Death of a 14-year-old boy in November 2009. Family was well-known to agencies and Daniel and his parents had made several requests to children's services that he be accommodated by the local authority. Includes a collated, chronological list of risk factors to demonstrate how much information was known to agencies about the risks Daniel was exposed to, including: underage sexual relationships; periods of going missing; difficulties in parent-child relationships; drug and alcohol misuse; self-harm; poor school attendance; overdose and suicidal thoughts; offending; significant sexual experimentation; and possible sexual exploitation. Issues identified include: shared view among professionals that a child could not be suffering significant harm unless that harm was attributable to their parents; shared view among children's services workers that it was the parent's responsibility to manage the risk; and insufficient professional challenge of children's services. Makes various interagency and single agency recommendations.
      
 Title:  'Daniel': the overview report from a serious case review LSCB: Kent Safeguarding Children Board Author: Carol Gallagher Date of publication: 2013  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.                         Page 1 of 48  LOCAL SAFEGUARDING CHILDREN BOARD         ‘DANIEL’   THE OVERVIEW REPORT FROM A SERIOUS CASE REVIEW      Originally approved by KSCB on 9 September 2010  Reviewed and prepared for publication in May 2013 following conclusion of legal proceedings   Page 2 of 48 TABLE OF CONTENTS  TABLE OF CONTENTS ............................................................................... 2 1. INTRODUCTION ...................................................................................... 4 2. SERIOUS CASE REVIEW PROCESS ..................................................... 4 3. CHRONOLOGY ....................................................................................... 5 3.1 Background history relevant to the review............................................ 5 3.2 January 2009 ............................................................................................ 6 3.3 February 2009 ........................................................................................... 6 3.4 March 2009 ............................................................................................... 7 3.5 April 2009 .................................................................................................. 7 3.6 May 2009 ................................................................................................... 7 3.7 June 2009.................................................................................................. 8 3.8 July 2009 ................................................................................................. 10 3.9 August 2009 ............................................................................................ 11 3.10 September 2009 ................................................................................... 12 3.11 October 2009 ........................................................................................ 13 3.12 November 2009 .................................................................................... 14 4. OPPORTUNITIES FOR ASSESSMENT ................................................ 18 4.1 February to May 2009 ............................................................................ 18 4.2 June to July 2009 ................................................................................... 19 4.3 August to October 2009 ........................................................................ 22 4.4 November 2009 ...................................................................................... 25 5. PARENTING CAPACITY ....................................................................... 26 6. RISK FACTORS .................................................................................... 28 7. FOCUS ON THE CHILD ........................................................................ 30 7.1 School ..................................................................................................... 30 7.2 Hospital-based Health Services ............................................................ 30 7.3 CAMHS .................................................................................................... 30 7.4 General Practitioner ............................................................................... 31 7.5 Police ...................................................................................................... 31 7.6 Children’s Social Services .................................................................... 31 8. DIVERSITY ............................................................................................ 32 9. IMPLEMENTATION OF PLANS ............................................................ 33 10. POLICY CONTENT AND COMPLIANCE ............................................ 34 11.  INFORMATION SHARING .................................................................. 35 12.  KNOWLEDGE AND EXPERIENCE OF STAFF ................................. 35 13. MANAGEMENT AND SUPERVISION ................................................. 36 13.1 Children’s Social Services .................................................................. 36 13.2 School ................................................................................................... 37 13.3 Police .................................................................................................... 37 13.4 Health Services .................................................................................... 37 14. CAPACITY ........................................................................................... 37 15  FINDINGS AND LESSONS LEARNT .................................................. 39 16. CONCLUSION ..................................................................................... 41 17. RECOMMENDATIONS ........................................................................ 43 17.1 Introduction .......................................................................................... 43 17.2  Recommendations to the Kent Safeguarding Children Board ........ 43 17.3 Recommendations to all agencies ..................................................... 43 17.4 Recommendation to Children’s Social Services ............................... 44  Page 3 of 48 17.5 Recommendation to Children’s Social Services, Education, Police & Child Adolescent Mental Health Services (CAMHS) ................................. 44 17.6 Recommendations to the Local Drug and Alcohol Team (LDAAT) . 44 APPENDIX A: SCR Panel Membership ................................................... 45 APPENDIX B:  Terms of Reference ......................................................... 46  Page 4 of 48 1. INTRODUCTION  1.1 Daniel, aged 14, was found dead in November 2009.  He lived with his parents and siblings. He had not returned home for some days prior to this and there had been evidence that he had been using illegal drugs and putting himself at risk in other ways. There had been substantial significant involvement with Daniel and his family from a number of local agencies.  2. SERIOUS CASE REVIEW PROCESS  2.1 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as one where (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  2.2 In this instance it was known that Daniel had extensive involvement with a number of services from January 2009 onwards. He was beyond his parents’ control and his risk taking behaviour had escalated very quickly during 2009.    Daniel and his parents requested that he be looked after by the local authority on a number of occasions but this was not agreed by Kent Children’s Services.   2.3 The circumstances of Daniel’s death and the preceding events were considered by local agencies and by the Independent Chair of the Kent Safeguarding Children Board (KSCB) who decided in January 2010 that the criteria for a Serious Case review were met.   2.4 Arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. Ms Carol Gallagher; Independent Social Work Consultant drew up the Overview Report. The SCR Panel was chaired by Mr Donald McPhail.  2.5 The membership of the Panel, on which all key local agencies were represented, is detailed at Appendix A. The Terms of Reference for the Review are at Appendix B. The period under review was from January 2009 to 12.01.10 (when the SCR decision was taken).   2.6 The agencies which contributed to the review are as follows. Individual management reviews were provided by the following agencies: • Kent County Council, Children’s Social Services (CSS) • Kent County Council, Children’s Safeguards Unit - Education • Kent County Council, Youth Services • Kent and Medway NHS and Social Care Partnership Trust • NHS West Kent • South East Coast Ambulance Service  Page 5 of 48 • Kent Police • Kent County Council, Youth Offending Service  (An overview report of the three health IMRs was also carried out by the West Kent PCT).  2.7 The author interviewed both of Daniel’s parents. Daniel’s siblings decided not to contribute. The review also had access to: • The witness statements of both parents made at the time of Daniel’s death • Correspondence from the parents to CSS  • The report of the Forensic Scientist • Information from the Drug Treatment Service   2.8 The review was completed without significant delay and the Overview Report was agreed by the KSCB in September 2010. The report made a number of recommendations. These recommendations and the ensuing actions and developments since that time, are detailed in the Action Plan which accompanies this report.   2.9 The Coroner had deferred the inquest arising from Daniel’s death until he had seen reports from this SCR. After they were provided to him a number of legal matters arose which were eventually determined in the High Court in October 2012.   2.10 Following the resolution of these matters the current Chair of KSCB, Ms Maggie Blyth, who had been appointed in April 2011, considered the next steps to be taken in relation to the SCR. In the period between the conclusion of the review process and the determination of the legal issues arising from the Coroner’s decisions, government guidance had changed so that, other than in exceptional circumstances, such reports should be published. The original report had not been written in the anticipation that it would be published and consequently contained confidential material. It was therefore decided that the report should be re-drafted for publication and that task has been undertaken by Mr Kevin Harrington. He has extensive experience of contributing to SCRs and has written a number of such reports for publication.  3. CHRONOLOGY  3.1 Background history relevant to the review  3.1.1 Daniel attended nursery from the age of 3½ and was identified as having some difficulties of social communication, disruptive behaviour and social immaturity. These were positively addressed and concerns had eased when he left nursery.  3.1.2 His primary school experience was overwhelmingly positive; his Year 5 report identified good academic progress and attitude.  In Year 6 he sat, and passed, a Selection Test and achieved a Grammar School place and was considered a high achiever.  Throughout this period his childhood was  Page 6 of 48 unremarkable; the parents supported their children in individual activities outside school and they enjoyed many activities as a family.    3.1.3 Daniel entered a single sex grammar school in 2007. The transition from primary to secondary went well but as the year progressed his parents reported that his group of friends changed.  He was particularly influenced by one boy who was reported to self-harm and who introduced Daniel to “free running1 ”.  By the summer of 2008 at the end of Year 7, his school report said he had made a positive contribution but too frequently failed to fulfil his potential.   3.1.4 The latter part of 2008 was a significant period.  When Daniel was still only 12 years old he entered into a relationship with another young person whom Daniel’s parents identified in interview as very vulnerable. This relationship was described as intense and quickly progressed to a sexual relationship.  3.2 January 2009  3.2.1 There was no contact with either Children’s Social Services (CSS) or the police prior to 16.01.09, which was the first occasion that Daniel was reported missing by his parents. At this time, Daniel’s father and mother were both unwell and were receiving medical treatment.  3.3 February 2009  3.3.1 Daniel’s parents identified February 2009 as the period when he began self-harming. On 06.02.09, Daniel attended a local Minor Injuries Unit with injuries he said arose from having sexual intercourse with a 13 year old girl. Daniel’s school said that that there had been a significant and rapid deterioration in his learning, behaviour, attitude and attendance since shortly after his 13th birthday.  Daniel was made the subject of a School Pastoral Support Plan and offered school counselling.  3.3.2 The first referral to Children’s Social Services (CSS) on 16.02.09, was from Daniel himself. He approached the Contact and Assessment Service stating that he wanted to be adopted due to a poor relationship he identified with his parents.  He also said that he had been in a sexual relationship with his girlfriend for the past six months.  An initial assessment was completed by a Duty Social Worker1 (DSW 1) and the family were signposted to Child and Adolescent Mental Health Services (CAMHS) and the Adolescent Resource Centre (ARC), which is a KCS resource. The case was then closed to the Duty and Initial Assessment Team (DIAT) on 16.03.09.    3.3.3 The GP made a home visit on 19.02.09 at the request of Daniel’s parents and without Daniel’s knowledge, as they were unable to persuade him                                             1 A training discipline that developed out of military obstacle course training.  Practitioners aim to move from one place to another, negotiating the obstacles in between. The discipline uses no equipment and is non-competitive.   Page 7 of 48 to attend the surgery.  Daniel was seen with his parents. The family requested a referral to CAMHS which the GP completed.  Daniel did not express any suicidal thoughts, but the GP felt that Daniel thought his parents had little control over him.    3.4 March 2009  3.4.1 Daniel’s mother contacted CAMHS to chase up an appointment.  She gave additional information that Daniel had been self-harming, had bruises and cigarette burns on his arms and may have been using drugs, the first indication of this risk factor.  At an initial appointment two days later Daniel was seen on his own and with his parents. He confirmed that he had self-harmed, by cutting himself and burning himself with a cigarette.  He felt he was not listened to and not cared about.  He identified trouble sleeping, feeling tired, and a low energy level.  He reported transient, fleeting suicidal ideation.  He identified that his mother was “in charge” but also thought his mother may be frightened of him.  His mother informed the psychologist that his father has lost two brothers to drug related deaths.  The psychologist noted extreme conflict between Daniel and his father, which she identified as linked to the father’s anxiety.  3.4.2 During this month the school recorded that Daniel was using drugs.  This is the first report of drug use to the school; it appears that the school did not take any further action or notify anyone. At a second CAMHS appointment on 20.03.09 Daniel’s parents said that he had been burning items in the home and Daniel confirmed he had also used a lighter to burn his arms.  On 31.03.09 the case was allocated to ARC worker 1.  He made contact with Daniel on 01.04.09 and made an appointment for 07.04.09 which Daniel did not attend.  3.5 April 2009  3.5.1 Daniel and his parents were seen by a Consultant Psychiatrist on 06.04.09.  Daniel only stayed in the room for 10 minutes.  The parents said they believed Daniel was at considerable risk. Daniel’s father stressed he was becoming angry with Daniel due to his frustration and concern for him.  The Consultant Psychiatrist considered that there may be a possibility of Daniel having Aspergers, ADHD or attachment difficulties.  She identified the need for CSS to continue to work with CAMHS and wrote to CSS suggesting a joint meeting.  3.5.2 Later that month Daniel was arrested in London for possession of drugs and theft of cash from his grandmother.  On 27.04.09 Daniel was again reported missing and was returned home by the police, but no agency followed this up. Daniel had now not kept any appointments offered by ARC.     3.6 May 2009   Page 8 of 48 3.6.1 The Consultant Psychiatrist made a referral to a Family Therapist on 08.05.09. At a further appointment on 18.05.09, Daniel described feeling very depressed at times and reported that he had cut himself and tried to break his fingers with a rolling pin. There were 40 scars on his left arm and old cigarette burns.  He refused counselling but asked for anti-depressants which were refused.  3.6.2 On 29.05.09 Daniel’s father reported him missing to the police.  Daniel returned late on 31.05.09. At his father’s request both the police and ambulance services attended and assessed Daniel’s physical and mental condition, which did not require further medical treatment.  The police passed this information to their Child Abuse Investigation Unit (CAIU) but they did not make a referral to CSS. The father did however telephone the Consultant Psychiatrist and the school to advise them of this. Daniel was interviewed at school and is recorded as saying  “I’m cold and hungry … but it is better than going home”.  3.7 June 2009  3.7.1 On 05.06.09 CAMHS arranged a meeting attended by the parents, the psychiatrist, the school and a CSS representative although ARC worker1 did not attend. The Consultant Psychiatrist identified there were some mild features of ADHD that were significantly affecting Daniel’s functioning; he was recorded as oppositional at home but not at school, he was not assessed as clinically depressed.  The Consultant Psychiatrist made a further high priority request for family therapy.  She prescribed medication for ADHD and stated that ADHD placed him at heightened risk of substance misuse, had affected his relationship with his family and predisposed him to high risk behaviours.  During the meeting the Duty Social Worker in attendance stressed a view that that the parents had to take responsibility for Daniel’s safety.    3.7.2 On 08.06.09 Daniel assaulted his mother. He was arrested but his mother did not wish to support a prosecution.  Daniel was kept overnight at the police station and received a reprimand.    3.7.3 On 24.06.09 Daniel telephoned the police and alleged that his parents had been hitting him.  Police officers attended and felt that this was a “revenge call” following the recent incident with his mother.  Daniel then saw the school counsellor and informed her that his father had regularly been violent towards him, often 2-3 times a week, over the past two years.  He said that he had reported this to the police but they didn’t believe him.  The Counsellor made a referral to CSS that day expressing her concerns about the situation.    3.7.4 On 25.06.09 the CSS District Manager took a call from School Support Officer 2 (SSO2) detailing the school’s concerns. SSO2 asked CSS to convene a multi-agency meeting but was advised that they should make a Child in Need referral. The father made three telephone calls that day, two to CSS and one to ARC. He reported continued behavioural difficulties with Daniel which were a risk both to Daniel and others and requested a multi- Page 9 of 48 agency meeting and plan.  He was told the allocated worker at ARC was on annual leave and was advised to “chase” ARC to get involved.    3.7.5 The father telephoned again that day expressing the view that CSS were not viewing his concerns as serious.  He said he and his wife could not cope any more and requested that Daniel be looked after (accommodated) by the local authority under section 20, Children Act 1989.  He contacted ARC requesting an immediate visit and, on his second call, was offered a home visit for 30.06.09.  3.7.6 At some point during 25.06.09, Daniel telephoned ChildLine and alleged physical abuse by his father. He stated that he had involved the police but they had not pursued this matter and his interpretation of this decision by the police was that he was believed to have “thrown the first punch”.  Daniel requested 5-7 days respite from his family.  This was referred to the local authority where the Contact and Assessment Service identified the case as being dealt with by the Duty and Initial Assessment Team (DIAT). They transferred Daniel’s call but he rang off whilst waiting to speak to a Duty Officer. CSS did not follow this up.  3.7.7 On 26.06.09, Daniel attended school and informed them that his father had asked him to leave the home.  The school made three telephone calls to the CSS DIAT Team, only gaining access to an Assistant Social Worker.   Arrangements were made by the school for Daniel to stay at his girlfriend’s house for the weekend. Daniel’s father was informed but it is not recorded whether the parents agreed to this.    3.7.8 The following Monday, 29.06.09, the father telephoned DSW 1. He said Daniel was refusing to return home and requested short-term respite care.   He told the social worker he did not want to use Section 20 accommodation and would like Daniel to return home if he would agree to abide by the rules set by them.  The school contacted ARC worker 1 the same day, reporting events of Friday and insisting Daniel be taken into care.  A Duty Social Worker telephoned the school to inform them that two ARC workers were visiting the home the following day to review the situation.  The school followed their telephone conversation with a detailed referral which fully outlined the risks: • There had been a serious deterioration in the home situation to the extent that Daniel was out of his parents’ control and the danger of violence within the home had significantly increased. • Further indicators of concern were poor school attendance, Daniel’s sexual relationship and drug contacts, and that he was not returning home at night.   The school attached a full record of the incidents known to them and advised DIAT that they had negotiated somewhere for Daniel to stay over the previous weekend but there was a  “grave danger of his sleeping out overnight from tonight”.  3.7.9 On 30.06.09 2 ARC workers visited the family home.  Daniel asked to be accommodated for 2-3 months.  He confirmed his previous allegations of  Page 10 of 48 aggression and physical violence towards him, particularly from his father and made allegations against his mother. Daniel had scratch marks to both arms and what appeared to be cigarette marks to his left arm. The family accepted a referral to a mediation service and Daniel agreed to see ARC worker 1 individually.  ARC worker 2 agreed the parents could contact her for advice and support, although no planned sessions were offered. The Senior Practitioner at ARC telephoned DSW 1 the following day with details of this visit.    3.7.10 Later that day the school contacted CSS, leaving 2 messages on an answer phone, expressing concern that Daniel had nowhere to stay that night.  The DIAT Senior Practitioner returned their call at 3.30pm giving them the number for the Out of Hours services, but offered no immediate advice or assistance to the family.  3.8 July 2009  3.8.1 Daniel’s father telephoned the DIAT Team Manager on 02.07.09.  He advised her that his family was breaking up and requested Section 20 accommodation for Daniel due to his risk taking behaviour.  The Team Manager agreed to seek a one week respite fostering placement. On 03.07.09 the fostering service advised that no foster placement was available.  3.8.2 On 06.07.09 Daniel’s father personally delivered a letter to all the agencies involved, outlining the deteriorating situation and asking for a period of respite care for Daniel and a co-ordinated response from the various agencies. On the same day ARC worker 2 spoke on the telephone to the mother, who advised that Daniel was now in a sexual relationship with a male and had broken into the family home when the rest of the family had been on holiday.  By 08.07.09 Daniel had not been in school for two weeks. The Head Teacher instructed his staff to provide a daily update to CSS of all information received from Daniel or his father.  3.8.3 That evening Daniel approached two detached youth workers complaining of injuries he said had been inflicted by his father which police and social workers had done nothing about. He had visible facial injuries and was advised to attend the minor injuries unit at the hospital.  The outreach workers went to the hospital and saw Daniel with a nurse who had strapped his fingers, though the hospital was closed.  The Youth Worker reported this to DIAT the next morning with further information received from Daniel that he was going to stay with friends for the night.  A decision was taken by the Principal Social Worker that this referral should be dealt with under Section 47 Children Act 1989 investigation (a child protection investigation).  3.8.4 The school were contacted by DIAT and stated that in their opinion the parents were unable to deal with Daniel’s behaviour despite the involvement of CAMHS.  A strategy discussion was then held over the telephone between DIAT and the police.  A decision was made to undertake a joint police and DIAT investigation but not until the following week. Police then sought to defer this for a further week because of staffing problems. DIAT initially resisted but  Page 11 of 48 were contacted by the father who had been told by school staff that there was to be a child protection investigation. He was very concerned about this and a social worker agreed to investigate without police involvement. Daniel was seen alone, denied that a broken finger had been caused by his father and said that he did not wish any further action to be taken regarding this allegation.    3.8.5 Daniel was then reported missing on the 17th and 18th July and was returned by the police each morning after 4.00am.  No missing person reports or follow up visits were completed by the police. He was not in school for the last three weeks of term.    3.8.6 On 22.07.09 ARC Worker 1 discussed the case in supervision.  He did not appear to be up to date with events that had occurred and did not even know whether Daniel was in fact accommodated as had been agreed.  He expressed concern that Daniel was not engaging.  His supervisor agreed to request a multi-agency meeting in September.  3.8.7 On 23.07.09, Daniel’s mother contacted DIAT to inform them that Daniel had been reported as missing and had turned up, “in a terrible state” at his paternal grandmother’s home in London.  She agreed to a Family Group Conference and to the suggestion made by ARC for a multi-agency meeting.    3.8.8 On 23.07.09 the Consultant Psychiatrist sent a letter to the local authority, which was not marked as received until 28.07.09.  Crucially it did not appear to have been seen by the DIAT Team Leader at the time and indeed she had still not seen it prior to her interview for this review.  The Consultant Psychiatrist shared information she had received from a family member that Daniel was living on the streets, self-harming, buying alcohol and drugs, and having sex with boys and girls. The Consultant Psychiatrist stated that Daniel had shown no evidence of ongoing mental illness when she last saw him and could not be detained under the Mental Health Act.  She thought that Daniel would benefit from a “secure placement” and said that she felt his behaviour was such that he met the criteria for this.    3.9 August 2009  3.9.1 The case was now allocated within CSS to the Children and Families Team as a Child in Need case (CHIN) on 03.08.09.  The allocation was to a social work student, SW1, who was awaiting registration and was therefore working as a Social Work Assistant. She had extensive experience of working with adolescents.  3.9.2 She made immediate telephone contact with the family and both parents requested accommodation for Daniel, stating the situation was desperate.  She consulted with a Senior Practitioner who spoke to Daniel’s father. He emphasised the continuing problems and that Daniel was now sleeping rough.  3.9.3 On 04.08.09 SW 1 visited.  She informed the family that Daniel would not be offered Section 20 accommodation and offered additional work to the  Page 12 of 48 parents from ARC, and a Family Group Conference to consider alternatives to accommodation within the family network.   3.9.4 In late August the father informed the police that his home had been burgled whilst the family was on holiday, implicating Daniel. He left a message for SW1 stating Daniel had been missing for four days and could be in serious trouble with drug dealers.  The parents requested that Daniel either be “sectioned” under the Mental Health Act or placed in Secure Accommodation.  SW 1 said that the Local Authority would not accommodate Daniel and that the parents had to take responsibility for him.  3.9.5 The same evening Daniel came to the attention of police and his parents refused to have him home. The local authority’s Out of Hours Service (OOH) was involved and adamantly refused to bring Daniel into care, despite concerns from police. The parents finally agreed to take Daniel home that evening and to discuss alternative action the following day. The next day the father rang SW 1, again requesting accommodation and was again informed that Daniel would not be accommodated, but the family would be offered support.    3.10 September 2009  3.10.1 Daniel had his first session with ARC worker 1(nearly six months after the case had been allocated) on 29.08.09, with three more sessions during September.  3.10.2 SW 1 made a home visit on 03.09.09. Daniel’s father requested a professionals’ meeting and Section 20 accommodation.   SW 1 had sought advice from the Drug Treatment Service Young People’s Service who had advised that they were unable to support parents unless the young person was willing to engage with their service. The following day the father reported that Daniel had gone missing and that he wanted it recorded that he considered him at risk.  3.10.3 During the weekend of 19.09.09 Daniel was arrested for smashing a window at home. He admitted the offence and was bailed.  He stayed one night with a school friend who informed the school that Daniel was “high on weed” and intimated that he was using needles to take drugs.  He also said that Daniel told him his father hit him regularly.    3.10.4 SW1 made a home visit on 21.09.09, the second and final time she saw Daniel.  He was reluctant to engage and she observed an argument between him and his father.  Daniel told SW1 that he had contacted the Drug Treatment Service, saying he  “takes too many drugs and knows that it’s not doing him any good”.     3.10.5 On 24.09.09 a new referral was received from the police.  A Police Community Support Officer (PCSO) had a conversation with Daniel during which Daniel stated that agencies had not helped him when he was being sexually abused by a family member.  A telephone strategy discussion was  Page 13 of 48 held between police and CSS and it was agreed the allegation of sexual abuse should not be treated as a child protection matter.  It was agreed that SW1 would speak to Daniel and referred back to for joint investigation if necessary. This was never done.  3.10.6 Daniel met with ARC worker 1 on 24.09.09. He disclosed experimentation with drugs and alcohol and that he had friends who abused both.  He indicated he would go to the Drug Treatment Service and ARC worker 1 contacted the school who confirmed that Daniel had asked the school to make a referral on his behalf.  ARC worker 1 recorded a significant improvement as Daniel had kept the last four appointments.   3.10.7 On 28.09.09 a professionals’ meeting was held at Daniel’s school. In attendance were all agencies other than CAMHS, (although it is not clear whether they were in fact invited). It is not clear who chaired this meeting or what its status was. It was recorded at the meeting that CSS  “would not seriously consider respite … until family, parents and Daniel had engaged with support offered and taken responsibility for the position they found themselves in“.  3.11 October 2009  3.11.1 SW 1 had supervision on 12.10.09.  Daniel had disengaged for the last 3 weeks with ARC worker 1 but SW1 was apparently unaware of this.  It was agreed that SW 1 would address the referral to drugs services requested by Daniel on 24.09.09 and would attend a professionals’ meeting to be held on 05.11.09. There is no reference to the allegations of abuse made by Daniel on 24.09.09.  3.11.2 On 14.10.09 Daniel was discussed at school. An Educational Psychologist in attendance was concerned and consulted with the Children’s Education Safeguarding Unit.  They in turn contacted the school and advised them to make a further referral, which was received by CSS on 16.10.09.  The school indicated this was their third referral and identified persistent and escalating concerns, notably continued drug use which had progressed to injecting, sexual activity with males and females, staying out overnight, a very poor relationship with parents and poor school attendance.    3.11.3 On 15.10.09 ARC worker 1 met Daniel who appeared to be under the influence of drink or drugs and was  “shabby, withdrawn, unfocused and disengaged in conversation”.   He told the worker that he had taken Lorazepam and had also injected drugs.  This information was shared with the school and included in a referral they made on16.10.09 to CSS.    3.11.4 There was also now mounting evidence of criminal behaviour by Daniel. He was given a Final Warning on 17.10.09 after failing to engage with the Youth Offending Service on three occasions. His engagement in criminal activity had increased and he had now been arrested on a number of  Page 14 of 48 occasions in London for offences involving theft (from his paternal grandmother) and drug use.  3.11.5 On 27.10.09 ARC worker 1 discussed the case in supervision.  He highlighted Daniel’s disengagement during October; that Daniel was not attending school; and was offending.  It was agreed that he would make renewed efforts to contact him. He did see him at home on 30.10.09 when Daniel informed him that he had taken Valium the previous evening.      3.11.6 On 28.10.09 Daniel’s mother telephoned ARC worker 1 and informed him that Daniel had been arrested in possession of Cannabis and unidentified tablets and that SW 1 had advised them that Daniel would not be accommodated under Section 20.  She was informed that if they as parents wanted Daniel to be “sectioned” they should contact Mental Health Services.  The parents stated in interview with the author of the Overview Report that at this stage Daniel was unreachable and completely out of their control.    3.12 November 2009  3.12.1 Daniel was reported missing on 1st and 3rd November 2009 and on each occasion the attending police officers and their supervisors classified him as “non-vulnerable”.  On 04.11.09 Daniel was returned home by the police. There was a dispute between the family and police about whether he should be reported missing when, police believed, the parents did know where Daniel was. Daniel was not reported missing again after this.  3.12.2 In November Daniel was no longer attending school as evidenced by the referral and was often not at home, although his parents continued to talk to school staff about him.  3.12.3 On 06.11.09 Daniel was seen by a PCSO, who observed that his speech was slurred and he was unsteady on his feet.  He was very cold and wearing a thin t-shirt.  He was taken home and his mother has said that he was in an agitated state. At times he appeared to be hallucinating and not to recognise her.  When she questioned Daniel he said one of his friends had shown him how to distil Codeine from Co-codamol tablets which he had then injected into his arm.  He also said that his friend had allowed him to try his Methadone which he received on prescription. The police IMR states that the police sent a referral to CSS but there is no record of this being received.    3.12.4 The mother telephoned CSS and spoke to a social worker in the Children and Families Team, saying that Daniel had been returned home by the police having taken crystal meth, Diazepam and alcohol. She was reported to be distressed and expressed her fear that Daniel would be found dead at some point. There is no record of any action by CSS.     3.12.5 On 09.11.09 Daniel went to school where he reported taking a mixture of Diazepam and Valium and had a bad arm where he had injected into the muscle.  Daniel was given details of a medical drop-in centre, but his parents  Page 15 of 48 were not informed in accordance with Daniel’s wishes and no referral was made to any other agency.    3.12.6 On 13.11.09 Daniel’s father sent a further copy of a previous e-mail to SW 1.  He advised the worker that Daniel had spent very little time in the family home over the past fortnight and they thought he was staying with someone older who was living independently.  He reported the events of 06.11.09 and detailed the evidence of his serious drug use.     3.12.7 He stated that they could not persuade Daniel to stay at home. He gave details of his usual midnight trawl of open places in the hope of locating his son.  He stated  “we are concerned about the level of risk Daniel is putting himself in at the moment, and I don’t believe that he has the capacity or maturity to make decisions about where he should be staying or the other lifestyle choices he is making”.   The father requested a professionals’ meeting and suggestions for how Daniel could be supported.  3.12.8 On 14.11.09 Daniel returned home  “clearly on opiates and falling face first into his supper”.   The following day he came home with stolen clothing and a large quantity of alcohol which he drank. On 16.11.09, Daniel’s mother challenged his behaviour suggesting that he should find somewhere else to live if he would not stop using drugs and alcohol.  Daniel left the home after this and presented himself to the Housing service as homeless. They redirected him to CSS.    3.12.9 He was seen by a Duty Social Worker, where the interview focused on establishing whether he was in fact homeless.  The Social Worker made contact with his mother who requested that he be offered Section 20 accommodation.  She says she was told that this would increase his vulnerability as he might abscond.  Daniel was then taken by CSS to see ARC worker 1, where he stayed for about an hour. He was observed to be under the influence of drugs.  3.12.10 Daniel returned home later in the day accompanied by a female friend with whom he said he planned to stay. He and his father argued and Daniel left the home angrily. Although he maintained some telephone contact this was the last time that his father saw him. Daniel met with ARC worker 1 on 17.11.09, again apparently under the influence of drugs.  He disclosed significant sexual experimentation and use of morphine.  He would not go home.      3.12.11 On 18.11.09 Daniel’s father received a call from CSS enquiring about Daniel.  It appears that this conversation became unproductive and ended up in an argument about who should report Daniel missing.  Daniel telephoned his mother that evening, not apparently under the influence of alcohol or drugs, and said he had found a job.   Page 16 of 48 3.12.12 On Thursday 19.11.09 it became known that Daniel had stayed with the family of a friend. A PCSO had spoken to the father of this friend, who was happy for Daniel to stay one night. Daniel saw ARC worker 1 that day. The meeting was brief and Daniel appeared under the influence of a substance, but denied using anything when challenged.  He was reported to have been scratching profusely and said  “that’s the effect all opiates/barbiturates have on the body”.   He was described as agitated and emotional about an argument with his girlfriend.  ARC worker 1 unsuccessfully attempted to delay his departure.  Daniel maintained that he planned to return home by the weekend.  3.12.13 Daniel telephoned his father at 6.00pm that evening.  Although Daniel sounded very upset, as he said he had split from his girlfriend, he did not give the impression that he was intoxicated.  Daniel said he would return home after the weekend. Later that evening it is reported that an adult associate of Daniel found him lying outside his flat door, took him in and covered him with a blanket.    3.12.14 On the morning of 20.11.09 Daniel’s father had a long telephone conversation with ARC worker 1.  The worker told him that he had seen Daniel the previous day and outlined his concerns.   ARC worker 1 described the complaints process and advised him that he could approach his solicitor or M.P. and gave him details of a law centre.  He also said that a period in secure accommodation might be necessary at some stage if Daniel’s risk taking continued.  The father reported that ARC worker 1 said that the local authority was failing Daniel, and that their decisions were driven by financial considerations, but ARC worker 1 has denied this.  3.12.15 Following this conversation, Daniel’s father sent a letter by e-mail to CSS and to the Local Safeguarding Children Board.  He detailed the events of the previous week and expressed concern that Daniel may have been subject to sexual exploitation.  He asked the Local Authority to consider their duty under Section 47 Children Act and to look at the use of Secure Accommodation under Section 25 of the Children Act.  He stated,  “I believe that Daniel’s behaviour is at present at a level that he is putting his life in jeopardy, he has just turned 14 years old and I ask that you take affirmative action to protect him”.    3.12.16 He also telephoned the Consultant Psychiatrist and informed her that Daniel hadn’t been seen since Monday.  He was not at school and living on the streets, having sexual relationships with older men and injecting drugs.  The Consultant Psychiatrist agreed to consider the use of the Mental Health Act to protect Daniel but advised that it was complicated.  She agreed to discuss this further at an appointment in two days time.    3.12.17 On the same day ARC worker 2 had supervision and reported that the levels of risk taking by Daniel had significantly increased to include sexual promiscuity and experimentation.  It was agreed that she would pass her concerns to CAMHS and the supervisor attended CSS later that morning  Page 17 of 48 intending to escalate matters, but was informed upon arrival at the office that Daniel was already dead.  3.12.18 Again on that day SSO 1 sent an email to all involved professionals noting her serious concerns for Daniel’s safety and expressed the view that he needed to be brought into a “place of safety” otherwise he might die of a drugs overdose.  She contacted CSS and recorded their response as follows. They “stated again that they could not do anything until they had had family meetings, case meetings, etc. and this would probably take several weeks to set up”.   She expressed her concern that this was an emergency that required an immediate response.  3.12.19 An ambulance was called to the flat of Daniel’s friend on the morning of 20.11.09 and Daniel was found to have died.  Page 18 of 48  ANALYSIS  4. OPPORTUNITIES FOR ASSESSMENT  4.1 February to May 2009  4.1.1 When Daniel went to hospital in February with injuries said to have been caused during sexual activity staff did not comply with local arrangements by completing the Sexually Active Young Person’s Risk Assessment Tool. This was a missed opportunity to consider whether there were child protection issues arising from Daniel’s sexual activity.   4.1.2 Daniel referred himself to the Contact and Assessment Service in February, and stated that he had been in a sexual relationship with his girlfriend for 6 months. This relationship would therefore have started when he and his girlfriend were both 12 years old.  The Contact and Assessment Service identified this as a referral to be dealt with under child protection arrangements because of the ages of the young people.  However the DIAT Team Leader decided that this should not be dealt with in this way. That decision appears to have been based on the manager’s understanding of the response by local police to similar cases previously. This was inappropriate. If it had been managed as a child protection referral, a strategy discussion should have been held, agency enquiries would have been more robustly completed and the vulnerability of both young people could have been fully considered.    4.1.3 The decision instead was to complete an Initial Assessment. The assessment relied solely on what was presented by the parents and there is no evidence that Daniel’s views were explored.  A self referral of this sort from a child of this age is unusual but no consideration was given to exploring his wishes and feelings in a confidential setting. He was not seen until the home visit to the family some two weeks after he came to the office.  Agency checks were not undertaken; this meant that some information held by the General Practitioner was not gathered. The school, where there was information about a significant and rapid deterioration in Daniel’s presentation and attitude, was not consulted. A significant opportunity was lost for a multi-agency plan to be developed.  4.1.4 The Initial Assessment identified CAMHS and ARC as appropriate resources and the case was closed to DIAT on 16.03.09.  In fact both of these resources believed that DIAT remained the lead agency.  ARC informed DIAT that Daniel had failed to engage with them, which indicates that they saw individual work with him as their defined role in supporting DIAT. CAMHS assumed that DIAT were still involved when they wrote on 8.04.09, requesting a joint appointment.   When the Consultant Psychiatrist received no response, she did not follow up this request and a significant period of time passed with no-one accepting lead responsibility for assessing the harm experienced by Daniel.  DIAT telephoned CAMHS on 18.05.09 to advise that they were not  Page 19 of 48 the lead agency and that Daniel’s case had been closed to their team for a couple of months.  CAMHS appeared to accept this and did not re-refer.    4.1.5 It is of further concern that the psychologist who interviewed Daniel on 20.03.09 was informed by him that he had taken an overdose on 16.03.09 and had urinated blood for two days afterwards.  Although she reported this to the Consultant Psychiatrist and a further appointment was offered to complete a risk assessment of Daniel, his immediate medical needs were not addressed and no onward referral was made.  4.1.6 Once the Consultant Psychiatrist was made aware that DIAT had closed the case she organised a meeting at CAMHS. ARC were absent, presumably because CAMHS did not know of their involvement.  It would have been appropriate at this stage for the Consultant Psychiatrist to have considered escalating concerns directly within CSS and, if necessary, then to have escalated this within her own agency.  4.1.7 The status of the meeting was unclear.  The representative from CSS who attended made it clear that the parents had to take responsibility for Daniel’s safety, though this assertion did not appear to include any consideration of Daniel’s needs. The Consultant Psychiatrist had received information from the GP in respect of health problems in the family, but there is no evidence she had analysed the impact of this herself or sought further updating information.   No Lead Professional was identified at this meeting, which resulted in a lack of co-ordination between agencies.  4.1.8 As a result of this meeting, Daniel’s father was advised that he should be using ARC for support.  When he contacted ARC worker 1 he was told that their role was only to work with Daniel, dependent on Daniel engaging with them.  ARC’s non –attendance at the meeting and the failure to identify a lead agency led to confusion.  4.2 June to July 2009  4.2.1 In June there were a number of unsuccessful attempts to have Daniel’s situation dealt with under child protection arrangements. By late June there were two referrals detailing Daniel’s allegations of assault, three telephone calls from his father, three contacts from the school and Daniel had told his story to 4 different people.    4.2.2 The response of CSS to these events and referrals should have been to convene a strategy discussion, thus ensuring effective information sharing, and an assessment of the perceived risk from each of the agencies involved with Daniel.  This was not done. In fact there appears to have been no new assessment by CSS. The previous social worker (DSW1) was asked to deal with the matters but it appears that the only contact was a telephone conversation with the father and the school.  The completed assessment referred to an interview with the family on 02.03.09 which was the date of the first initial assessment and there was no reference to the current referrals, particularly the allegations made by Daniel, nor any attempt to interview  Page 20 of 48 Daniel. The assessment repeated the information and recommendations from the March assessment.    4.2.3 The CSS Duty Manager signed off the assessment with the comment  “this young man is at risk from his own behaviours which are part of the culture he identifies with; however, it is appropriate for CAMHS to address this with him and his family”.   At this point Daniel was seen as capable of making a choice regarding his behaviour, for which he had to take responsibility. There was no analysis of the risks he was engaged in and what steps should be taken to protect him.  There was no indication that Daniel, his parents or the referring agencies were advised of the outcome.  Most importantly, no-one from CSS interviewed Daniel.  His hope that he would be helped must have been significantly reduced.  It may be that as a result of this Daniel became even more pessimistic about the willingness of agencies to help him.    4.2.4 As concerns continued, CSS equally continued to fail to engage. Daniel’s school has records of a number of unreturned telephone calls, including a call requesting contact from the Principal Social Worker. There is no information in CSS files that these calls were received or how they were dealt with.  The school has recorded that they were left with the sense that CSS were “not interested”.  In fact the school took it upon themselves to accept responsibility for the situation of Daniel having nowhere to stay. They organised a bed for the weekend at Daniel’s girlfriend’s home, thereby placing Daniel and themselves in a potentially vulnerable position, as this was an informal arrangement and it is not recorded whether Daniel’s  parents agreed to this (although the father was informed).  The school should have escalated the matter within CSS, perhaps also seeking the support of the Education Children’s Safeguarding Unit.  4.2.5 The response of CSS was to delegate the matter to the ARC workers, who had a planned visit to the family the following day.  They were not however qualified workers and there was no evidence they were aware that this had become their responsibility.  The workers felt unable to respond to the situation and Daniel was left in a situation that had deteriorated further as a result of their limited intervention.  The ARC senior informed DIAT of this the following day in writing and may well have felt that any delegated responsibility was handed back to DIAT.  However, the observations made by the workers do not appear to have been sufficiently analysed within ARC in respect of the urgent need that Daniel had for a place of safety.  There is no indication of any action by DIAT upon receipt of this further information. It appeared to be viewed rather dangerously as “more of the same”.  4.2.6 On 02.07.09 the father requested “secure accommodation” for Daniel based on the escalation of his risk taking behaviours.  Agreement was given by DIAT to seek a respite fostering placement for one week, although there was no clarity about why it was offered on this occasion and never offered again.  It was not possible to identify a placement within the Authority’s own resources, but there is no evidence that the private and voluntary sector were approached, or any indication when and whether a placement would have  Page 21 of 48 become available.  Daniel had slept “rough” the previous night but there appeared no understanding of the urgency of the situation and no acceptance of their responsibility by DIAT.  No attempt was made for a qualified worker to meet with Daniel or with his father to analyse the risk and develop a plan to manage this.       4.2.7 The letter from the father received on 06.07.09, fully details the risk Daniel was exposed to and provides the most comprehensive view of how the situation had deteriorated.  He requested respite care for Daniel and a coordinated response from the various agencies.  This is an articulate letter from a father who was clearly anxious about his child’s welfare and unable to keep him safe himself.  There is no evidence to suggest anyone responded to this letter. There is however, a suggestion that more than one file was open in the office and correspondence may have therefore not been seen.  This was an unsafe system which allowed for information to be misplaced and unread and damaged relationships with other professionals and the family.  CSS have advised that action was taken at the commencement of this review to address this vulnerability.   4.2.8 Events were moving very quickly by July and the Head Teacher of Daniel’s school asked his staff to e-mail CSS daily regarding events.  Whilst the school was diligent in sharing information, the attempt to instil a sense of urgency in CSS did not succeed.  The e-mails contained unfiltered information which may have served to desensitise the reader from assessing what was most relevant to Daniel’s safety.  This action was ineffective and the appropriate response would have been to escalate their concerns in line with LSCB procedures for professional challenge.    4.2.9 On 09.07.09 Daniel alleged to two detached youth workers that his father had been violent towards him.  He mentioned a broken finger and a bruise to his back.  Both the hospital and police have been unable to trace their records of this event. This allegation met the threshold for a Section 47 investigation but no agencies except police and CSS were involved in agreeing how to respond. The agreement to delay a joint investigation (during which time Daniel’s circumstances were unclear and he appeared not to be at home) was not safe. Investigations such as these are cannot safely be postponed.   4.2.10 In the end police failed to make resources available and DSW2 visited. It is not clear whether this social worker was aware of the level of professional concern regarding Daniel and addressed this, or whether she addressed any other issue other than the allegation.  The father had not allowed Daniel to leave the house in the morning, but there was no acknowledgement that this was a less than ideal situation in which to elicit Daniel’s wishes and feelings. The potential need for a medical examination was not identified.    4.2.11 A Core Assessment that was completed as a result of this visit does not address the accumulating concerns.  There was no re-assessment of risk.  It is incomplete, duplicating elements of the first initial assessment.  Some of these problems were related to new information systems being introduced at  Page 22 of 48 that time but it is clear that agency checks were not made and that the key agencies in the case - CAMHS and ARC – were not included in the process or even informed of it by DIAT.  A Core Assessment must rely on information from all agencies to form a view about the level of risk, and to comprehensively analyse the child’s current situation.  4.2.12 DIAT appear to have been overly influenced by the criminal threshold in determining whether to undertake a Section 47 child protection investigation.  Daniel’s risk taking behaviour alone caused him to suffer significant harm but this was not considered to meet the child protection threshold.     4.2.13 In July the Consultant Psychiatrist wrote to CSS detailing her concerns and shared her opinion that Daniel could not be detained under the Mental Health Act but should be offered secure accommodation. There is no evidence of any response to the psychiatrist, nor is there any follow up by the psychiatrist when she did not receive a response.  When the level of professional concern reached this point the correct action would have been for the psychiatrist to make a referral to CSS and if the response was considered inadequate, then it should have been escalated by the psychiatrist until the matter was resolved.  The psychiatrist appeared unaware of how to challenge the lack of response from CSS.  4.2.14 Use of secure accommodation was identified as an issue in the terms of reference for this review and this was requested by the father.  A measure of confusion was created by using this term but the psychiatrist says she meant secure as in a “stable” placement.  This is not explicit.  The reference to the use of secure accommodation indicates a lack of understanding of the criteria.  In order to evidence the need for this the local authority must be able to demonstrate that: the child has a history of absconding and is likely to abscond from any other description of accommodation and; • If they abscond they are likely to suffer significant harm or; • If they are kept in any other description of accommodation they are likely to injure themselves or other persons. As Daniel had never been offered the opportunity of “other accommodation” he had no history of absconding and would not have met the criteria at this point.       4.2.15 On 31.07.09 the case was designated as Child in Need and transferred from DIAT to the Children and Families Team.  The designation as Child in Need is important, as this dictated the experience of the worker to whom it was allocated.  In this case it was allocated to a social worker who had just completed her social work training but could not be viewed as qualified as she was not yet eligible to register with the General Social Care Council.    4.3 August to October 2009  4.3.1 Consideration was not given at this time to offering “Section 20 accommodation” to Daniel.  This was emphasised by the social worker, when  Page 23 of 48 during her visit of 04.08.09, she appeared to be carrying a strong message that Daniel would not be accommodated.  It is unlikely that this was based upon her own assessment. It appears that SW 1 was sent to work with the family without the one resource – coming into public care - that was now necessary to protect Daniel. SW1 reiterated a commonly used phrase by other members of CSS that they as parents had parental responsibility and they needed to make their own alternative arrangements.    4.3.2 SW 1 sought advice from the Drug Treatment Service but was informed that they only offered support to parents if the young person themselves had engaged with their service.  This is a gap in provision.  Social workers need to be able to access specialist knowledge about drug use and to be able to refer parents to such a service (which may well increase the number of young people who engage with the service).    4.3.3 Daniel was missing for three nights from 23.08.09. When found he refused to go home and his parents requested Section 20 accommodation or “Secure Accommodation”.  The police contacted the CSS Out of Hours (OOH) Service who repeated the advice given by previous social workers that the parents had to take responsibility for identifying alternative accommodation if they did not want Daniel to return home.  This was accepted by the Police Constable dealing with this and his comment was illuminating in terms of the unwillingness of all agencies to view Daniel as vulnerable: he stated that he had found Daniel  “to be a very mature, intelligent and streetwise boy who looked older than his 13 years”.   This maturity was illusory and not informed by any analysis of his increased risk taking behaviour. The refusal by OOH to provide accommodation appears to have been a re-affirmation of the decision taken by the local office and did not consider the needs of this child at that time.    4.3.4 SW 1 undertook a home visit on 21.09.09, the second and last time she actually saw Daniel, and it is clear that this was a difficult session where Daniel was angry and frustrated.  This meeting does not appear to focus on any plan of work with either Daniel or the family.  It is difficult to understand the purpose of the visit other than to restate the need for the family to engage with previously offered services that were not effectively protecting Daniel.  4.3.5 The next referral was from the police on 24.09.09 because Daniel had alleged sexual abuse by a relative. A telephone strategy discussion was held with the police and it was decided that this would not be dealt with under child protection arrangements. It is difficult to understand why this decision was made without any gathering or analysis of information.  When this decision was made, a vague agreement was reached that SW 1 (who was unqualified and inexperienced in child protection) would speak to Daniel and if necessary refer the matter back to the police for a joint investigation.  This meeting with Daniel never in fact took place and was not followed up by the DIAT prior to their closing this referral.     Page 24 of 48 4.3.6 On 28.09.09 a meeting was held at the school.  The meeting had no particular status and was not part of formal inter-agency arrangements. It may have been hoped that it could have led to a shared understanding of the issues for Daniel and his family.  Instead the meeting ended without a summary of the concerns expressed and with no structured plan to address these.  The identified actions were insufficient and over optimistic.  ARC worker 1 was reported as  “currently seeing Daniel on a weekly basis and in touch with father and able to offer Daniel support and access to clubs, activities etc through ARC”.   In fact he had only achieved 4 recent sessions with Daniel since his work commenced in March and achieved no further sessions after this.  There is no sense of SW 1 being the lead worker and the few tasks that were identified were to be undertaken by the school.    4.3.7 Neither Daniel nor his parents were included in this meeting and therefore it was not possible to directly consider their response to the proposed action.  The statement of SW 1 that the parents needed to take responsibility for the situation was totally unrealistic.  As previously stated, these were intelligent parents who shared information, sought help and recognised Daniel’s behaviour as harmful.  They were very clear that Daniel was out of their control and they could not keep him safe.  They identified the need for a period of Section 20 accommodation which had been rejected by CSS, but no alternative plan had been put forward.  There is no sense of the chaotic and unsafe position Daniel was in and no consideration of the recent referral that CSS had received from the police regarding possible sexual abuse.  4.3.8 CSS and ARC records independently state that the school had agreed to refer Daniel to the Drug Treatment Service during the professionals’ meeting.  ARC worker 1 subsequently confirmed this with SSO1 and with Daniel, who had given permission for the referral. Daniel was never referred.  4.3.9 In October, after taking specialist advice, the school made another referral to CSS. It identified all the areas of concern felt by the school, namely drug use which included injecting, sexual activity with males and females, staying away from home for significant periods and a very poor relationship with parents.  It also raised the allegation contained within the police referral of 24.09.09 regarding possible sexual abuse of Daniel by a relative.    4.3.10 Upon receipt by CSS this information was not comprehensively reviewed but focused on the sexual abuse element alone.  It was decided that the sexual abuse allegation had already been considered and designated as a Child in Need Referral which SW1 would discuss with Daniel.  Even setting this aside, the other concerns in the referral, particularly information from direct observation of Daniel’s physical presentation, should have indicated that the child protection threshold was reached.  The appropriate action would have been to hold a strategy discussion and Section 47 investigation and take action to assess Daniel’s immediate needs. This was not done.   Page 25 of 48 4.3.11 There was a further opportunity to assess Daniel as a result of his criminal activity and the involvement of the Youth Offending Service (YOS). The case was allocated as appropriate for a Final Warning.  The worker made a good effort on three occasions to meet him at a neutral venue but he did not attend.  With the information that was known about Daniel, and his young age, this lack of engagement should have prompted more concern.  It would have been desirable to meet with Daniel when the Final Warning was administered when crucial information may have been gained about the possible link between his drug use and recent criminal behaviour. This did not happen.  4.3.12 The ARC service did not respond adequately to the continuing decline in Daniel’s circumstances. They reviewed their involvement on 27.10.09. At this time Daniel was not attending school, he had not seen SW 1 since 21.09.09 nor was he seen by CAMHS during this period. ARC worker 1 was the only professional worker who had seen Daniel recently and could advise on his deteriorating physical presentation and the increasing level of harm he was exposed to. The action record from this supervision is that ARC worker 1 was to make renewed efforts to contact Daniel which did not deal with the immediate need for Daniel to be protected from significant harm. The social worker should have been contacted.  4.4 November 2009  4.4.1 Daniel was reported missing on 1st and 3rd November 2009 and on each occasion the attending police officers and their supervisors classified him as “non-vulnerable”.  This was said to be the direct result of a new missing persons policy introduced in August 2009.  This classification had the effect of limiting police action so that no further enquiries were necessary. However, there were also examples of this action on occasions before August 2009.  It is extraordinary that anyone assessing Daniel could have classified him as “non-vulnerable”.  This policy was revised after Daniel’s death and no longer applies to children under 16 years of age.  4.4.2 When Daniel was returned by police on 4.11.09 there was a disagreement between his parents and police about when he should be reported missing. This conversation was held in Daniel’s presence and effectively gave him permission from the police to decide where he stayed.  Daniel was just 14 years old and his parents were by that time only able to keep a very tenuous link to him by insisting he return home in the late evening or be reported missing. This effectively cut off their link with an agency that should support them in exercising their parental control.  The parents accepted the view expressed by the police officer and did not report Daniel missing again.  4.4.3 Two days after this increasingly clear evidence emerged that Daniel’s drug use had escalated to become chaotic and indiscriminate. His mother told a social worker that Daniel had taken crystal meth, Diazepam and alcohol and shared her fear that he would be found dead. The police record that they made a referral to CSS stating Daniel had been picked up high on substances, freezing cold and begging.  This referral and the preceding  Page 26 of 48 information clearly reached the threshold for a strategy discussion and child protection intervention but there is no record of any action being taken by CSS.   4.4.4 On 13.11.09 the father informed CSS via e-mail that Daniel’s drug use  “now includes injecting Codeine distilled from Co-Codamol tablets, using a friend’s prescribed Methadone as well as amphetamine and marijuana”.   SW1 sought advice from a Senior Practitioner and their manager, a Team Leader. The Team Leader said her judgement was that his behaviour did not constitute significant harm.    4.4.5 This was a seriously flawed judgement. It supported the statement presented to the parents on numerous occasions as a mantra by most of the CSS staff they came into contact with; namely that they had to take responsibility for Daniel. It is unclear whether the view expressed was through a lack of knowledge or whether this was actually a further attempt to avoid Section 20 accommodation regardless of need. It seems more likely to be the latter as it is entirely obvious that CSS should take respond proactively to such information.   4.4.6 In any event it demonstrates no understanding of the fact that some teenagers become out of their parents’ control and suffer or are at risk of suffering, significant harm.  This is enshrined in the Children Act 1989, as a reason why a Court would consider making an order to safeguard a child.  This is exactly the situation that faced these parents and the facts are absolutely clear. Daniel was only just 14; he was out of his parents’ control and was suffering significant harm.    4.4.7 In the week prior to Daniel’s death he was returned home by the police on 14th and 15th November and on both days he was under the influence of alcohol and drugs. On 17.11.09, he was seen by ARC1 - under the influence of drugs, adamant he would not return home, discussing significant sexual experimentation and disclosing possession of 4 milligrams of Morphine - but no referral was made.      4.4.8 A number of opportunities were missed when strategy discussions and Section 47 investigations should have been undertaken.  When assessments were carried out they did not systematically highlight the risks to Daniel and formulate a plan for intervention.  In the absence of a coherent plan and desired outcomes work could not begin to address the risk and harm that would have been evident.  Any assessment must have a full range of interventions for consideration.   In this case the provision of Section 20 accommodation was explicitly removed from the range of options, save for one occasion.  This option should have been further considered particularly from September onwards.   5. PARENTING CAPACITY  5.1 The mother was unwell when Daniel was very young and felt this may have contributed to bonding and attachment difficulties between her and  Page 27 of 48 Daniel.  However there was no evidence of this affecting parenting capacity before the end of 2008.  The parents invested a great deal of time supporting their children in their chosen activities.  Daniel was a successful child at primary school, with no evidence of low self-esteem.  5.2 In 2008 there were reported difficulties in the relationship between Daniel and his mother as he began to seriously challenge her authority.  She became unwell again in November 2008 and was not in a position to meet the accumulating challenges that caring for Daniel involved. It is likely that Daniel received inconsistent boundary setting at this stage.  5.3 The parents worked shifts with one or the other at home at each end of the school day, but their challenging jobs meant they relied on the children to conform to basic expectations, such as getting up to go to school.  It is easy to see how major arguments ensued when Daniel constantly challenged this.  5.4 The father was also unwell in January 2009.  Information was not sought from the GP about either parent to inform the Initial or Core Assessment.  Information was however provided to CAMHS in the GP referral.  CAMHS were best placed to advise on the impact of illness and how it might affect parenting capacity, but did not do so.  5.5 These parents were very aware of their role and responsibilities. They are an intelligent couple who were able to present their concerns to the appropriate agencies and were very open in their view that Daniel was out of their control and that they felt powerless to change this.  The father in particular kept in constant contact with the school.    5.6 The parents generally reported Daniel missing although this ceased when they were advised against it on 04.11.09.  The father regularly went looking for Daniel in the evenings and brought Daniel home himself where possible.  The parents wrote to the Area Commander of police and visited local public houses with photos of their son asking that they refuse to serve him.  The father regularly contacted CSS and shared his escalating concern for his son.  He requested multi-agency meetings and safe accommodation for Daniel when he was failing to return home. The parents attended all appointments offered to them by CAMHS, by the school and by CSS.  5.7 Daniel made allegations about violence and aggression by his father.  These allegations were never actively pursued.  There were failed opportunities to address these on 25.06.09, 30.06.09, 10.07.09, and 24.09.09.    5.8 The view of the parents is that they were seen as totally responsible for Daniel’s behaviour and had to find their own solution which they felt unable to do.      5.9 In summary, the parenting capacity of these parents was never properly assessed or addressed with them.   No account was taken of the effects of each parent’s health.  Their capacity may have been enhanced if they had  Page 28 of 48 understood and been part of a focused plan to address the major anxiety they both had due to the risks Daniel was taking.    6. RISK FACTORS  6.1 These have been collated and set out below to demonstrate how much information was known about the risks and consequential harm that Daniel was exposed to without his being the subject of any child protection action.  6.2 From January 2009 – March 2009 the following risks were known;  • underage sexual relationship • missing overnight from home • previous illness of both parents • relationship difficulties between Daniel and his parents including extreme conflict with his father • Daniel’s stated wish to be adopted / come into care • free-running • mixing with an older child whose father reportedly dealt drugs • self-harm • history of drug abuse in his extended family • possible drug abuse • poor sleep patterns and low morale • feelings of emotional abandonment • possible ADHD/attachment difficulties/Aspergers.   6.3 From April 09 – 22nd June 2009, in addition to the above there was evidence of; • being arrested for possession of drugs • other criminal activity  • school attendance at  50% • advice from a Consultant Psychiatrist that Daniel was non-compliant • an attempt to break his own fingers with a rolling pin – 40 scars on his arms and old cigarette burns • overdose and suicidal thoughts • coming home under the influence of substances  • being away from home (and possibly sleeping rough) for more than 2 nights  • assault on his mother • being held overnight in a police station.   6.4 From June 24th – 6th July Daniel; • requested urine testing for drugs as he was concerned about misuse • alleged physical violence from parents on a regular basis over 2 years  • sought assistance from ChildLine, CSS, school counsellor and police • was told to leave home and requested accommodation • started living with “friends” • was identified by his school as out of control  Page 29 of 48 • had a particularly difficult relationship with his father  • requested accommodation again • entered a sexual relationship with a male of unknown age • is alleged to have broken into the family home • misused alcohol • refused ADHD medication • said to have been setting fires  6.5 During the months of July - August 2009 Daniel;  • was said to be having sexual relations with boys and girls • was not in school at all for the last 3 weeks of term • was not monitored by any agency during the holidays • increasingly evidenced involvement in the use of illegal drugs and consequent criminal activity  6.6 During September 2009 Daniel; • was reported to be using intravenous drugs • made an allegation of sexual abuse against a relative • was found out late at night, extremely cold, wearing thin clothes and with a cold; fresh ligature to his arm • disengaged from ARC worker at the end of September and last saw the SW1 on 21.09.09.   6.7 During October 2009 Daniel; • caused school staff to fear that he might kill himself • was seen under the influence of drink/drugs, shabby, withdrawn and unfocused • disclosed injecting drugs, admitted taking Valium and was arrested for possession of Class B drugs • did not engage with youth offending services  6.8 In the weeks prior to his death Daniel; • was reported to be incoherent and hallucinating after taking crystal meth, diazepam and alcohol • was observed out at night cold and begging • reported himself homeless • disclosed significant sexual experimentation  • may have been sexually exploited • had morphine in his possession   6.9 The risks to which Daniel was exposed were enduring, escalated quickly and were undoubtedly causing significant harm.  Significant harm was misunderstood by CSS, who appeared to believe that unless a parent or carer was causing the harm it did not indicate a need for child protection intervention.  6.10 Whilst this information was available on records held in various places on the CSS computer system, it was not properly compiled as a comprehensive  Page 30 of 48 chronology at that time.  A new computer system at that time caused problems in terms of the recording of information in an accurate manner.    7. FOCUS ON THE CHILD  7.1 School  7.1.1 The most significant contact for Daniel was his school. He chose to maintain this contact even when he no longer regularly attended.  Contact was mainly with two School Student Support Workers (SSO’s).  They provided Daniel with open access and gave him the opportunity to discuss his wishes and feelings in a familiar setting.  They were alert to the seriousness of the information he gave them and ensured this was passed on to other agencies.  When they were no longer in contact with Daniel they kept closely in contact with the father.  They were not however able to ensure Daniel’s voice was effectively heard, which may have been possible if they had made timely referrals to CSS and if they had escalated unmet concerns.  7.1.2 The school arranged counselling for Daniel through a school counsellor.  He attended a number of sessions and used the counsellor appropriately for support.  When Daniel told the counsellor that his parents were hitting him regularly, she gained his consent to make a referral to CSS which was good practice. However, despite the Serious Case Review Panel requesting the counsellor’s notes, these were not made available.  These may have informed us directly of Daniel’s views and would have assisted the understanding of the school’s intervention with Daniel.  This should be addressed with those commissioning this service.  7.2 Hospital-based Health Services  7.2.1 When Daniel sought sexual health advice his wish not to inform his parents that he was sexually active was listened to.  Whilst this may have been an appropriate response there is no evidence that the tension between his wishes and the risk were considered.     7.2.2 It is a matter of concern that Daniel was seen at a hospital on 06.07.2009, being assisted by a nurse who had strapped his injured fingers together, but it has not been possible to locate any reference to this in the hospital records or Daniel’s GP’s records.   7.3 CAMHS  7.3.1 Daniel was seen on 6 different occasions at CAMHS, both alone and with his parents. CAMHS were clear that Daniel was not suffering from any clinical mental health problems. He appeared to respond well to individual sessions but declined a number of offers of services. He disclosed information which should have led to a referral to medical services.   Page 31 of 48 7.3.2 The Consultant Psychiatrist wrote to CSS to suggest that Daniel’s behaviour warranted a secure placement but she did not make a referral and did not follow up her letter or offer Daniel an urgent individual appointment. Her use of the term “secure placement” was loose and caused confusion, as Daniel could not have been made subject to an order for secure accommodation in the meaning of section 25, Children Act, 1989. There is no evidence that a risk assessment was completed by CAMHS which could have challenged the CSS position that the local authority would not offer to admit Daniel to care because he was solely his parents’ responsibility.  7.3.3 Daniel requested a drugs test during an appointment and the Consultant Psychiatrist wrote to the GP to arrange a urine test.  The GP did not have the capacity to order this and it was not done.  It appears that Daniel himself wanted this information suggesting he was concerned about his drug use.  Obtaining this might have provided the opportunity for the psychiatrist to further explore his drug use, complete a risk assessment in respect of substance misuse and support him to attend an appropriate service.    7.3.4 Daniel was seen for the last time at CAMHS on 12.06.09. There is little sense in the summary of this session of any planning with Daniel or how his issues would be addressed and no further sessions were offered to him.  .    7.4 General Practitioner  7.4.1 The GP saw Daniel on one occasion only during a home visit in response to a request from his parents.  He spoke directly to Daniel whilst in the presence of his parents, which was appropriate in the circumstances, and made a referral as requested to CAMHS  7.5 Police  7.5.1 Daniel was reported missing to the police on 12 occasions and on only 8 occasions is there evidence that he was physically seen and spoken to by police following his return.  There is also little evidence from these encounters that this was used as an opportunity to discuss with Daniel why he had been missing or to examine what risks he had been exposed to whilst missing.  On only one occasion did a report of him as a missing person result in a notification to CSS.  It is important to remember that during most of this time he was only 13 years old.    7.5.2 Daniel became a well-known figure to some of the Police Community Support Officers who appeared to “look out” for him and attempted to engage him in conversation.  They reported he was generally polite and conversant.  He did discuss problems at home with them. Although Daniel maintained a reasonable relationship with the various police officers he met, there were many missed opportunities to try to intervene in a more focussed way.      7.6 Children’s Social Services   Page 32 of 48 7.6.1 This case was known to CSS from January 2009 until Daniel’s death in November 2009.  There is little evidence of any planned work with Daniel during this time.    7.6.2 The case was allocated to ARC worker 1 on 31.03.09. He attempted unsuccessfully to engage Daniel but the first session with Daniel was not till 29.08.09.  After that he formed a good relationship with Daniel, who was generally relaxed and open with him, but this did not lead to any change in Daniel’s circumstances. Other agencies and SW1 appeared to think there was far more engagement than there was.  There was in fact no-one within any of the CSS teams who was able to ascertain Daniel’s wishes and feelings and gain any understanding of his distress.  7.6.3 Daniel appeared to be seeking out ARC worker 1 in the last week of his life. He may have been disappointed that the response he received was no different despite sharing information of escalating harm, no longer living at home and direct observation of his distressing physical presentation.    7.6.4 Daniel only saw SW 1 twice. She was not in a position to have acquired sufficient insight into his circumstances to make an informed decision regarding what was in his best interests or to adequately consider his views. In any case the allocation of such a demanding case to a newly qualifying social worker was entirely inappropriate.  7.6.5 Daniel, although only 13 years old for most of the review period, was able to articulate his wishes and feelings clearly.  Although he was not consistent, he did seek help from appropriate adults and continued to do so right up until the time of his death. A number of adults individually listened to him and tried to act upon what he told them but they were ultimately ineffective in protecting him.    8. DIVERSITY   8.1 This family see themselves as White Working Class British.  In fact the father was born in the Caribbean, but any possible significance of this was never raised with the family by any of the agencies.  The parents expressed their view to the author that they were discriminated against because they were working class.  They said that they did not fall into the category of what professionals viewed as abusive or neglectful parents, but also they did not possess the skills to challenge CSS in a way which they felt better connected middle class parents might have been able to do.  8.2 The mother made a perceptive comment when she told the overview writer  “I think they may have thought we could have dealt with the problems ourselves when we were telling them otherwise”.   This family were viewed as articulate but their inability to meet their son’s needs was never sufficiently assessed and it remains unclear why this family experienced such acute problems.   Page 33 of 48 8.3 During most of the period under review both parents experienced problems with their health.   8.4 The father had lost close relatives through substance misuse.  In interview, he said  ”These deaths …did impact on my attitude towards drug use.  When it became clear that Daniel had started to take dangerous drugs, rather than simply contributing towards my anxiety, I was acutely aware of how this could impact on his safety and well being”. This information was provided during the initial assessment and to CAMHS but it does not seem that it was properly explored and analysed.  8.5 Daniel attended a selective school and was potentially a high achiever.  He looked older than his age, more like a 16 or 17 year old.  He could be articulate and confident in his manner and was often described as polite and engaging, which appeared to have been confused with emotional maturity. It may be that agencies failed to keep in mind that he was a 13 year old and wrongly assumed he was more emotionally mature than was the case.  Daniel was diagnosed with mild ADHD which the Psychiatrist assessed as having a significant impact on his behaviour.  ADHD is associated with delayed emotional maturity and other vulnerabilities but there was no overall assessment in which this was considered.  8.6 Agencies contributing to the review were asked to consider whether they had been influenced by the nature of the parents’ employment (in health / social care).  There is no evidence that this information influenced the approach that individual agencies took to these parents. However there was a lack of appreciation of potential effects on the father’s employment of the family’s difficulties and the stress caused to the father by this.  8.7 In summary, although there were diversity issues known to the agencies, there is little evidence that any agency addressed this.  9. IMPLEMENTATION OF PLANS  9.1 There was never any clear process, either within or between agencies, of assessment, planning and review. CAMHS responded quickly to early concerns but failed to build this into an effective multi-agency response, in the face of repeated failures by CSS to respond appropriately to evidence of cause for concern.  9.2 The school made 3 appropriate referrals to CSS between June and October 2009 but had no contingency plan for dealing with the weak and ineffective responses they received. The school was clearly dissatisfied with the response from CSS but did not seek to escalate this within their own agency or within CSS.  There is no evidence of a plan by them to gain access for Daniel to appropriate services other than sending all information to CSS.    9.3 CSS were the lead agency following the February 2009 referral.  ARC, a CSS resource, was requested to work with Daniel.  It is clear that there was  Page 34 of 48 no written plan nor were the family given any sense of what any plan was, how this would protect Daniel and what expectations the professionals had of the family, other than that they should manage Daniel’s behaviour themselves  9.4 Once Daniel was treated under Child in Need arrangements SW1 was the lead professional but was not effective in this role.  SW1 was not sufficiently experienced to assess and manage such a challenging case. Overall there is no sense of the agency having any understanding of how difficult and demanding this case was.  9.5 In June 2009, the provision of accommodation was requested by Daniel and his parents and supported by CAMHS and the school.  Section 20 accommodation was agreed although not successfully identified.  This is the only time when this was even considered by CSS. There was no assessment at any other time of whether this may have been appropriate to protect Daniel.    9.5 From June onwards there was no adequate plan to protect Daniel from harm due to his increasingly dangerous risk taking behaviour. This was a very serious failure by CSS.  10. POLICY CONTENT AND COMPLIANCE  10.1 This case mirrors many other serious case reviews where policies and procedures are in place but are poorly understood or not followed.  10.2 Agencies did not consider the use of the CAF (Common Assessment Framework) which initially may have been an appropriate way to have focused their work.   10.3 The “Procedures and Practice Guidance for Working with Young People who are Sexually Active” were not followed at any time by any of the professionals involved, although this was a cause for concern from the outset.  10.4 There was no challenge to the entirely inappropriate position taken by CSS. Clear LSCB procedures are in place to encourage challenge between professionals and agencies.  Previous Serious Case Reviews in Kent have identified this lack of challenge as a problem but little progress appears to have been made.     10.5 A number of police policies and procedures relating to “missing person” arrangements were not followed so that important information was lost.  The CAIU were not informed that Daniel had been missing and therefore did not inform CSS.  The Missing Person Liaison Officer was not aware that Daniel had been missing as a result of which Daniel did not become classified as a repeat missing person.  Senior police officers were not alerted to his increased vulnerability and a Multi-Agency Conference was not instigated as policy requires.     Page 35 of 48 10.6 There did not appear to be a policy for ensuring that specialist services commissioned by a school, such as counselling, are formalised with an agreement to share information appropriately and keep relevant records.   Each school is required to have a Drug Policy but they are not required to have a designated person which may account for the lack of consultation with the County Drugs Advisor.    10.7 Child protection referral procedures appear to be poorly understood despite clear policies and a legal framework.  DIAT did not follow policy and procedures for dealing with referrals, holding strategy discussions, undertaking agency checks and conducting Section 47 investigations. They clearly had a flawed view of an appropriate threshold for intervention when children need to be protected.  11.  INFORMATION SHARING  11.1 From July onwards the school distributed all the information they received in a way which was unfiltered, unfocussed and appeared to overwhelm the other agencies.   11.2 There was never an effective Lead Professional arrangement. CSS did not make appropriate enquires from other agencies.  There was no clarity on how and when to share information internally within CSS.  The computer database hampered effective information recording and retrieval.  11.3 The police did not share sufficient information regarding Daniel because policies were not adhered to and because his vulnerability was not understood. This confusion was compounded by the introduction of a new policy in August 2009, which has now been changed..    11.4 CAMHS shared appropriate information regarding their assessments with CSS and the GP.  CSS did not pass this information to the ARC worker working directly with Daniel, nor was he given information regarding the first multi-agency meeting.  11.5 Conversely, the child and the parents shared a great deal of information with professionals but the agencies did not make best use of that information in planning how to keep Daniel safe.  12. KNOWLEDGE AND EXPERIENCE OF STAFF  12.1 The Principal Social Worker moved to DIAT as a result of restructuring.  She had previously worked in a different setting.  She had no targeted training for this new role. There was an unrealistic expectation that her skills were directly transferable without induction, support and managerial oversight.    12.2 In August the case was allocated to an unqualified social worker, on the basis of her experience with adolescents.  As previously observed, this case required a worker experienced in undertaking their own assessment and  Page 36 of 48 formulating a plan that other agencies could sign up to and who was confident and experienced in assessing significant harm.    12.3 There was a lack of knowledge across CSS of how to assess significant harm where adolescents are engaging in risk taking behaviour.  There appeared to be a shared view that a child could not be suffering significant harm unless that harm was directly attributable to their parents.    12.4 There is evidence from the police investigation that those officers with whom Daniel most often came into contact were Police Community Support Officers and patrol constables.  They identified that they had no basic training on child protection procedures and whilst recognising that he had problems lacked confidence in knowing how to assist him.    12.5 The person with responsibility for child protection at the school was on long term sick leave during the period in question.  However, the two School Support Officers involved were trained and experienced in this role.  12.6 The professionals at CAMHS were appropriately trained and qualified but appeared to lack expertise in working within a child protection remit.  Procedures for when and how to make a referral were poorly understood.  12.7 This case would have been demanding for any professional network. The rapid acceleration of risk taking behaviour at a very young age was particularly challenging.  There was never any real understanding of the sudden deterioration in family relationships.  12.8 Brandon provides an important insight into working with this complex and challenging age group.   “Agencies often appear to run out of helping strategies and “give up” on young people…failure to respond in a systematic way to the young person’s extreme distress often led to neglect of these extremely vulnerable young people’s needs”   13. MANAGEMENT AND SUPERVISION  13.1 Children’s Social Services  13.1.1 There was no effective system in place in this district for tracking caseloads, strategy discussions and Section 47 checks.  The result was that these were sometimes not completed and there was a lack of managerial oversight with regard to analysis and outcomes.   13.1.2 There was no evidence that the supervision offered to workers routinely analysed harm or the risk of harm that a child may be experiencing, nor provided a framework for specific work with the family to address this.  There were no contingency plans if a strategy failed.     Page 37 of 48 13.1.3 It is of concern that all CSS workers quoted the same view that it was the parents’ responsibility to manage the risk.  This must have been based upon a culture generated within the organisation for it to be so forcefully quoted by so many people.    13.1.4 Within the DIAT team there was evidence that the threshold for a Section 47 investigation was matched to police thresholds regarding whether an offence could be identified.  CSS need to ensure they are the lead child protection agency and use decision-making criteria in line with KSCB Procedures.  13.1.5 There was no management oversight of the information received in respect of this child and particularly the information received on 24th and 25th June 2009.  13.1.6 The Panel was informed that the Director of Children’s Social Services had given instructions that a management investigation be conducted in this district to consider the practice issues which were identified from their own investigation and during the course of the Serious Case Review.   13.2 School  13.2.1 The School Support Team was a dedicated unit working to provide pastoral support and mentoring to students.  However, analysis shows little intervention from the senior management team within the school to address the growing concerns of the support staff or to ensure effective use of the escalation process.      13.3 Police  13.3.1 Daniel was deemed, at Inspector level, to be non-vulnerable.  A missing 13 year old is vulnerable by the very nature of his age.  13.4 Health Services  13.4.1 Within health services it appears that safeguarding was not routinely addressed as a specific element of supervision.    14. CAPACITY  14.1 CSS, the police and CAHMS all had capacity issues which impacted on the service provided and their potential for multi-agency working.  14.2 CSS provided evidence of a lack of capacity within the team to respond to an increase in referrals, at that time combined with a 33% vacancy rate.  A Principal Social Worker joined DIAT as part of a restructuring process without relevant experience and still carrying her own caseload from her previous role, further limiting her capacity.  The impact of a new database (ICS) was onerous and time consuming. These issues were identified as factors which impacted on practice in two previous Serious Case Reviews during a similar  Page 38 of 48 period in time. The recommendations of those Serious Case Reviews have been addressed and action has been taken in response.    14.3 The police were not able to provide an officer to enable a joint visit to be undertaken.  Availability to respond to a child protection issue cannot be neatly planned and there must be some spare capacity within CAIU to respond appropriately to emergencies.  14.4 CAMHS offered a very prompt response to the initial family crisis but having identified the need for family therapy there was a 5 month delay during which for 2½ months the case was classified as “urgent”.  The Health IMR suggested that CAMHS in this area had significant capacity issues and was under-resourced compared to other localities.  14.5 The Drug Treatment Service did not provide a full service to parents.  They indicated that this gap in service was being currently addressed.  14.6 Further resources in themselves would not have impacted on the tragic outcome in this case. There was a fundamental failure to grasp the responsibilities of Children’s Social Services. The thresholds for intervention were far too high. They were not based upon the child’s welfare or the significant harm that Daniel was known to be suffering.   Page 39 of 48  15 FINDINGS AND LESSONS LEARNT  15.1 Daniel’s voice was not effectively heard.  He was thirteen years old during most of this period but was more able than many young people articulately and persistently to present a consistent view that he was deeply unhappy living with his family.  Some professionals, notably the school, CAMHS and the worker from ARC, provided him with the opportunity to be heard and his school was vigorous in advocating for him.  However, when they encountered resistance from CSS they proved ineffective in challenging this.  15.2   Thresholds for intervention in the CSS Duty and Initial Assessment Team and the Children and Families Team were far too high.  Many opportunities to assess this young person’s needs were missed and his immediate need for protection was repeatedly left unaddressed.   15.3 There was confusion between thresholds held by the police for intervention for criminal investigation and those of CSS. The police were deferred to on a number of occasions, when determining how referrals would be treated, as though they, not CSS, were the lead agency.  15.4   The eligibility criteria for establishing significant harm or harm or the likelihood of significant harm were not considered to be reached in this case due to the incorrect view that any such harm had to be attributable to the parents.  Insufficient attention was given to the capacity of the parents to respond to Daniel’s complex needs.  15.5 Professionals did not challenge decisions even when they considered the child remained at serious risk of harm.  They did not appear to understand how to follow up or escalate their concerns using the procedures set out by the KSCB.   15.6 Assessments that were conducted were not holistic nor focused on the needs of this child.  Insufficient attention was given to the risks inherent in the behaviour he was engaged in, particularly his drug taking, sexual conduct, criminality and the regularity with which he was a missing person.  As a result of this there was no plan to address these immediate risks and referrals to other agencies did not specify this requirement.  15.7 CSS should have been the lead agency in this case at least from June onwards when it was undeniable that Daniel was suffering or likely to suffer significant harm.  The result of not taking lead responsibility and using it effectively was that there were a number of missed opportunities for effective multi-agency working.  15.8 Within CSS there was a lack of management oversight of this case in respect of the duplication of files for cases held on duty, the response to referrals, the allocation of this case to a then unqualified worker and the absence of an updated assessment and coherent plan.  There is insufficient  Page 40 of 48 evidence of reflective practice within supervision.  There is evidence that the “mantra” of the parents needing to take responsibility precluded the establishment of a positive working relationship with family and a sensible approach to the case.  15.9 Although there were attempts by CSS to use evidenced based practice to signpost this family to CAMHS and ARC, the lack of a robust co-ordinated plan and lack of assessment adversely affected the impact of these services.  The relationship between CSS and ARC did not sufficiently detail roles and responsibilities and led to false expectations of each service.  15.10   Daniel was not referred to the Drug Treatment Service by any agency although CSS, the school, CAMHS and ARC were aware of his escalating drug use.   SW1 and ARC understood that the school had taken responsibility for making this referral and this is accepted by the school.   15.11    Whilst communication from the school to all agencies was frequent and contained important information it was unfiltered from July 09 onwards and contained child protection information mixed with less important information.    15.12      The concerns expressed by CAMHS in July 2009 were such that the Consultant Psychiatrist suggested Daniel required a secure placement but these were presented in a general letter rather than a focussed referral to CSS. This letter was not seen by the DIAT Team Leader and the information was not therefore used to build a comprehensive picture of the increasing level of harm to Daniel.     15.13 There was confusion in respect of the different agencies’ use of the term “secure placement”.  The Consultant Psychiatrist confirmed that she had meant a placement that offered security when she used this term but the parents understood her to mean Secure Accommodation in the sense implied by section 25, Children Act. 1989.    15.14 There was an over optimistic view of the ability of Daniel’s parents to manage their son’s risk taking behaviour and to keep him safe.  There was insufficient analysis by CSS and CAMHS of the capacity of the parents to exercise their parental responsibilities in these demanding circumstances.  15.15 The employment background of the parents was not found to have influenced the service that either they or Daniel received.  15.16 The parents sought help from appropriate agencies; they regularly provided updating information and attended all appointments made for them.  Their analysis of the harm that Daniel was suffering was far more accurate than that of CSS.  There was no coherent plan that might have alleviated the anxiety they had about Daniel’s behaviour.  At one point a second ARC worker was offered, to provide support to the mother, but this was not part of a robust plan.   Page 41 of 48 15.17 The needs of other children in the household were not sufficiently considered in the assessments of CSS, although CAMHS did provide a more comprehensive service to the family.  15.18 Agencies appeared confused in respect of when and how to make referrals to CSS. They also appeared to be influenced by the lack of an adequate response to previous referrals.  The school, CAMHS, ARC and the police missed opportunities when they should have made a new referral.  15.19 Opportunities were missed to address the risk of sexual harm in the early stages of this case as the LSCB Procedures and Practice Guidance for Working with Young People who are Sexually Active was not used.  This may have formed the framework for continued assessment when concern was expressed at a later date that Daniel was at risk of sexual exploitation.   15.20 The police did not adhere to their policy in respect of missing persons. They did not demonstrate that they properly took Daniel’s age or his risk taking behaviour into account when they assessed him as “non-vulnerable”.  There were a number of missed opportunities for providing CSS with an informed risk assessment based on the information they held.   15.21 A significant gap in resources was identified in that no drug advice service is commissioned to work specifically with parents of this age group unless their child has already engaged with the Drug Treatment Service. Although The Drug Treatment Service report that they have given advice to parents in this situation this needs to be an expectation of a service rather than an ad hoc arrangement.   15.22 Given the level of identified risk Section 20 accommodation should have been considered by CSS at an earlier stage to provide a safe base whilst work was undertaken with Daniel and his family.  15.23 Some of these findings are not new and have been raised in a number of previous Serious Case Reviews in Kent and elsewhere.   There are many very basic issues ranging from a lack of understanding of significant harm to agencies not making a referral where one was clearly required. However this Review does raise significant issues in respect of the service that is provided to “harder-to-reach” adolescents where there is the additional dynamic of risk taking.   16. CONCLUSION  16.1 Daniel appears to have had a positive childhood until the latter part of 2008.  Little is understood about why his behaviour then deteriorated so rapidly but opportunities for early intervention were missed as agency checks and subsequent assessments were not coordinated, rigorous or based upon the information that was readily available.   In the early months individual agencies were working in isolation rather than to an agreed plan.   When the case was allocated under “Child in Need “arrangements in July 2009, CSS did not adequately take on their role as Lead Professional to achieve a robust  Page 42 of 48 plan for all agencies to address Daniel’s immediate needs and the harm he was undoubtedly suffering.  There were many missed opportunities, as agencies did not follow the procedures for identifying and reporting their concerns and did not challenge decisions when they viewed the response as inadequate.  16.2 It was predictable by July 2009 that Daniel’s behaviour and the risks associated with this would continue to escalate.  His drug taking further increased his vulnerability.  It cannot be concluded that a different approach would have prevented Daniel’s death but there may have been a different outcome had agencies complied with local guidance and basic professional practice expectations.                                                                                        Page 43                   Overview Report ‘Daniel’ Final                                       17. RECOMMENDATIONS  17.1 Introduction  17.1.1 Each of the contributing agencies made individual recommendations which can be seen in the action plan which accompanies this report.  These recommendations arise from the Overview Report which reflects the views of the SCR Panel and the independent Overview Report author. They have been endorsed by the KSCB.   17.2 Recommendations to the Kent Safeguarding Children Board  17.2.1 Thresholds must be applied in accordance with the procedural framework set by the KSCB.  17.2.2 There must be one agreed and recognised route for all referrals into CSS that is understood and adhered to by all professionals.  17.2.3 Management and supervision within all agencies should be in place to ensure practitioners are able to discuss complex cases providing clarity on safeguarding, managing risk, methods of intervention and adequacy of progress.  17.2.4 All professionals will follow the requirements set out in the KSCB procedures regarding the “Resolution of Professional Disagreement”, whenever they are not satisfied that a child is being effectively safeguarded.   17.2.5 KCT identify how agencies will respond to a small group of adolescents who are highly vulnerable.  17.2.6 Agencies must adhere to the KSCB procedures identifying a Lead Professional when required.  17.2.7 KSCB should clarify the status of the “Procedures and Practice Guidance for Working with Young People who are sexually active” identifying what is procedure and what is policy.  17.2.8 Professionals need to be clear about their use of the terms ‘strategy discussion” and ‘secure accommodation’ to ensure these are used consistently.  17.3 Recommendations to all agencies  17.3.1 Agencies must demonstrate in their assessments that the young person’s wishes and feelings are effectively heard in accordance with guidance contained in Working Together 2010.  17.3.2 All assessments should be holistic and regularly reviewed including the child’s needs, those of their siblings and parental capacity to provide care.                                                                                         Page 44                   Overview Report ‘Daniel’ Final                                      17.3.3 Agencies to report regularly to the KSCB on their capacity to meet the level of demand for safeguarding services.  17.4 Recommendation to Children’s Social Services  17.4.1 There must be clarity that “significant harm” does not have to be caused by a parent or carer but may be caused by the child’s own actions.  17.5 Recommendation to Children’s Social Services, Education, Police & Child Adolescent Mental Health Services (CAMHS)  17.5.1 Work needs to be undertaken to ensure effective working between CSS, the police, CAMHS, and schools in this district.  17.6 Recommendations to the Local Drug and Alcohol Team (LDAAT)  17.6.1 All professionals should be clear when to make a referral to the Drug Treatment Service when a young person is misusing substances.  17.6.2 LDAAT should review their commissioning arrangements to ensure there is adequate support for the parents of children who misuse drug.                                                                                            Page 45                   Overview Report ‘Daniel’ Final                                                                           APPENDIX A: SCR Panel Membership   Name / Designation Organisation Role Mr Donald McPhail Independent Independent Chair Designated Nurse Primary Care Trust Panel Member Child and Adolescent Psychiatrist CAMHS Panel Member Safeguarding Policy & Performance Manager KCC Panel Member Acting Detective Chief  Inspector  Kent Police Panel Member Designated Doctor Primary Care Trust Panel Member Safeguarding Manager, Education Safeguards Service KCC Panel Member Lead General Practitioner for Child Protection NHS Panel Member Head of Safeguarding Mental Health Services Mental Health Trust Panel Member Children’s Services District Manager KCC Panel Member Director,  Youth & Community, Support Services, Youth Offending Service Panel Member Integrated Services Manager KCC Panel Member Area Director Probation Service Panel Member Ms Carol Gallagher Independent Independent Overview Report author – in attendance                                                                                                   Page 46                   Overview Report ‘Daniel’ Final                                                                           APPENDIX B:  Terms of Reference  1) Each agency is asked to enquire into involvement with Daniel and his family from January 2009 to the present day.   2) Each agency to check for any significant relevant family history and background which helps us to understand the past and current situation including a critical analysis of the impact of the family dynamics on the care of Daniel.  3) Perform a critical analysis of work undertaken by your agency and how it contributed to the wider multi-agency response.  4) Consider whether your agency’s assessment and response was influenced by the fact the parents were health / social care professionals.  5) What was known by all the services in contact with Daniel about his substance misuse.  What was recorded?  Was a referral made, and if not, why not?  6) Were internal agency and local Safeguarding Children Procedures and protocols followed and acted upon prior to Daniel’s death (and concerns escalated appropriately)?  7) Whether or not multi-agency plans sufficiently reflected the level of need and risk and were effectively executed?  (paying particular attention to the request for Daniel to be accommodated and the request for ‘a secure social services placement’)  8) Identify the lessons to be learnt from this case in relation to the way in which local professionals and agencies worked together to safeguard and promote the welfare of Daniel.  On 25.02.10 these additional Terms of Reference were requested by the LSCB Chair.  9) This SCR needs to focus, in particular, on the quality and effectiveness of single-agency and multi-agency working in respect of this family.  It needs to explore the level, quality and timeliness of single and multi-agency assessment, planning, information sharing and joint working  10) Whether agencies responded with the correct degree of urgency to the unfolding, and deteriorating, situation.  11) Whether the interventions / services put forward by agencies were evidence-based, i.e. whether they were services / interventions that were known to be effective in addressing the identified needs.                                                                                              Page 47                   Overview Report ‘Daniel’ Final                                                                           12) The quality and level (management) of decision-making in respect of Daniel’s request to be accommodated and the recommendation for secure accommodation.   13) Whether there was clarity about who was the lead professional / agency.  14) Whether there were any resource issues that prevented or delayed particular responses / services.  15) Whether the views and wishes of Daniel and his family were adequately considered and weighed.  16) Whether there are indications that agencies could have intervened to help this family at an earlier stage in the development of concerns.  17) Whether those involved with Daniel were appropriately qualified and experienced.                                                                                                 Page 48                   Overview Report ‘Daniel’ Final                                                                             