily resident in the area of a local authority in England, that local authority in England may take over the provision of accommodation for the child within— . (a)three months of being notified in writing that the child is being provided with accommodation; or . (b)such other longer period as may be prescribed in regulations made by the Secretary of State.] . (3)Every local authority shall provide accommodation for any child in need within their area who has reached the age of sixteen and whose welfare the authority consider is likely to be seriously prejudiced if they do not provide him with accommodation. . (4)A local authority may provide accommodation for any child within their area (even though a person who has parental responsibility for him is able to provide him with accommodation) if they consider that to do so would safeguard or promote the child’s welfare. . (5)A local authority may provide accommodation for any person who has reached the age of sixteen but is under twenty-one in any community home which takes children who have reached the age of sixteen if they consider that to do so would safeguard or promote his welfare. . (6)Before providing accommodation under this section, a local authority shall, so far as is reasonably practicable and consistent with the child’s welfare— . (a)ascertain the child’s wishes [and feelings] regarding the provision of accommodation; and . (b)give due consideration (having regard to his age and understanding) to such wishes and feelings] of the child as they have been able to ascertain. . (7)A local authority may not provide accommodation under this section for any child if any person who— . (a)has parental responsibility for him; and . (b)is willing and able to— . (i)provide accommodation for him; or . (ii)arrange for accommodation to be provided for him, . objects.  (8)Any person who has parental responsibility for a child may at any time remove the child from accommodation provided by or on behalf of the local authority under this section. . (9)Subsections (7) and (8) do not apply while any person— . (a)who is named in a child arrangements order as a person with whom the child is to live;] . (aa)who is a special guardian of the child; or] . (b)who has care of the child by virtue of an order made in the exercise of the High Court’s inherent jurisdiction with respect to children, . agrees to the child being looked after in accommodation provided by or on behalf of the local authority.  (10)Where there is more than one such person as is mentioned in subsection (9), all of them must agree. . (11)Subsections (7) and (8) do not apply where a child who has reached the age of sixteen agrees to being provided with accommodation under this section.    73 Section 25 - Use of accommodation for restricting liberty  (1)Subject to the following provisions of this section, a child who is being looked after by a local authority [or local authority in Wales] may not be placed, and, if placed, may not be kept, in accommodation [in England] provided for the purpose of restricting liberty (“secure accommodation”) unless it appears— . (a)that— . (i)he has a history of absconding and is likely to abscond from any other description of accommodation; and . (ii)if he absconds, he is likely to suffer significant harm; or . (b)that if he is kept in any other description of accommodation he is likely to injure himself or other persons. . (2)The [Secretary of State] may by regulations— . (a)specify a maximum period— . (i)beyond which a child may not be kept in secure accommodation [in England] without the authority of the court; and . (ii)for which the court may authorise a child to be kept in secure accommodation [in England]; . (b)empower the court from time to time to authorise a child to be kept in secure accommodation [in England] for such further period as the regulations may specify; and . (c)provide that applications to the court under this section shall be made only by local authorities [or local authorities in Wales]. . (3)It shall be the duty of a court hearing an application under this section to determine whether any relevant criteria for keeping a child in secure accommodation are satisfied in his case.  (4)If a court determines that any such criteria are satisfied, it shall make an order authorising the child to be kept in secure accommodation and specifying the maximum period for which he may be so kept.  (5)On any adjournment of the hearing of an application under this section, a court may make an interim order permitting the child to be kept during the period of the adjournment in secure accommodation. . (6)No court shall exercise the powers conferred by this section in respect of a child who is not legally represented in that court unless, having been informed of his right to apply for [the provision of representation under Part 1 of the Legal Aid, Sentencing and Punishment of Offenders Act 2012] and having had the opportunity to do so, he refused or failed to apply.  (7)The [Secretary of State] may by regulations provide that— . (a)this section shall or shall not apply to any description of children specified in the regulations; . (b)this section shall have effect in relation to children of a description specified in the regulations subject to such modifications as may be so specified; . (c)such other provisions as may be so specified shall have effect for the purpose of determining whether a child of a description specified in the regulations may be placed or kept in secure accommodation [in England]. . (8)The giving of an authorisation under this section shall not prejudice any power of any court in England and Wales or Scotland to give directions relating to the child to whom the authorisation relates.  (9)This section is subject to section 20(8).  Section 31 - Care and Supervision  (1) On the application of any local authority or authorised person, the court may make an order— . (a )placing the child with respect to whom the application is made in the care of a designated local authority; or  (b) putting him under the supervision of a designated local authority.   74 (2)A court may only make a care order or supervision order if it is satisfied— . (a)that the child concerned is suffering, or is likely to suffer, significant harm; and . (b)that the harm, or likelihood of harm, is attributable to— . (i)the care given to the child, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him; or . (ii)the child’s being beyond parental control. . (3)No care order or supervision order may be made with respect to a child who has reached the age of seventeen (or sixteen, in the case of a child who is married). . [(3A)A court deciding whether to make a care order— . (a)is required to consider the permanence provisions of the section 31A plan for the child concerned, but . (b)is not required to consider the remainder of the section 31A plan, subject to section 34(11). . (3B)For the purposes of subsection (3A), the permanence provisions of a section 31A plan are such of the plan's provisions setting out the long-term plan for the upbringing of the child concerned as provide for any of the following— . (a)the child to live with any parent of the child's or with any other member of, or any friend of, the child's family; . (b)adoption; . (c)long-term care not within paragraph (a) or (b). . (3C)The Secretary of State may by regulations amend this section for the purpose of altering what for the purposes of subsection (3A) are the permanence provisions of a section 31A plan.] . (4)An application under this section may be made on its own or in any other family proceedings. . (5)The court may— . (a)on an application for a care order, make a supervision order; . (b)on an application for a supervision order, make a care order. . (6)Where an authorised person proposes to make an application under this section he shall— . (a)if it is reasonably practicable to do so; and . (b)before making the application, . consult the local authority appearing to him to be the authority in whose area the child concerned is ordinarily resident.  (7)An application made by an authorised person shall not be entertained by the court if, at the time when it is made, the child concerned is— . (a)the subject of an earlier application for a care order, or supervision order, which has not been disposed of; or . (b)subject to— . (i)a care order or supervision order; . [(ii)a youth rehabilitation order within the meaning of Part 1 of the Criminal Justice and Immigration Act 2008; or] . [(iii) a compulsory supervision order or interim compulsory supervision order as defined by sections 83 and 86 of the Children’s Hearings (Scotland) Act    2011. ] . (8)The local authority designated in a care order must be— . (a)the authority within whose area the child is ordinarily resident; or . (b)where the child does not reside in the area of a local authority, the authority within whose area any circumstances arose in consequence of which the order is being made. . (9)In this section— . “authorised person” means—  (a)the National Society for the Prevention of Cruelty to Children and any of its officers; and  (b)any person authorised by order of the Secretary of State to bring proceedings under this section and any officer of a body which is so authorised;  “harm” means ill-treatment or the impairment of health or development [F5including, for example, impairment suffered from seeing or hearing the ill-treatment of another];   75  “development” means physical, intellectual, emotional, social or behavioural development;  “health” means physical or mental health; and  “ill-treatment” includes sexual abuse and forms of ill-treatment which are not physical.  (10)Where the question of whether harm suffered by a child is significant turns on the child’s health or development, his health or development shall be compared with that which could reasonably be expected of a similar child. . (11)In this Act— . “a care order” means (subject to section 105(1)) an order under subsection (1)(a) and (except where express provision to the contrary is made) includes an interim care order made under section 38; and  “a supervision order” means an order under subsection (1)(b) and (except where express provision to the contrary is made) includes an interim supervision order made under section 38.  Section 47 –  Local Authority’s duty to investigate  (1)Where a local authority— . (a)are informed that a child who lives, or is found, in their area— . (i)is the subject of an emergency protection order; or  (ii)is in police protection;  (b)have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm,  the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.   (2)Where a local authority have obtained an emergency protection order with respect to a child, they shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide what action they should take to safeguard or promote the child’s welfare. . (3)The enquiries shall, in particular, be directed towards establishing— . (a)whether the authority should— . (i)make any application to court under this Act; . (ii)exercise any of their other powers under this Act; . (iii)exercise any of their powers under section 11 of the Crime and Disorder Act 1998 (child safety orders); or . (iv)(where the authority is a local authority in Wales) exercise any of their powers under the Social Services and Well-being (Wales) Act 2014; with respect to the child;]  (b)whether, in the case of a child— . (i)with respect to whom an emergency protection order has been made; and . (ii)who is not in accommodation provided by or on behalf of the authority,  it would be in the child’s best interests (while an emergency protection order remains in force) for him to be in such accommodation; and (c)whether, in the case of a child who has been taken into police protection, it would be in the child’s best interests for the authority to ask for an application to be made under section 46(7).  (4)Where enquiries are being made under subsection (1) with respect to a child, the local authority concerned shall (with a view to enabling them to determine what action, if any, to take with respect to him) take such steps as are reasonably practicable— . (a)to obtain access to him; or . (b)to ensure that access to him is obtained, on their behalf, by a person authorised by them for the purpose, . unless they are satisfied that they already have sufficient information with respect to him.  (5)Where, as a result of any such enquiries, it appears to the authority that there are matters connected with the child’s education which should be investigated, they shall consult   76 [F4the local authority (as defined in section 579(1) of the Education 1996), if different, specified in subsection (5ZA). . (5ZA)The local authority referred to in subsection (5) is— . (a)the local authority who — . (i)maintain any school at which the child is a pupil, or . (i)make arrangements for the provision of education for the child otherwise than at school pursuant to section 19 of the Education Act 1996, or . (b)in a case where the child is a pupil at a school which is not maintained by a local authority, the local authority in whose area the school is situated.] . (5A)For the purposes of making a determination under this section as to the action to be taken with respect to a child, a local authority shall, so far as is reasonably practicable and consistent with the child’s welfare— . (a)ascertain the child’s wishes and feelings regarding the action to be taken with respect to him; and . (b)give due consideration (having regard to his age and understanding) to such wishes and feelings of the child as they have been able to ascertain.] . (6)Where, in the course of enquiries made under this section— . (a)any officer of the local authority concerned; or . (b)any person authorised by the authority to act on their behalf in connection with those enquiries— . (i)is refused access to the child concerned; or . (ii)is denied information as to his whereabouts, . the authority shall apply for an emergency protection order, a child assessment order, a care order or a supervision order with respect to the child unless they are satisfied that his welfare can be satisfactorily safeguarded without their doing so.  (7)If, on the conclusion of any enquiries or review made under this section, the authority decide not to apply for an emergency protection order, a child assessment order, a care order or a supervision order they shall— . (a)consider whether it would be appropriate to review the case at a later date; and . (b)if they decide that it would be, determine the date on which that review is to begin. . (8)Where, as a result of complying with this section, a local authority conclude that they should take action to safeguard or promote the child’s welfare they shall take that action (so far as it is both within their power and reasonably practicable for them to do so). . (9)Where a local authority are conducting enquiries under this section, it shall be the duty of any person mentioned in subsection (11) to assist them with those enquiries (in particular by providing relevant information and advice) if called upon by the authority to do so. . (10)Subsection (9) does not oblige any person to assist a local authority where doing so would be unreasonable in all the circumstances of the case. . (11)The persons are— . (a)any local authority;  (b)any local housing authority; . (c)the National Health Service Commissioning Board;”, and] . (d)any clinical commissioning group, Local Health Board , Special Health Authority, National Health Service trust or NHS foundation trust; and . (e)any person authorised by the Secretary of State for the purposes of this section. . (12)Where a local authority are making enquiries under this section with respect to a child who appears to them to be ordinarily resident within the area of another authority, they shall consult that other authority, who may undertake the necessary enquiries in their place.  Inherent jurisdiction of the High Court Birmingham City Council v Sarfraz Riaz and Others [2014] EWHC 4247 (Fam)  Inherent jurisdiction was used in the above case where injunctions were obtained against men found to have engaged in child sexual exploitation. Reporting restriction orders in respect of the men were lifted.   77  Mr Justice Keehan was concerned with a vulnerable 17 year-old young woman, AB.  The local authority asserted that AB had been a victim of child sexual exploitation by at least ten older men.  In October 2014, the court made a secure accommodation order so as to keep her in a place of safety and support her in coming to an understanding of the risks of harm the men posed to her. The police concluded that there was insufficient evidence to secure criminal convictions against the ten men.  The local authority decided to take the "bold and novel step" of applying for civil injunctions under the inherent jurisdiction to prevent the men from contacting AB or associating with any female under the age of 18 who was not already known to them. The judge concluded that using the inherent jurisdiction to make injunctive orders to prevent child sexual exploitation was appropriate.  In respect of each man, the judge concluded they had been engaged in the sexual exploitation of AB. In respect of the injunctions, in Re J (A Child) [2013] EWHC 2694 (Fam) the President observed that the courts will not make orders that cannot be enforced.  The court had a duty to consider whether the terms of the proposed orders were fair, necessary and proportionate to the facts of the case and capable of being enforced.  The judge concluded that the orders as sought were clear, unambiguous, enforceable and necessary and proportionate to the risks of sexual exploitation of AB or other vulnerable girls under the age of 18.  The orders sought were made final against each of the respondents Glossary of terms  BSCB Bradford Safeguarding Children Board BDFCT Bradford District Care Foundation Trust BMDC Bradford Metropolitan District Council CCG Clinical Commissioning Group responsible for arranging a lot of local Health care provision. CSE Child Sexual Exploitation CEOP Child Exploitation and Online Protection Centre DfE Department for Education HMET Homicide and Major Enquiry Team IAR Independent Agency Review. The report produced by an agency by an author independent of the case which summarises, analyses the involvement of the agency, identifies learning and proposes action LSCB Local Safeguarding Children Board MAACSE Multi Agency Action on Child Sexual Exploitation. A monthly meeting of LSCB Partners and the Voluntary Sector to review individual cases and co-ordinate action.  PACE Parents Against Child sexual Exploitation.  A CSE support group for parents and family members-previously known as CROP see above. Partnership Learning Review A collaborative inquiry based approach to Serious Case Reviews with a focus on shared learning and development of safeguarding systems. VIVID VIVID - Vulnerable Individual Victims Database - this was a police standalone database designed in house and adopted about 2002.  