Serious and prolonged sexual exploitation of a young person who was looked after under section 20 of the Children Act 1989. The young person had severe learning difficulties, her mother had arranged for her to live with family members and her father was in prison. She attended A&E frequently and often went missing from care. Issues identified include: unqualified staff; inadequate supervision; inadequate assessments; barriers to information sharing; a sense of helplessness by professionals in how to intervene to protect this young person and a lack of understanding about the complex relationships that sometimes exist between perpetrators of child sexual exploitation and their victims. Contains multi-agency and single agency recommendations covering: decision-making in regard to specialist placements for young people with complex needs; reviewing escalation policies; developing knowledge, skills and processes around child sexual exploitation, reviewing procedures to reinforce agencies' responsibilities around 16 and 17 year olds. Review was carried out in parallel to the review in respect of Young People 1,2,3,4,5&6 and this report does not seek to duplicate what was included there.
      
 Title:  The overview report of the serious case review in respect of Young Person 7. LSCB: Rochdale Borough Safeguarding Children Board Author: Sian Griffiths 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.                          RBSCB YP 7 Publication 20th Dec 2013    This report has been redacted for legal reasons   The Overview Report of the Serious Case Review in respect of  Young Person 7              This report has been commissioned and prepared on behalf of Rochdale Borough Safeguarding Children Board and is available for publication.       1    Contents                Page  Glossary 3 1 Introduction 4 1.1 Summary of circumstances leading to the SCR 4 1.2 Terms of Reference 5 1.3 Membership of the Serious Case Review Panel 8 1.4 Timescale for the Serious Case Review 9 1.5 Methodology 9 1.6 Parallel Processes 11 1.7 YP7 Contribution to the Review 12    2 : Factual Information  2.1 Genogram  13 2.2 Composite chronology of significant events 14 2.3 Relevant ethnic, cultural or other equality issues 14 2.4 Contextual Family Information 15 2.5 Information Provided by YP7 16    3. Summary of information known to the agencies during the timescale of the SCR 18 3.1 1111111111111111111111111111111111111111 1 3.2 111111111111111111111111111111111111111111111111 1 3.3 111111111111111111111111111111111111111111111111 1 3.4 111111111111111111111111111111111111111111111111 1 3.5 11111111111111111111111111111111111111111111111111 1 3.6 11111111111111111111111111111111111111111111111111 1 3.7 11111111111111111111111111111111111111111111111111 1 3.8 11111111111111111111111111111111111111111111111111 1 3.9 11111111111111111111111111111111111111111111111111 1 3.10 1111111111111111111111111111111111111111111111111 1    4 Critical Analysis 20 4.1 Introduction 20 4.2 National and local strategic approach to child sexual exploitation during the timeframe 20 4.3 Grounds for intervention by Children’s Social Care 21 4.4 Identification of CSE and resulting multi-agency response 28 4.5 Engagement with YP7 34 4.6 Long term planning and Review 36 4.7 Inter Agency Relationships 38 4.8 Managing Risk of Harm 1111111111111111111 40 4.9 The Impact of and responses to Race, Gender, Disability and Disadvantage 42 4.10 Could the harm to YP7 have been prevented or predicted? 45    2  5. Multi Agency Recommendations 47 6. Individual Agency Reports and Recommendations 48 6.1 CAFCASS 48 6.2 Children’s Social Care (Targeted Services) Rochdale MBC 49 6.3 Children’s Social Care (Safeguarding Children Unit) 51 6.4 Connexions Rochdale (Careers Solutions) 52 6.5 Early Break (Young People’s Drug and Alcohol Service) 53 6.6 GP Services Rochdale 55 6.7 Greater Manchester Police 56 6.8 Pennine Acute NHS Hospitals Trust 58 6.9 Pennine Care NHS Foundation Trust 59 11 11111111111111111111111111111111111 11 6.11 RMBC Strategic Housing Services 62 6.12 Schools (RMBC Children’s Services, Early Help & Schools) 63 11 11111111111111111111111111111111111111111111111 11 6.14 Heywood, Middleton and Rochdale PCT (Commissioning) 65  Endorsement of Rochdale Borough Safeguarding Children Board Chair  Bibliography                         3  GLOSSARY    FAMILY  YP7   Subject 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111  SIGNIFICANT OTHERS  An anonymised list of other family members can be found at the end of this report.   Other Acronyms:  A & E Accident and Emergency ACPO Association of Chief Police Officers CAF Common Assessment Framework CAFCASS Children and Family Court Advisory and Support Service CPS Crown Prosecution Service CSC Children’s Social Care FWIN Force Wide Incident Notice (Police record of incident) GP General Practitioner IMR Independent Management Review LSCB Local Safeguarding Children’s Board OFSTED Office for Standards in Education PCT Primary Care Trust PPIU Police Public Protection Investigation Unit RMN Registered Mental Health Nurse SCR Serious Case Review SCRP Serious Case Review Panel TOR Terms of Reference  4   1. INTRODUCTION  This Serious Case Review has been prepared in relation to Young Person 7 who experienced serious and repeated sexual exploitation as a child.  The purpose of the Serious Case Review is to identify whether agencies which provided services to this young person acted appropriately and whether lessons can be learned from YP7’s experience.  1.1   Circumstances that led to this Review  1.1 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 1.2 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 1.3 111111111111111111111111111111 referred YP7 to the multi-agency Serious Case Review Screening Panel which met on 13th February 2013. The panel recommended that a Serious Case Review should be undertaken and this decision was formally approved by the Chair of the Board.  As was required at the time, OFSTED and the Department for Education were informed of the decision to undertake a Serious Case Review on 20th February 2013. 1.4 The focus of the Serious Case Review was specifically to consider learning arising out of YP7 having been identified as suffering serious harm as a result of experiencing child sexual exploitation.  For this reason, the Serious Case Review was undertaken purely in relation to YP7 and not her siblings. 1.5 The Independent Chair and Independent Author who were undertaking the Serious Case Review in relation to YP1-6 also relating to child sexual exploitation, were appointed to undertake the same role for YP7. The Serious Case Review Panel (SCRP) was at that point established to manage the process with representation from the relevant agencies.   5  1.2   The Terms of Reference of the Review  1.2.1 The Terms of Reference for the Serious Case Review, which fully set out the scope and context of the Review are attached as Appendix A.  A summary of the Terms of Reference is as follows: 1.2.2  The Terms of Reference were established in line with the requirements of Working Together 20101, which states that a Serious Case Review must:  Establish what lessons are to be learned from the case about the way in which local practitioners and organisations work individually and together to safeguard and promote the welfare of children  Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result  Improve intra and inter agency working and better safeguard and promote the welfare of children 1.2.3 The Terms of Reference highlighted that: “The prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. The lessons learned should be disseminated effectively, and the recommendations should be implemented in a timely manner so that the changes required result, wherever possible, in children being protected from suffering or being likely to suffer harm in the future. It is essential, to maximise the quality of learning, that the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings are at the centre of the SCR, irrespective of whether the child died or was seriously harmed.” 1.2.4 In addition to the overall Terms of Reference the following Key Lines of Enquiry were identified for specific consideration by the Individual Management Reviews:                                                   1 Working Together 2010, which was the relevant version at this time, is the statutory guidance relating to safeguarding and protection of children. 6  Key Lines of Enquiry 1.  Recognition a)  Consider whether your organisation recognised that YP7 was a victim of child sexual exploitation and responded to her as such.  Comment on the effect of her challenging and 1111111111 behaviour on your agency’s understanding of her needs. b) Comment on your organisation’s ability to recognise child sexual exploitation at an operational level and to proactively intervene to safeguard victims and support their families c) When did your agency first recognise that  YP7  was subject to child sexual exploitation; and when did you identify that abuse as organised .What was the agency response following this understanding  2.  Intervention  a) Consider and comment on the timeliness and quality of intervention, including early intervention services, offered to the subject of this review by your agency. This should specifically include consideration of:- i. CAF process ii. Teenage pregnancy services iii. Children missing from home iv. Children missing from education v. Learning disability services vi. Physical disability services vii. Drug and alcohol support services viii. Mental health services ix. Schemes to divert young people from the criminal justice   system.  b) Consider and comment on the effectiveness and development of your agency’s strategic approach to CSE during the period of the review. c) Consider and comment on your agency’s ability to effectively provide appropriate services to the subject, which reflected both her welfare and safeguarding needs and also any risks she might pose. d) Consider the effectiveness of any services provided to the subject in relation to her own children, given the history of CSE.  This ToR does not seek to review the services provided to the subject’s children directly, but to consider any learning for services regarding the implications of the subject’s’ experience as she moved into parenthood.  e)  What protocols, policies and procedures nationally were in place that would have informed and guided operational staff when undertaking assessments, interventions and escalation in relation to this case f) Comment on the level and impact of managerial oversight, control and challenge to case work in this case  3.  Diversity  7  a) Did assessment and intervention at an operational level fully reflect consideration of ethnicity, culture, equality and diversity raised in this case?   4.  Partnership working  a) Consider what, if any, barriers existed within the review period to inhibit appropriate information sharing in both inter agency and multi-agency settings and identify the barriers to effective inter-agency and multi-agency working in this case. Identify any good practice examples of interagency work.   b) Comment on the interface between yours and any other agencies in determining the operational lead and subsequent actions to safeguard the subject of the review with consideration to the criminal/safeguarding threshold.   5. Context  a) Identify whether there were lessons available from contemporary serious case reviews (local and national) which, if learnt, would have better informed practice and decision-making in this case.     6 .  Overview Author Specific Terms of Reference:  Consider national direction and any relevant frameworks available to strategic leads and practitioners with regard to child sexual exploitation during the review period.      1.2.5 The Terms of Reference (ToR) identified that the time period for consideration by the Serious Case Review should begin at the point when YP7 first became known to the 111111111111111111 System1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111.   The ToR would finish at the point at which the Leaving Care services which YP7 was entitled to receive from the Local Authority ended, that is, after she reached the age of 21 years. 1.2.6 The agreed timescale was therefore:  November 2003 – Summer 2011 1.2.7 IMR authors were however specifically required to consider any relevant contextual historical information pre-dating the ToR that was available to them.  This was to be included as appropriate in summary form and used to inform their analysis of the services that had been provided. 8  1.3   Membership of the Review Panel The Serious Case Review Panel was made up as follows:  Agency or Organisation Role Audrey Williamson Independent Chair CAFCASS Head of Service, Greater Manchester,  CAFCASS Connexions(up to April 2013, when replaced by Positive Steps) Connexions Service Manager until April 2013 Assistant Director, Early Help and Schools, post April 2013 (commissioner) Early Break Chief Executive Early Help and Schools Head of Schools Greater Manchester Police  Detective Superintendent, Specialist Protective Services 111111111111111111111111111 11111111111111111111111111111 Heywood, Middleton and Rochdale CCG Designated Nurse for Safeguarding, Heywood, Middleton and Rochdale Heywood, Middleton and Rochdale CCG Designated Doctor for Safeguarding, Heywood, Middleton and Rochdale Rochdale Children’s Services Safeguarding Unit Manager  Rochdale Children’s Services Interim Assistant Director RMBC Strategic Housing Services Homelessness Service Manager Pennine Care NHS Foundation Trust Acting Head of Safeguarding Children Pennine Acute Hospital NHS Trust Head of Safeguarding 11111111111111111111 11111111111111111111111  Also in attendance at the Panel meetings were the following:  Sian Griffiths, Independent Overview Author  Rochdale Borough Safeguarding Children  Board Business Manager  Rochdale Borough Principal Solicitor or deputy  Administrator, Rochdale Safeguarding Children Board  Advisor from The National Working Group (Tackling child sexual exploitation), a charitable organisation formed from a UK network of practitioners working on child sexual exploitation. 9   Audrey Williamson is the Independent Chair of this Serious Case Review. Audrey qualified as a social worker in 1981 and is registered with the Health and Care Professions Council.  Ms Williamson has worked in Social Care in a number of local authorities in the North West and was a senior manager in both children and adult social care services before becoming independent in 2011. Ms Williamson is the Independent chair of Warrington, Halton, Cheshire West and Chester Safeguarding Children Boards.     Sian Griffiths is the Independent Author of the Overview Report.  Ms Griffiths works as an Independent Social Worker.  She is not employed by any Local Authority or Agency other than for commissioned pieces of work of an independent nature.  Ms Griffiths has been a qualified social worker since 1987, working both in the Probation Service as a practitioner and manager and later as a Family Court Advisor in CAFCASS.  Ms Griffiths is registered with the Health and Care Professions Council.  She has previously authored Overview Reports for Serious Case Reviews for a number of Safeguarding Boards and is accredited by SCIE to undertake Learning Together Reviews adopting a systems learning approach.  1.4   Timescale for undertaking the Review 1.4.1. This Review was commenced whilst a major Serious Case Review regarding child sexual exploitation (SCR YP1-6), was already ongoing.  It was agreed that the Review for YP7 should run in parallel to this larger review.  A decision was made by the Chair of the LSCB to appoint the same Independent Chair and Author who were undertaking the Review for YP1-6 so that the learning from the two Reviews could be linked most efficiently.  Given the complexity of the two Reviews it was agreed that completing this Review within a 6 month period, as normally required for a Serious Case Review was not practically possible.  The completion date for this Review was reviewed with the Chair of the Safeguarding Board periodically. A final completion date was set for one month after the presentation of the SCR for YP1-6 to the Safeguarding Children Board. 1.4.2. This Serious Case Review was presented to the Rochdale Safeguarding Children Board on 17th December 2013.  1.5   Methodology of the Review 1.5.1 This Serious Case Review was conducted in line with the requirements of Working Together 2010. The Review Panel was aware of the ongoing redrafting of Working Together and the development of a systems approach to undertaking SCRs.  The possibility of adopting such a methodology was considered, but following earlier advice from the 10  Department of Education  regarding YP1-6, the Review was undertaken in line with existing statutory guidelines, reflecting the method taken in relation to the SCR YP1-6.   1.5.2 The SCR Panel agreed that the framework for the Review should be that required by Working Together.  However, the underlying principles adopted as far as practicable reflected the Systems learning model as outlined in the recently published Munro Report.2  In particular IMR authors were encouraged to reflect with practitioners on the context of their decision making at the time, in order to maximize the learning from this review and to increase the focus on why things happened, not simply what happened and whether it met the required standards.  1.5.3 The Panel was explicit in its view that any early lessons identified during the Review should be responded to in practice without delay where this was possible.  Agencies were required to provide  the Panel and the Board with updates regarding any early learning during the process including a written update prior to the Overview Report being presented to the Board.  Where this was provided it is referenced during Section 5 of the Review. 1.5.4 The Panel requested and received Individual Management Reviews (IMRs) from the following agencies:   CAFCASS   Early Break  GP Services Rochdale  Greater Manchester Police  1111111111111111111111111111  Pennine Acute Hospital NHS Trust  Pennine Care NHS Foundation Trust (Community and Mental Health Services)  Rochdale Borough Housing   Rochdale Children’s Social Care (Targeted Services)  Rochdale Children’s Social Care (Safeguarding Children Unit)  Rochdale Connexions Trust  Schools  1111111111111 1.5.5 Additional information was provided to the Review by some of the services involved later in the process when gaps in the information in their IMRs were identified.  In particular some significant gaps in information and the detail of contacts were identified in the CSC IMR at a late stage in the process.  It was agreed that due to the time constraints at this point, and in order to ensure that independence was                                             2 Munro (2011) 11  maintained, the IMR author would undertake a limited review of CSC files written and electronic files as a result of which some further information has been included.    1.5.6 Information was sought from the following agencies who confirmed that they had no relevant knowledge of the family during the time period identified:  Hopwood Hall College  Action For Children  Barnardos 1.5.7 A Health Overview Report was commissioned from Heywood, Middleton and Rochdale NHS Primary Care Trust to encompass the IMRs of the two NHS providers listed above.  The report was authored by the Designated Nurse who was also a member of the Serious Case Review Panel.  1.5.8 The Serious Case Review Panel met on the following dates:  26 February 2013 (half day meeting)  8th May 2013 (half day meeting)  19th July 2013 (half day meeting)  20th August 2013 (half day meeting)  19th September 2013 (half day meeting)  22nd November 2013 (half day meeting)  6th December 2013 (half day meeting) 1.5.9 A meeting was also held on 12th March 2013 with IMR authors were also provided with individual feedback on their reports.   Authors had access to ongoing advice and support from Panel members and the Independent Chair and Author.  As a result all the IMRs were resubmitted following first drafts and several of the resubmitted IMRs provided a subsequently improved depth of learning. 1.6  Parallel Processes 1.6.1 Police investigations were ongoing during the period that this report was undertaken, including the possibility that YP7 would as a result become a witness in future court proceedings.   1.6.2 CSC have, prior to and during the course of this Review, undertaken a number of internal proceedings in relation both to managers and front line practitioners. The outcome of these proceedings has included disciplinary action and referral to the Health and Care Professions Council (HCPC), the regulatory body for Social Workers.  12  1.6.3 The other agencies which provided services to YP7 have confirmed that they reviewed the actions of individuals and concluded there was no basis for triggering internal proceedings.   1.6.4 The Local Authority had commissioned a report by an Independent Consultant which was published in May 20133.  The  primary purpose of this report was:  To highlight opportunities which the Council and its partners may take to reduce the risks and ensure the safety of children and young people within the borough of Rochdale.   To review the interactions and supporting processes within the Council departments and between the Council and external agencies.  1.7  Young Person 7’s Contribution to the Review 1.7.1 In line with the expectations of Working Together (March 2010) early consideration was given by the panel to seeking a contribution to the Review by Young Person 7.  Contributions were also sought from YP7’s parents.   1.7.2 The Chair of the Panel wrote to YP7 to explain that a SCR was taking place.  This was followed with a visit to YP7 by the Business Manager of the Safeguarding Board and a 1111111111111111111111111.  YP7 indicated that she would like to contribute to the Review and subsequently met with the Independent Overview Report Author and the111111111111111 Manager.  1.7.3 A number of attempts were made to contact YP7’s parents to offer the opportunity for them to contribute their views to the SCR.  However, although messages were left for both parents, neither responded to this request.                                               3 Klonowski, May 2013 13   2.1 Genogram    RBSCB YP 7 Publication 20th Dec 2013 2.2   COMPOSITE CHRONOLOGY OF SIGNIFICANT EVENTS  A full chronology of significant events was prepared to inform this review.  Each individual agency provided a chronology as part of their IMR and also provided brief historical information which whilst outside the timeline provided relevant contextual information for the Review.  2.3 RELEVANT ETHNIC, CULTURAL OR OTHER EQUALITIES ISSUES 2.3.1 In line with the requirements of Working Together, IMR authors and the authors of both the Health Overview and this Serious Case Review Overview Report were directed specifically to consider any particular issues of race, culture, language, religious identity or disability of significance to the family.   2.3.2 Those agencies which recorded information regarding diversity identified the family as white British or white English.   2.3.3 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.3.4 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   15 111111111111111111111111111111111111111111111111111111111111111111111111111111 2.3.5 YP7’s father told her school that YP7 was Roman Catholic, however she was recorded by her GP as Church of England. There is no other information to identify that religion was important in YP7’s life. 2.3.6 It was apparent that YP7 was brought up within a family which lived in economically impoverished areas of the borough where there was significant intergenerational disadvantage.  The 2010 Index of Multiple Deprivation results placed Rochdale borough as the 29th most deprived out of 326 districts in England (DCLG website4). 2.3.7 Information about the perpetrators’ race, culture and ethnic background as understood by the Services involved at the time, is limited.  There are a number of references to men as “Asian” without specifying what this meant, or indeed why it was considered significant to record it.  Within this review the term “Asian” or other references to race or ethnicity, will be used where it was the term used either by Services or by the subjects and their families.  Analysis of the use of this term and what it signifies will be included in Section 4 (Critical Analysis).    2.4 Contextual Family Information  2.4.1 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.2 Reference has been made by CAMHS to YP7 previously being looked after by another Local Authority, but no information has been identified to confirm this and YP7 herself said that her first involvement with CSC was when she was 1111111 .  2.4.3 There is also reference by a Social Worker in 2007 to a substantial file including several child protection referrals.  A file regarding the family predating the timeline for this Review has been identified and reviewed by the Independent Overview Author.  The records identify evidence of financial pressures within the family and a number of allegations of domestic violence. There are references to concerns about the children’s care, school attendance and supervision.  There were also two referrals regarding injuries, but medical opinion was that these were non-accidental and therefore no further action was taken.                                                4 https://www.gov.uk/government/organisations/department-for-communities-and-local-government    16 2.5   Information provided by YP7  2.5.1. YP7 met with the Independent Author of this Review in order to provide her views about the services that she had received. 2.5.2. YP7’s experience of being a Looked After Child was not a very positive one.  She feels very strongly that she was failed by CSC in particular and that, because of this failure, her later life has been badly affected, not least because her own child has been adopted and 11111111111111111111111111111111.  She believes that if CSC had taken proper care of her, she would not be in the position that she is now in. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 2.5.3. 1111111111111111111111111111111111111111111111111, YP7 had no recollection of being involved with CSC, although she said that her mother contacted CSC on several occasions when YP7 was younger, due to domestic violence perpetrated by her father.  YP7 first remembered having contact with CSC when she was 13 and her mother had left YP7 and her siblings to live with a family friend.  YP7 talked about the fact that she wanted to live with her father rather than her mother and that the main reason was that she knew her father would not try to make her go to school.  She said that CSC knew about what sort of a person her father was, that he had been violent to her mother and that he had been in prison, and she felt it was wrong for them to place her with him, even though that is what she said she wanted. 2.5.4. YP7’s strongest criticism of CSC was that they had not allowed her to live in residential care when she felt she really needed to.  YP7 spoke positively about the Residential Home in 1111111 , where she felt she had done well and where her behaviour had been much better. She remembered the system of gaining privileges for good behaviour, which she thought was good and that there was a therapist who worked with the children. At the end of the 6 month placement she had wanted to stay in the home, but had been returned to her mother in Rochdale.  YP7 believed she should have been allowed to stay in 111111111 at that time, but also that when her relationship with her mother broke down CSC should have put her back in residential care.   2.5.5. YP7 describes asking her Social Worker to let her go  back to the Home, but says that she was told that she could not go back into residential care as she was now 16 and the funding was not available.  This is something she feels really angry about.  She now believes that she should have been removed from Rochdale and that she needed to be somewhere safe. 2.5.6. YP7 had limited recall of other services, but did remember some professionals more positively.  She felt that the 1111 workers, Early    17 Break and CIT had been good to work with and when asked what it was about these professionals that she had liked, she said it was because they  stuck by her.  She knew that the 111111111 had been very flexible with her so that she was not taken back to 1111111.  She described the CIT team as helpful and said that she could talk to them and that the manager at 1111111111115 was good to her and would give her a second chance.  YP7 knew that her behaviour wasn’t always easy and clearly appreciated those professionals who did not give up on her. 2.5.7. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.5.8. YP7 did not like going to school.  One of the reasons was that she needed to have individual attention rather than being in a classroom which she did not get at school.  She contrasted this with help she was given by one of the 111111111111, who spent time working with her alone.  She also said that she had enjoyed the few months that she spent at college, but this did not last because of problems that she was experiencing at home which meant that she was homeless again. 2.5.9. YP7 gave a powerful description of her relationship with some of the men who abused her and why she would turn to them rather than to professionals.  “I thought they (the men) cared about me…….they (the professionals) go home at night to their families … I had no-one, I was in a kids home…..”   2.5.10. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111                                                         18 Replacement for redacted Section 3    3    INFORMATION KNOWN TO AGENCIES DURING THE TIMESCALE OF THE SCR As with all SCRs a comprehensive chronology was prepared and detailed the relevant contact episodes between YP7 and each agency. Each IMR and the Health Overview Report included a full detailed chronology and narrative containing all the information regarding the agencies’ involvement with YP7. The detail cannot be published for legal reasons.  This section therefore   provides a summary of YP7’s experience during the period under consideration. Section 4 will critically analyse the detail of events and contacts with agencies.  3.1. YP7 became known to Children’s Social Care (CSC) when she was 111111111111 and was living with a family friend.  Her mother had moved temporarily to another country returning only for very short periods of time.   YP7’s father served a number of custodial sentences and was for most of the period under consideration either unwilling or unable to care for his daughter.   3.2. It was known to the wide range of services that were involved with her that YP7 had very significant problems.    3.3. When the private arrangement with the family friend broke down, YP7 lived for periods with other family members but effectively became homeless and was placed for a short period in a local children’s home.  At this point it had become apparent to the agencies that she had been subject to child sexual exploitation by a group of men in Rochdale and elsewhere and within a matter of months was placed in a Secure Children’s Home.  No Care Proceedings were taken by CSC who believed that they could meet her needs with the agreement of her parents without applying for a court order which would have given them Parental Responsibility.  This approach was not supported by the other agencies. 3.4. In the absence of any family able to care for her, YP7 was placed in a residential children’s home in another county, where she remained for 6 months.  This was comparatively successful and she was felt to have responded well.  However at the end of the placement, CSC arranged for her to return to live in Rochdale, with her mother, who had moved back to the UK.   3.5. The arrangement for YP7 to live with her mother lasted for a very short period after which YP7 then spent a few weeks in supported accommodation in another county.  When this also broke down YP7 returned to Rochdale and for approximately the next two years was effectively homeless, moving repeatedly between friends, temporary accommodation and various hostels.      19 3.6. YP7’s circumstances during this period caused considerable concern for many of the agencies.  It was known that she was being abused by a group of men, initially a group of men later by a number of men who were only loosely connected with each other, if at all, that she had met in hostels or elsewhere.  3.7. YP7 became pregnant when she was 1111111111111.   A pre-birth assessment was undertaken by CSC and concluded that YP7’s child should be placed in foster care at birth, given the extent of YP7’s difficulties and the impact on her ability to parent her child.                                  20   4       CRITICAL ANALYSIS  4.1 Introduction 4.1.1. This analysis is based on the individual Agency contributions to the Review, discussions held within the SCR Panel and the author’s own contributions.  IMR authors were required to structure their reports using the Key Lines of Enquiry established within the Terms of Reference.   The IMRs provided for this Review contain a high level of detail and analysis regarding the actions of individual agencies, which will not be routinely replicated here.  However, where there appear to be gaps in individual agency learning these will be identified. 4.1.2. This critical analysis has considered all of the Terms of Reference, including the Key Lines of Enquiry which provided the working hypotheses for consideration within this review.  The analysis will begin with a brief summary of the context within Rochdale at that time and then consider in detail a series of decisions by CSC which were crucial in establishing the pattern of intervention for YP7 throughout the period considered by this Review.  This is considered to be at heart of the service provided to YP7.     It will then consider a number of overlapping themes which have emerged during this review as being key areas for future learning. The analysis will be structured by using illustrative examples to identify these themes.   4.1.3. This Serious Case Review was conducted in parallel with another, larger, Review in relation to child sexual exploitation (YPs1-6). A detailed scrutiny of the services provided to YP7 has been undertaking in order to ensure the SCR panel had a full understanding of YP7’s individual experience.  The Critical Analysis for this Review will not routinely repeat the themes and contextual information regarding the approach taken to CSE by the agencies in Rochdale which are fully examined in SCR YP1-6.  What is evident from the SCR regarding YPs1-6 is that the young people had remarkably similar experience of the agencies that worked with them, which is reflected once again in relation to YP7 Where issues of concern have been covered in depth by the Review for YP1-6 that Review will provide the prime source of detailed analysis, with this more focussed Review analysing the particular practice that was specific to YP7.   4.2 National and local strategic approach to child sexual exploitation during the timeframe. 4.2.1. The Serious Case Review for YPS 1-6 concluded that there had been significant weaknesses in the strategic leadership provided within Rochdale regarding child sexual exploitation.  In summary, there was a lack of effective prioritisation or focus at a strategic level which had a consequent impact on the response at the operational level, both in terms of agency recognition of CSE and of effective intervention.  Prior to 2007 there was no evidence of any leadership role taken by the Safeguarding Children Board with regard to CSE and none of the agencies had specific CSE policies.  In 2007 the Board set up a    21 Sexual Exploitation Working Group, which led to a decision in 2008 to develop a multi-agency team to respond to CSE in the borough.  This eventually became the Sunrise team; however this team did not become operational until 2010, too late to be relevant to the experience of YP7. 4.2.2. It is also important to note that understanding of child sexual exploitation at a national level in the early years covered by this Review was still quite limited.  Research and advice regarding CSE was available, although not necessarily easily accessible, and there had been a number of well publicised prosecutions in the North West.  However, Statutory Guidance6  referred to ‘child prostitution’ until 2009, language which is evidently reflected in the early stages of involvement with YP7.  4.2.3. In this context it quickly becomes apparent that the same gaps in leadership and understanding evident for YPs1-6 are also equally applicable in relation to YP7.  As such many, if not all, of the underlying contributing factors that helped explain why decisions were taken or not taken with regard to YPs1-6, are relevant to the service provided to YP7.  4.3 Grounds for intervention by Children’s Social Care    4.3.1. The history of CSC’s response to YP7 shows a pattern of confused and contradictory decision making.  There is a clear failure either to recognise the degree of YP7’s vulnerability and the risks that she was facing, or to accept statutory responsibility for managing her welfare and safety.  There were a number of points when there was an adequate, sometimes compelling grounds for statutory intervention which were not pursued, and which could and should have been recognised at the time. Throughout each of these episodes what is most noticeably lacking is any evidence of skilful, consistent supervision which ensured that the primary focus was on the child and that staff were effectively supported.  This lack of good quality management   provides some insight into why the quality of intervention was so ill conceived.   4.3.2. April 1111:  The first involvement of CSC with YP7 during the timeline for this review was in April 1111 when it came to their attention that YP7’s mother had handed over ‘full authority’ for % of her children to a family friend.  Initially CSC recognised that there might be a problem as to who had parental responsibility for the children.  An Initial Assessment was undertaken but   the quality is unknown.  What is known is that significant information was available at the time which should have led to questions as to whether YP7, and/or her siblings’ welfare was being properly met in this placement including:  School concerns re YP7’s behaviour, 11111111111, history of exclusions and assessment as having severe learning difficulties                                             6 Working together - ref    22  Allegations that Yp7’s sibling had been assaulted by her sister’s partner  YP7’s father serving a prison sentence.  No coherent reason as to why MYP7 was in %%%% or evidence that she was prioritising her children’s needs. 4.3.3. There is no evidence of any investigation regarding the allegation of assault on one of YP7’s siblings; no evidence of further enquiries, for example as to how long the mother had been in 1111111111 or why the father was in prison. There is no evidence that the assessing Social Worker spoke to the school, despite the fact that the School Nurse had specifically left messages. There is no evidence that the children were seen on their own as is required. The issue of Parental Responsibility remained unresolved and there appears to have been an acceptance that this was a private fostering arrangement without consideration as to whether this was in the children’s interests.  Given the unanswered questions about the arrangements, combined with what is known about YP7’s learning difficulties and her personal presentation a much more detailed assessment was clearly warranted. 4.3.4. The passage of time has made it more difficult to know precisely why this assessment was so limited.  However, the SCR for YP1-6 has identified that at this time there appeared to be a number of factors influencing the quality of practice in the assessment team of CSC, including: management oversight; staffing and resource problems, some of which led to problematic organisational responses; the competence of individual workers and a lack of a quality culture in some parts of the service.  A particular factor in relation to YP7 may also have been the perception of private fostering arrangements by CSC at the time.  4.3.5. Private fostering had become an increasing cause for concern at a national level, in particular following the death of Victoria Climbie case which highlighted the potential vulnerability of children living within such arrangements.  There was also national recognition that many Local Authorities considered that scrutinising private fostering was a low priority7 .  New statutory regulations were enacted in July 2005 identifying the responsibilities of Local Authorities; nevertheless there was already in 2004 a requirement on the Authority to check the suitability of such arrangements.  In this context it is possible that the assessing Social Worker was reflecting the culture or expectations of the Local Authority in not considering the possible risks within such an arrangement.                                                 7 Dept Of Health (2001)    23 4.3.6. Another opportunity to re-assess the case quickly re-presented itself in that within a matter of weeks the family placement was breaking down and there were further concerns about YP7’s behaviour, specifically that she was aggressive to other children in the family. The Social Worker recorded previous Child Protection referrals, 1111111111111111111111111111111111111111111111111111111111111 and was specifically asked by the family friend to take YP7 into care.  Instead of recognising or acknowledging that this was a young person at significant risk and therefore necessitated a Core Assessment, YP7 was allocated to a trainee Social Worker whose role appeared to be to support her move to live with her father on his release from prison.  The highly predictable breakdown of this arrangement meant that YP7 soon afterwards had to be found emergency accommodation, instead of a planned approach to her needs having been adopted.  4.3.7. At this point there was no-one effectively exercising Parental Responsibility for this 13 year old girl with complex needs.  Neither of her parents was able or willing to look after her, and the family or friends suggested as alternatives were evidently not stable or adequate for her needs.  It is therefore of particular concern that  the Local Authority did not pursue Care Proceedings which would have allowed them to share Parental Responsibility with the parents, but instead accommodated YP7 under S20 of the Children Act.  4.3.8. Becoming a Looked After Child under S20 requires the consent of those who have Parental Responsibility, generally, as in this case, the parents.  This can be withdrawn at any point, which given all the indicators that her parents were failing to care for her meant it was clearly inadequate as a safeguard for YP7.  Even were it not withdrawn the fact that neither of her parents was taking an active role in her care should have led to the conclusion that YP7 was a young person experiencing neglect. Again, this mirrors a feature of the SCR for YP1-6 where there was also a  failure to recognise neglect in relation to adolescents. There is a body of research evidence to suggest that this is a comparatively widespread problem (Rees et al, 2011; OFSTED 2011) and this has been identified as one of the areas for attention as a result of the SCR for YP1-6.  4.3.9. It is also of note that on at least two occasions it was recorded by the Social Workers that there were discussions with the Police about a possible offence of Child Abandonment by the mother.  There is however no information as to what advice was given by the Police to CSC and no evidence of a Strategy Meeting given that this was a potentially serious criminal offence. It is a weakness in the information provided by the police that there is no information about this episode and therefore whether they met their safeguarding responsibilities.  For the next few months any intervention by CSC appears reactive and purely short term.   4.3.10. Until this point there does not appear to have been any direct evidence of child sexual exploitation, but it became very clear during    24 YP7’s stay at the children’s home is 111111111111 that she was being abused by older men. Although this was not, as far as is known, specifically understood as sexual exploitation. Given YP7’s age, both chronologically and developmentally, this should have led to a Strategy Meeting and a comprehensive assessment of her welfare. There is no explanation as to why there was no Police or multi-agency investigation at this time and again, Greater Manchester Police have been unable to find any information about this incident.  The subsequent decision by CSC simply to close the case at the point when YP7’s Aunt in 1111111111 refused to be assessed as a carer was an unacceptable abdication of responsibility, given all the evidence that suggested YP7 would go missing again and would continue to be at risk.  4.3.11. Judging to what degree the approach taken by CSC was the result of confused decision making by an inexperienced, unsupported worker or a conscious decision at a management level to avoid taking formal proceedings so as to secure her legal position remains unknown.  However, given information regarding the management position taken over subsequent months, it is highly likely that the (trainee) Social Worker was following instruction from her managers.   Whatever was the immediate reason for the decision, the lack of proper case management which focussed on the needs of this child represented very poor practice. 4.3.12. Minimal evidence has been found at this time as to the routine managerial oversight of this case or that  the student social worker receiving regular planned supervision, which would have been vital to ensure accountability and quality of service.  After the case was closed there was occasional contact between the Social Worker and YP7’s family and with other agencies.  The one recording of supervision identified three actions including a planning meeting – but no reference to this being followed up or reviewed.  The approach was primarily to ‘monitor’, an intervention which risks being very passive. Over the following months despite further referrals and sharing of concerning information by other agencies, these did not lead to any child protection investigation. 4.3.13. The CSC IMR has highlighted that the practice of allocating such a complex case to a student social worker without very close supervision and support was unrealistic and has made a recommendation to CSC as a result.  Although there is no evidence that would suggest it was understood as a complex case. 4.3.14. April1111 :  The second significant episode in relation to CSC began in April 1111 following a particular episode when YP7 was missing from home; she was accommodated by CSC in a local Children’s Home again under S20 of the Children Act.  The impression given by  the events leading up to this, is that it was ultimately the urgency to find somewhere for YP7 to stay, the only remaining option being a residential children’s home, that led to her becoming  accommodated under S20 and therefore a Looked after Child.       25 4.3.15. There was now a growing body of concern regarding sexual exploitation, self-harm, substance misuse, injuries to YP7, difficult and at 111111111111111 by YP7.  Irrespective of whether CSE was fully recognised and understood, this was a child who was at serious risk of harm.  It was evident that YP7 had no-one in a caring position who could meet her needs and no reason to believe that this would change within any reasonable time frame.  Neither was there evident understanding that YP7 was experiencing profound neglect.   Finally, there is no record of any discussion as to whether she may have met the threshold for instigating Care Proceedings. 4.3.16. The inaction by CSC at this point was evidently difficult for other agencies to understand.  Whilst the CSC IMR tells us that there was regular phone contact with MYP7 in 1111111 there is a lack of any detail as to: the nature of these discussions; how consent to accommodate her was established and what assessment was made of MYP7’s parenting.  However, a series of e-mails between SWTM1 and CSCSM/AD has since been seen by the Overview Author and these provide insight into the approach being taken at a senior management level to YP7’s case.  It is apparent from the e-mails that the focus at this point was on sending YP7 to live with her mother in 1111111111.   4.3.17. Plans were discussed for commissioning an agency within 111111 to visit and ‘say if it is ok’.  The intention appeared simply to be to check the accommodation and there was no evident reference to other factors.  What is of significant concern in both this and other internal exchanges is a lack of apparent focus on the risks to or needs of YP7 as an individual, but instead a focus on the organisational priorities and risks.  There are inappropriately dismissive references to the legitimate concerns of other agencies and an informality of tone that is surprising and unacceptable when considering the needs of a vulnerable child.   4.3.18. June 11111 :  The risk and vulnerability factors already identified were increasingly evident during the following couple of months that YP7 was accommodated in Rochdale.  Evidence of sexual exploitation was increasingly alarming and YP7 was routinely missing from the home.  Despite this, although there is reference by other agencies to the possibility of a placement out of Borough, there is no evidence from CSC of a fundamental re-appraisal of their approach or of their duty towards YP7.  However because of the deteriorating circumstances, a decision was made in June 2005 to seek an order for YP7 to be accommodated in  a Secure Unit 4.3.19. What is of further concern is that despite having made an application for a Secure Order, the Local Authority absolutely resisted all suggestions that they should apply for a S31 Care Order.  Options that were being considered by CSC were viewed both by other agencies at the time, and by this Review, as inadequate to protect YP7 and considerable pressure had to be exerted before agreement was reached to find a residential placement out of Borough.  At the    26 same time the Children’s Guardian, was making a strong case for a Care Order which was dismissed as manipulative.  There was also a   clear indication by the Judge at the end of the Family Court Proceedings in November 2006 that a Care Order would be necessary if YP7 left the therapeutic placement which had eventually been agreed for her. Nevertheless, once again CSC relied on S20 to enable them to accommodate YP7. 4.3.20. June 111111:  After a period of around 6 months in Residential Care out of Borough, a decision was made to return YP7 to her mother’s care.    The placement was believed to have been a success and YP7 appeared to have stabilised to some extent.  The decision was therefore made to return her to her mother’s care with no statutory involvement from CSC other than providing her with the support she was entitled to as a child leaving care.     SW11 explained that both YP7 and her mother had wanted her to be returned and this was always the intention.   4.3.21. Given that YP7’s mother had effectively abandoned YP7 previously and in the absence of any assessment as to how she would be able to meet her child’s needs or keep her safe, this decision was not defensible.  What was required was a proper analysis of YP7’s current needs, in what way she had been stabilised, and whether the features that contributed to this improvement could be replicated if she returned to live with her mother in Rochdale.  What was absent was any evident understanding of the risks YP7 might face in Rochdale, from which she had been to a great extent protected from whilst she was out of the Borough.  This decision is described in the CSC IMR as “almost impossible to understand”.   In the context of the  clear direction that was being given by senior managers not to pursue care proceedings or a long term placement, the rationale becomes much easier to understand. 4.3.22. Within three months of her return to Rochdale YP7 there were reports that YP7 was being sexually exploited and she had left her mother’s care saying that she had been physically abused by her.  Again, this should have triggered a re-assessment as to whether YP7 could be kept safe but also whether her basic physical and psychological needs were being met.  However for the next 18 months no statutory safeguarding processes were invoked and instead, YP7 was only provided with support as a care leaver. The growing chaos, damage and distress that YP7 was living with did not lead to a rethink by CSC who appeared to be focussed entirely on attempts to get YP7 to take responsibility for her own welfare and safety 4.3.23. Again, the Review lacks direct information about the process of the Social Workers’ decision making throughout this period.  However, what is known is that a very strong direction was being given at a senior management level both regarding possible Care Proceedings and the option of long term residential care level.  It is also the case that discussions regarding YP7 at a management level take as their starting point the cost implications, rather than her needs.  One    27 comment states that “whilst she needs support to enable her to protect herself, she is also of an age where she carries some of that responsibility”.  This fails to recognise not only the dynamics of child sexual exploitation but also YP7’s developmental age and her capacity to manage her life without the support and protection of anyone taking parental responsibility.   An e-mail to the team manager from the Service Manager in 2007 states: “she has reached the age where anything other than secure accommodation can equally be made accessible as an eligible or relevant young person”.  It is the case that most services could be offered to YP7 if she was considered a ‘care leaver’ rather than a child in care, and she could chose to accept these services or otherwise.  However, what  this fails to acknowledge is that YP7 was a young person for whom no-one had exercised parental responsibility for several years, who remained vulnerable to abuse and was by no rational analysis at a point where she was ready to move into independence and protect herself.   4.3.24.  An issue of considerable concern which was identified in relation to YP1-6 was that priority for intervention at the time was focussed very largely on babies and young children, rather than on adolescents.  One of the ways in which this manifested itself was through a CSC policy, ‘Supporting Children and Young People to Remain within Their Family’ which was issued in September 2006 and therefore illustrates senior management thinking in the preceding months.  The policy was known colloquially as the ‘non-accommodation’ policy, and gave a very strong steer away from providing long term placements for young people.    4.3.25. There is evidence within this Review that the cost of funding a therapeutic or other long term placement was a very significant feature in the decision making by Senior Managers.  YP7 informed the Review that she was specifically told that it was because of funding that she was not able to stay longer in her placement in 1111111111111 or be placed elsewhere.  In the internal communications between managers the issue of funding often appears to be the primary consideration for decision making. 4.3.26.  Long term therapeutic placements are punishingly expensive for Local Authorities, who may have very limited means to fund such placements.  Further it appears to be politically impossible for an authority to acknowledge that an individual child may not receive a placement due to the resource costs.  As a result one response is to take a range of other steps to avoid the option of funding long term care, such as attempting to manage the young person’s needs in the community even in the face of considerable evidence that this is unlikely to succeed. There is no information to indicate whether prior to September 2006 there was a multi-agency approach towards decision making regarding placements for young people with complex needs, or any joint commissioning to plan for and fund such placements.      28 4.3.27. It appears therefore that there were a number of significant factors contributing to what can only be judged as inadequate practice.  Such factors  include:  Resource problems leading to organisational needs significantly impacting on case planning for individual young people  lack of agency focus on the needs of adolescents  Social Worker inexperience, capacity, confidence or skill  Poor quality or absent supervision  Lack of understanding of the dynamics of child sexual exploitation  Unrealistic expectations on family’s capacity or willingness to care for YP7  Unrealistic expectations on Yp7’s capacity to care for herself. 4.3.28. By examining these episodes in detail it is possible to see the primary importance of CSC in contributing to YP7’s experience and in shaping the overall multi-agency approach.  However, other aspects of practice played their part, not least the degree to which other agencies played an effective part in challenging, or formally escalating their concerns and the apparent lack of any means to agree a multi-agency approach to the funding of any specialist care that might be required. 4.3.29. Two recommendations have been made as a result of these identified weaknesses: Recommendation 1 and Recommendation 2    4.4 The identification of CSE and resulting multi-agency response 4.4.1. With hindsight we can now identify a number of indicators that YP7 may have been experiencing child sexual exploitation from the outset, including: symptoms of sexually transmitted infections and YP7’s statement that she had had a number of sexual partners at the age of 13.  These could not necessarily have been expected to lead to consideration of  CSE at the time given the level of awareness across agencies in 2004.  Nevertheless that this degree of sexual activity in a 13 year old girl with developmental delay did not raise a greater sense of curiosity or alarm is of concern.  One of the important issues for learning arising out of the SCR for YPs1-6 was the need for greater focus on safeguarding in these circumstances, particularly in relation to sexual health services.  This is highlighted once again with YP7. 4.4.2. The first specific reference to sexual exploitation is at a professionals’ meeting in April 2005 and from this point on it is a concept that is quite frequently referred to, although it was not known to all the agencies. It appears however that there was little understanding of the nature of  CSE including the persistence of the offenders and  its impact on victims and the nature of their responses. On a number of occasions references are made to YP7 having been a victim of CSE in the past    29 with an implication that it was now over.  What evidence there was for this conclusion is not clear and given what we now know about the nature of CSE was, with hindsight, unrealistic. What was understood by all the agencies was that she continued to be at risk. 4.4.3. There were repeated indicators from 1111111 when YP7 returned to Rochdale that either directly identified or suggested that YP7 was still experiencing the exploitation.  In the earlier stages this is most apparent in relation to her involvement with a group of Asian men where there were indicators of a degree of organisation.  Later in 2008 and 2009 there is evidence of various men, whose race is not identified, who appear to have exploited her in a more opportunistic way.  This was taking place in the context of YP7 believing these individuals were genuinely concerned about her or as being part of a loose group, it seems predominantly male, based 1111111111111.   The agency response was typically to try to encourage YP7 to keep herself safe either because her inability to do so as a victim of CSE was not understood, or because agencies were resigned to working with her in the community with little resources, guidance or  knowledge as to how they could effectively respond to the exploitation she was experiencing. 4.4.4. The degree to which different agencies recognised and understood the levels of risk varied over time and between agencies.  A common feature acknowledged by  all three of the health IMRs was a pattern of responding to YP7 in relation to her clinical need without a more holistic approach being taken with regard to her wider welfare needs.  There is for example no evidence that GPs at any point considered that YP7’s presenting symptoms might be indicators of sexual abuse or CSE. In attempting to understand why this was the case, the IMR recognises that GPs, along with other professionals had little knowledge about indicators of CSE at this time.  4.4.5. Another reason that GPs may not have questioned YP7’s circumstances  or followed up information provided to them by other health professions, was that  they were aware she was a looked after child and therefore assumed that this information was known to CSC and there was no need for them to contribute.  It should not be concluded that greater involvement of the GP Service would automatically have led to a different outcome.    Had, however, the GPs become more proactively involved, this should have led to a better analysis as to what was happening, but could also have introduced a new professional perspective including the potential for another challenge to the position taken by CSC. These underlying explanations for the lack of a proactive approach by GPs have led to recommendations within the IMR.  In taking forward these recommendations the  Review would particularly underline the importance of not making assumptions about what is or is not known by others and recognising the potential value of GPs as part of a wider team working in a child’s best interests, rather than as individuals dealing with individual clinical need.     30 4.4.6. It is also the case that the hospital held significant information that  could have better highlighted the nature of the risks that YP7 was facing.  Information was shared with other professionals including CSC, but this was inconsistent and there was little evidence that hospital departments, particularly the   Accident and Emergency Department and the wards where YP7 was then treated, recognised that she might be a victim of CSE.  The IMR for Pennine Acute Health Trust, clearly identifies opportunities to intervene which were missed  to intervene as a result of YP7’s repeated attendance at A&E – 17 occasions in a period of 15 months.  Again, recommendations are made for the Trust as a result. 4.4.7. In 2007, there was explicit recognition that YP7 was one of a number of young women experiencing exploitation by a linked group of offenders.  This led to three strategy meetings instigated by CSC in 11111111111111 2007 specifically in relation to the multiple abuse of vulnerable young people.  These meetings have been described as representing the first step leading to the recognition of the need for a joint approach to CSE and the development of the Sunrise Team in Rochdale.  Whilst this is undoubtedly the case, progress in 2007 faltered quite quickly.  Although a police investigation was initiated, YP7’s case was not ultimately one of the young people subject to the investigation.  The reason for this is recorded by the IMR as being due  to YP7’s unwillingness to co-operate.  After the three initial meetings, no further strategy meetings were put in place and there was no other structured means for sharing the information. 4.4.8. Whilst these Strategy Meetings had clearly begun to identify the pattern of CSE in the Borough, what was missing was ownership and direction from a senior level in the statutory agencies. In the absence of the involvement of   and leadership by senior managers who were able to take decisions about resourcing and who could have ensured that these issues were considered at the Safeguarding Board, the process was fundamentally flawed.  In reality the meeting predominantly involved those professionals already directly working with the young people.   4.4.9. Information was shared between agencies during this meeting.  However, a barrier arose which had a significant effect both on the police investigation, particularly relating to YP7 but also on the wider approach taken.  The Crisis Information Team Co-ordinator was unwilling to share the names of the young people they believed were experiencing CSE at the first meeting.   CIT took the view that the victims should remain anonymous or they would be placed at further serious risk of physical assault and intimidation.  The investigating Police Officer although clearly frustrated by this did not feel able to challenge what appeared to be the ‘expert’ view of the Crisis Intervention Team.  CITC was subsequently informed by senior management within the Trust, including the named nurse for child protection and the Deputy Director for Public Health that the information should be shared, and this is noted within the April meeting.  However, the information was then only shared verbally and    31 the list of names returned to CIT at the end of the meeting. The actual e-mail sent by the Deputy Director for Public Health was not as clearly worded as it should have been as to exactly how the information must be shared.  However, of more significance is that having taken the unusual step of giving CITC a direction regarding a particular course of action there is no information as to whether any  of the relevant managers followed up this direction to satisfy themselves that their instruction had been followed. 4.4.10. It is also evident from the notes of the meeting that CIT were strongly of the view that victims should not be contacted directly at their homes, and that most of the victims would not engage with the police.  In effect this meant that CIT was in the position of screening the victims who could be approached.  CITC also made it a pre-condition that the police would undertake surveillance.  It is noted that CIT considered that “there is a culture of fear or a misconception about the nature of the relationship between the girls and the men, which could make it impossible to break through”.  There was some dissension to this rather fatalistic view, including by Early Break and Legal Services, who both suggested other ways to intervene. However, the combination of the position taken the CIT and the view of the Police that a direct complaint was necessary to progress any prosecution effectively created a further obstacle in attempts to intervene.  It is now recognised by the Police that this ‘traditional’ model of investigating is not effective in cases such as CSE and requires a much more creative approach and better understanding of how to engage with victims.  4.4.11. It is clear in minutes of the meetings that there was a desire by the police to establish a multi-agency approach to this investigation, and that attempts were made by the Detective Inspector in charge of the PPIU to pursue this, but at this point these attempts were unsuccessful.  In the absence of proper resourcing, it was not possible for one investigating officer to effectively pursue such a complex investigation, including the expectation of surveillance, or to take a lead in the development of a multi-agency approach.  The failure by the police force at a strategic level to prioritise CSE in the Borough at this time has been considered in detail in the SCR regarding YP1-6 and has been accepted by the police.  However, during this Review GMP has also identified that a Serious Case Review (Child A) was published in Manchester in 2007 which specifically identified child sexual exploitation and recommended that this become a strategic priority for the force.   GMP’s resulting action plan was: 1.  Commission the Force Intelligence Bureau to scope the extent of the problem force-wide.  By June 2007. 2.  Determine a force wide response to tackling CSE by September 2007 4.4.12. What is now apparent is that little if any progress was made by GMP in relation to these actions and the opportunity to learn from the    32 Serious Case Review in relation to Child A was not pursued.  Why this was the case remains fundamentally unexplained, leaving the only conclusion available to this Review that this was not a priority for the force at that time.  4.4.13. Nevertheless, it was also the case that none of the other agencies took action to pursue these strategy meetings or attempted to establish an alternative multi-agency approach.  There is no evidence that any of the other agencies sought to challenge the GMP decision not to resource a complex investigation into CSE at this time.  Neither was there any evidence that Senior Managers in Health or Social Care, or through the Safeguarding Board, who were aware of these meetings taking place, took any proactive approach as a result.    Instead agencies continued to deal with the problems of CSE on an individual case by case basis.    4.4.14. The absence of any multi-agency forum or co-ordinated, strategic approach, meant that opportunities to develop more creative ways to deal with CSE were not available to practitioners during the timeline relevant to YP7, for example; disruption techniques; information sharing; awareness raising; joint approaches to the victims; management of confidential information.  4.4.15. Investigation of CSE as a wider phenomenon in the Borough was unable to progress effectively at this time; however other allegations continued to be made either directly by YP7 or by agencies on her behalf.  These often could not be progressed given a lack of information about individual perpetrators.  However, there were also a number of occasions in relation to YP7 were information about assaults on YP7 was held by agencies and individuals but not reported to the police or to CSC, meaning that opportunities either to investigate criminal offences or to undertake strategy meetings were lost.  Examples included:   YP7’s first presentation at 13 years and nine months of age with a disclosure of sexual activity  YP7  telling staff at the sexual health clinic (CIT) that she had had unprotected oral and anal sex, sometimes against her wishes and that the men would hit her if she refused.   YP7 disclosing to CIT and  a Connexions worker  that a man had poured petrol on her and threatened to set her alight because she refused to perform oral sex.  4.4.16. Whilst it is not possible given the passage of time to identify absolutely why such individual decisions were made, two  factors that are likely to have impacted on decision making can be seen at work.  Firstly there appeared to be a sense of helplessness amongst agencies about intervening to protect YP7, as is so clearly evidenced in relation to the 2007 Strategy meetings.  It is also the case that practitioners, including  the CIT workers and the Connexions worker referred to above, did on other occasions pass on information or make    33 referrals  which appeared to lead to little formal action by the statutory agencies.  Examples included:  11111111111111111111111111111111111111111  Injuries to YP7’s ear in 2005  Allegations of abuse against YP7’s father. However when these concerns were not responded to with a similar level of concern, this appeared to result in a sense of resignation by agencies.   4.4.17. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111.  Whilst it is apparent that agencies understood and were concerned for YP7’s wellbeing, there was limited evidence that they felt they were in a position to take action to protect her, given the perception that she placed herself in these settings by choice.  One of the agencies, Rochdale Borough Housing has identified that staff working in11111111111111111 , although often very skilled at engaging with residents, have to some degree become desensitised to what risks are viewed as ‘normal’ , seeing them as something that their client group may not be able to avoid. This once again linked with a tendency to refer to YP7’s lifestyle, or making choices, which is a fundamental misunderstanding of the response of victims of sexual exploitation. 4.4.18. That there was a lack of action at a number of key points also needs to be understood in the context of the development of knowledge about CSE.  Again this mirrors the learning from the SCR for YP1-6 where more detailed analysis is to be found regarding the developing research and practice knowledge in this field. The degree of control exerted by the perpetrators in now much more widely understood. In particular the research identifies that in order to survive traumatic and potentially life threatening experiences, victims may behave in ways that appear contradictory, for example returning to their abusers.8  For many young people the perpetrators may also be the only people that they have an attachment to, which even though it is damaging and dysfunctional acts as a powerful draw for the young person as YP7 herself described:  I thought they (the men) cared about me…….they(the professionals) go home at night to their families … I had no-one, I was in a kids home…..”  Breaking this cycle of re-victimisation is likely to require a long term multi-agency approach including in many circumstances the removal of the young person from the perpetrators sphere of influence for a significant period combined with therapeutic intervention. 4.4.19. A further incident necessitates comment, although it was not directly related to child sexual exploitation.  YP7 was placed at one point by CSC in private bed and breakfast accommodation and  whilst in this accommodation 111111111111111111.  That this had not led to any                                             8 Lodrik (2007)    34 comment or investigation either at that time or within the IMR has been a cause of concern.  Despite a specific request from the Overview Author, agreed by the SCR Panel,  limited further information has been provided by 111111111, whose IMR noted this incident,  as to how this was responded to or what the future implications might be for using this or other private providers. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.5 Engagement with YP7 4.5.1. Developing positive professional relationships with young people whose behaviour may be 111111111111, abusive, difficult to understand or rejecting, requires significant reserves of skill, empathy and support.  There is no doubt that YP7 was a highly complex individual, who presented an often contradictory mixture of assertiveness and vulnerability.  This was a young person who had experienced some degree of abuse and neglect as a child, who had been explicitly rejected by her parents, who had developmental delay and had been sexually exploited.  Her behaviour and her vulnerability also clearly led to a high level of anxiety and concern on the part of several of those working with her. 4.5.2. Despite this, and to some extent in contrast with the experience of the young people in SCR for YPs1-6, many of the professionals involved showed a considerable degree of concern and empathy for YP7, even though it was more difficult to achieve good outcomes.  These included Early Break, CAMHS, the Behaviour Improvement Practitioner, the Manager at 111111 and Connexions.  The health visitor for ChildYP7 also showed tenacity in attempting to maintain contact and engage YP7 in order to involve her fully.  Many of these professionals offered levels of contact, or prioritised YP7’s  needs in a way which was a step beyond expected practice.  One of the factors that is identified by the Early Break workers was that they felt supported by their organisation and managers in their work, but otherwise the Review has been provided with limited information as to what enabled these workers to maintain a positive empathetic approach. 4.5.3. Between 1111 when she returned to live in Rochdale and 1111111111111111111111111111111 the two services which had the most significant regular contact with YP7 were the CSC Young People’s Support Team which provided leaving care support and the 111111111111111111111111111111111111111111111111111111111111111111111111111111111  What is evident is that both services  provided a very high level of support, sometimes daily or even several times in one day.  Much of that support was in providing practical help, particularly relating to her very unstable housing position.  What also emerges however is that there was a significant difference in perspective between the two agencies as to the approach to engaging    35 with YP7.  It should be acknowledged here  that the Review has not been provided with the full detail from the perspective of  the Young Person’s Support Team, nevertheless there is enough information to allow some analysis. 4.5.4. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.5.5. What is apparent over a considerable period of time is that this mini team demonstrated a high level of empathy and care towards YP7 and attempted to work with her on a variety of levels, from providing practical help with independent living, to working with her on self-esteem.    To some degree they stood in the space where a parent should have been, providing support, attempting to establish boundaries, managing difficult behaviour, encouraging independence, listening to her when she was in distress and attempting to provide her with skills for survival.   4.5.6. It was evidently not easy to maintain this level of support, faced with YP7’s often childlike responses and inability to respond to structure.  That they were able to do so appears to have been in part due to the team approach and a willingness to work flexibly.  There was evidence also of a willingness to have difficult discussions with YP7 and a capacity not to allow themselves to be thrown off course by YP7’s unsettled and unsettling responses.  However, managing this balance was evidently difficult for the practitioners at times.  What appears to have been missing was an explicit management or supervisory structure within which their efforts could be reviewed, the impact assessed and alternative approaches considered.   In particular strong and thoughtful management could have ensured that the work of this team was more effectively linked with CSC  and could have taken a lead in co-ordinating the exit strategy and her transition into adult services. 4.5.7. The approach taken by the Young Person’s Support Team was much more focussed on moving YP7 into independence.  There was clearly a high level of activity by the YPST, not least in relation to YP7’s accommodation.  What is less apparent is whether there was an understanding or sense of empathy about the complexity of her situation.  What is more apparent is an increasing sense of  frustration with YP7’s repeating pattern of  behaviour and inability to ‘keep herself safe’. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   36 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. To what degree this mindset was a result of the individual experience, skills and capacity of the workers, or their support and working environment is difficult to assess. There is however, no evidence of management support or challenge and given the prevailing view identified by other workers and, possibly more significantly, senior managers within CSE that YP7 should accept responsibility for herself within a very clear timescale, it may not be surprising that individual workers adopted a similar approach. 4.5.8. Little information has been provided about the commissioning of a package of leaving care support for YP7 in11111111111 .  It would appear that at this point the YPST stopped having direct contact with YP7 instead receiving weekly updates from the provider.  It had been acknowledged that the numbers of professionals working with YP7 was often counterproductive.  The thinking behind this decision to introduce new workers at arm’s length is unknown, but there were inherent risks.  There is a well-established body of evidence that children value continuity in their relationships9 (introducing a change in professionals in this way might further impact on the quality of the relationship between YP7 and her worker at YPST.  There were of course other inherent risks, particularly in relation to information exchange with other key agencies.   4.5.9. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 4.5.10. It is apparent that there is a gap in the confidence, skill and knowledge base in working with adolescents, something which was also a feature of the SCR for YP1-6.  A consequential recommendation has therefore been made (Recommendation 3)  4.6 Long term planning and Review 4.6.1. At the front line much of the intervention with YP7 appeared  to be reactive, for example responding to individual episodes of crisis, clinical need or allegations with no overarching ,shared understanding of what outcome agencies were working towards or how they would be achieved.  That this was the case will have been due in no small part to the lack of a comprehensive assessment of her needs from the outset. As has previously been considered interventions were often                                             9 Munro (2011:32),    37 based on a complete misconception of YP7’s needs and capacity and at the practice level often seemed hard to understand.   4.6.2. YP7’s comparatively successful stay at the residential home in 11111111  could have provided information  an important opportunity to understand  what interventions might be successful in the future and therefore shape future planning.  However, it would appear that there was no sophisticated analysis of what this period meant in terms of the long term needs of YP7.  Instead Children’s Services appear to have assumed that because the placement was viewed as ‘successful’ it paved the way for rehabilitation with her mother.  Why it was successful, for example the degree to which the level of containment, structure and therapy at the placement were the reason for this success, and whether this could be sustained away from the placement does not appear to have been considered.  4.6.3. However, at a senior level within CSC there was a clear plan identified for YP which was to rehabilitate her to her mother’s care at the age of 16 and from that point the only intention was to respond to her as a care leaver.  Research10 has identified the existence of very common patterns in human reasoning, which can lead to poor decision making, particularly when those decisions are being made in highly complex work environments.  One of these common patterns is an unwillingness to reconsider our initial judgement about a situation, even in the face of new and contradictory evidence.  Recent analysis by Eileen Munro11 and others has applied this approach to understanding decision making within social care.  Although it is perhaps most commonly thought of in relation to front line practitioners, the same problematic patterns of human reasoning can be seen in operation by Senior Managers in CSC regarding YP7.  These managers reached an early conclusion as to what course of action was required, and even in the face of continuing or new opposing evidence were unwilling or unable to change their minds.  A particularly stark example of this can be seen in a letter from a CSC team manager to the CIT co-ordinator which argues, against empirical evidence that YP7 should be returned to her mother’s care:  “You raise your views that YP7’s mother has made little attempt to address her vulnerability or to meet her health needs, evidencing her failure to accompany YP7 to a health appointment when she was last home.  All of this is of course factually correct …..however it now appears that mother has changed her position and she is finally taking responsibility for YP7”   There was nothing to demonstrate that the mother had changed her position, only her assurances, which given the previous history could not be seen as adequate without supporting evidence.  This highlights                                             10 Woods et al (2010), Dekker, S (2006), 10  11 Munro (2008), (2011)    38 that the need for challenge and reflection across all levels of decision making within an organisation, and is not only  a requirement for front line practitioners. (see Recommendation 1)  4.6.4. That some agencies frequently struggled to plan effectively should be understood in the context of CSC’s decision not to take decisive action to protect YP7. An example identified by the Homelessness Service was that different agencies had different views about the sort of accommodation YP7 needed, making a challenging situation even more complicated.  Without primary safeguarding action by CSC it is difficult to envisage what plans could have been put in place to keep YP7 safe.  4.6.5.  Neither was there any clearly established means by which the agencies could co-ordinate their efforts.  Groups of professionals at different times organised meetings to consider particular  concerns or plans.  However, by their nature these did not consider YP7 holistically or have a route by which they could feed in to a more comprehensive planning process.  In the absence of one agency taking ultimate responsibility for drawing the threads together, the reality of anything up to 13 different agencies, with changing staff members attempting to work together was likely to have limited success.  4.6.6. Theoretically, even in the absence of a care or Child Protection Plan, CSC could have been expected to take the lead in planning.  However, it becomes evident that the 1111111team were in effect the lead role in the day to day work with YP7 and this was at times openly acknowledged by the Young People’s Support Team.  However, the 111111 team did not have access to the range of options available to CSC which might have kept YP7 safe or otherwise improved the outcomes for her.  In effect partner agencies were required to work with YP7’s complex problems without the tools to keep her safe.  4.7   Inter-agency relationships 4.7.1. The numbers of agencies involved combined with the level of contact many of those agencies had with YP7, meant that comprehensive information sharing would not be a realistic expectation. Nevertheless there was evidence in relation to several of the agencies and key practitioners of a good level of routine information sharing, discussion and joint meetings.  It is apparent that several of the agencies worked closely together and within smaller groupings attempted to co-ordinate and plan some of their work.  Following YP7’s 1111111111111111111 there is evidence of very well co-ordinated working between 1111111111111111111111111111111111111111111111111111, 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 very good level of liaison between the social worker and 11111111111111 staff in11111.    39 4.7.2. What however is also evident are some significant tensions between several of the agencies and CSC.  There were clearly fundamental differences between CSC and other agencies about the approach to working with YP7.  None of the other agencies appears to have supported the CSC position and this is particularly illustrated at the professionals’ meeting in April 2005.  There was evident frustration from other agencies about what they felt was a lack of progress in safeguarding YP7, frustration which the Social Worker’s manager felt had been unfair to the practitioner.  However well these tensions were or were not managed within the meeting, what it reveals is the lack of recognition by the CSC manager that there was a legitimate concern about the direction being taken.  The defensiveness of the management position, and the dismissive attitude towards other agencies that is displayed in her subsequent internal communications, was clearly recognised by other workers and acted as a barrier to constructive working, including appropriate professional challenge. 4.7.3. Other evidence of these tensions which can be seen include:   Frustrations when professionals not invited to meetings by CSC  Criticism by YPST of 111111 approach to their work, including an accusation that the 11111111111 approach was purely designed to “cover their backs”.  Disputes as to whether Connexions or YPST should lead on education and training.  111111111 worker implicitly criticising CSC for not properly informing YP7 about the pre-birth process.  CAMHS identifying in 11111111 that CSC should take the lead. 4.7.4. It is not in itself entirely unusual, or necessarily problematic, for there to be some tension between the perspectives of CSC and the Guardian within court proceedings. However in this case there was a particular degree of negativity towards the Guardian which was far from conducive to managing legitimate professional disputes in relation to YP7.  The Guardian’s view that the Local Authority should take Care Proceedings was, on all the evidence, asserted quite properly, however, internal communication between managers described the Guardian’s actions as manipulative.   4.7.5. The level of concern by the Guardian and her manager about the lack of protective action that had been taken by CSC, was so significant that in 1111111  a decision was made to write to the Head of Child Care Services in his role as Chair of the Area Child Protection Committee12 to request that a Serious Case Review be undertaken. It is understood that at that time there was no sub group whose role it was to make this decision.  Instead a decision was made, apparently by the Head of Child Care Services alone that there was no need to undertake a Serious Case Review.  A letter was sent to CAFCASS by                                             12 The Area child Protection Committee (ACPC)  was the body responsible for co-ordinating multi-agency child protection work, which pre-dated the creation of Safeguarding Children Boards.    40 the interim service manager on behalf of the Head of Childcare Service stating that this was being considered but asking why this had not been raised previously. Subsequent internal e-mails in October confirm that a decision had been made not to  undertake a Serious Case Review. There is no evidence that the CAFCASS manager pursued this any further. 4.7.6.  Whether this approach was the most constructive way of achieving change for YP7 merits some consideration given the level of tension that was already evident between the two organisations.  Having initiated the process and not it would appear received a satisfactory answer, it is surprising that this was not pursued further.  CAFCASS has informed this review that it is standard practice for this approach to be taken, but no further information has been provided.  It  was clearly legitimate for CAFCASS to escalate their concerns.  However whether seeking a Serious Case Review which is intended to provide lessons from past practice to inform future practice as a means to deal with concerns about a young person’s current situation may not be the most effective way of achieving the required outcome.  A recommendation has therefore been made by the Overview Report that CAFCASS review the effectiveness of this practice in achieving change. 4.7.7. What does not remain entirely explained is why the Guardian finally accepted the Local Authority’s view that there was no need for Care Proceedings.  It is noted that this was due to the return of YP7’s mother to the UK and the fact that she was said to be working constructively with the authority.  The IMR concludes that professional standards were met, but in the absence of a more detailed analysis this decision appears inconsistent given the history of MYP7’s parenting and the level of concern that was raised by CAFCASS. 4.7.8. What was significantly absent was effective challenge to CSC or escalation of agency concerns.  Evidence from this Review and that of YP1-6 suggests that one of the reasons agencies seemed unable to successfully escalate concerns was their experience of the inappropriately negative attitude taken at quite a high level by CSC.   That this sort of approach was taken by CSC is of significant concern both for the wider damage it causes to effective multi-agency partnership working, but also because it can lead to poor decision making in relation to individual cases not being reconsidered at an early stage.  Given the potential significance of this issue to the outcome for YP7 2 related recommendations have been made by the Overview Author: Recommendation 1&4.    4.8 Managing Risk of Harm 11111111111111111 4.8.1. The relationship between YP7’s involvement with the 11111111111111111 and the Child Protection system was a significant issue for consideration at the outset of this Serious Case Review and was identified as such within the Terms of Reference.     41 The Review wished to understand the degree to which the two systems worked together and in particular whether there was a proper balance of focus in relation to YP7 as a young person who had offended but also  as a young person in need of protection.  The SCR Screening panel was aware of wider debates at a national level about the degree to which young people who are victims of child sexual exploitation can become criminalised as a result of that exploitation, and the possibility that victims’ 111111111111 is more visible to agencies than the fact that they are being abused. 4.8.2. It is clear from this Review that agencies whose primary focus was to work with YP7 in relation to her 11111111111, also fully understood that YP7 was a child with complex welfare needs and worked with her on this basis.  There is considerable evidence that both the 1111111111111111111111111111111111111111consciously worked as part of the multi-agency child safeguarding partnership and balanced this with their primary focus on 111111111111111.  1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.8.3. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.8.4. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111    4.8.5. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   42 1111111111111111111111111111111111111111111111111111111111  111111111111111111111111111111111111111111111111111111111111111111111111  1111111111111  1111111111111111111  11111111111111111111111111111111111111111111  1111111111111111111111111111111111  111111111111111111111111111111111111111111111111111 4.8.6. 11111111111111111 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   4.9   The impact of and responses to Race, Gender, Disability  and disadvantage  4.9.1 As has also been found to be the case with  YP1-6 a thread that ran through much of the response to YP7 related to the understanding and professional confidence with regard to issues of diversity.  YP7 like the other young people faced particular pressures and barriers due to structural disadvantage and personal attributes.  4.9.2 Many of the features that played such a significant part in the understanding of YP1-6’s experience are repeated with regard to YP7.  Particular analysis has been provided in the SCR for YP1-6 regarding attitudes both towards the perpetrators and towards what    43 has been frequently described as the young people’s ‘lifestyle’ and are  equally relevant to YP7.   4.9.3 As was the case with Yps1-6 there is no evidence to suggest that there was an unwillingness by practitioners or agencies to make referrals about the abuse, because the men were ‘Asian’.  However, the regular reference to perpetrators as ‘Asian’ men without any explanation as to what this terminology signified or what it implied, is particularly noticeable in  YP7’s case, given that other men’s racial background or country of origin is never referred to.      What was absent both in the case of YP7 and of YPs1-6 was any attempt to understand why the fact that many of the men were “Asian” might  or might not have been relevant and legitimate for consideration.  In particular there is no evidence that practitioners asked questions as to why quite well established social and racial boundaries were being crossed so frequently.  This issue has been considered in more detail in the SCR for YP1-6, but in summary what it suggests is a lack of awareness by practitioners and a lack of confidence in articulating and analysing their responses with regard to race. Once again reflecting the young people subject to the related SCR what is  clear in relation to YP7 is that whatever the origin of the perpetrators, agencies ultimately seemed unable to intervene to prevent the abuse.  4.9.4 A key feature that in varying degrees was known to or recognised by all the agencies concerned was that YP7 had some form of learning difficulty or developmental delay.  Eventually it was assessed that this was very significantly a feature of her social and educational experiences with little evidence to suggest an underlying Learning Disability.  Whatever the cause, this highlights the degree to which education systems during YP7’s early years seemed unable to meet YP7’s needs or to access appropriate support for her from an early stage in her school life.  It is evident that the school at which YP7 was a pupil during the timeline for this report tried a number of interventions to help YP7, but there is little evidence as to how successful these interventions were.   By 11111 the Headteacher stated that a mainstream school was not suitable for her needs.  However it is unclear what options for a specialist school were considered,  rather than the decision to a move to the Pupil Referral Unit.    4.9.5 Although agencies were aware of her difficulties, there was a mixed approach in the degree to which interventions with YP7 were adapted in order to meet her needs. Practical advice had been provided to agencies following the assessment by CAMHS as to how best to communicate with YP7.  Whether this was put into practice is difficult to ascertain.  4.9.6 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   44 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111  4.9.7 One possible explanation for this, may be that as described in the Pennine Care IMR: “On paper YP7’s learning needs did not appear that severe even though, in practice, the combination of difficulties that she had (learning, memory, concentration, managing her emotional responses) disadvantaged her considerably.”    More worryingly in relation to the response by the Young People’s Support Team, there is some reason to believe that there was a failure to understand the significance of YP7’s learning difficulties and their complex link with her emotional and family experiences and instead to focus on attempts to change her behaviour, by insisting that she take responsibility for herself.  Whether this reflected poor skills and knowledge base is unknown, but once again, there is no evidence of management intervention to question or help improve practice.  4.9.8 111111111111111111.11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111    4.9.9 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   45 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111  4.9.10 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111   4.9.11 A question that was raised very significantly in relation to YP1-6 was whether the background and class of the young people affected professionals’ expectations as to their future options and what was normal for them to experience.  During the period of more than 4 years that YP7 was living in the community that is considered by this review, the level of harm and abuse she was exposed to is particularly shocking and again raises the same question.   Whilst there is much evidence from this Review to suggest that professionals were frequently distressed and worried for YP7, that they did not think what was happening to her was acceptable, ultimately however, there was perhaps a sense that there was little further they could do.  If this sense of helplessness in the face of young people  living with  brutal  and traumatising experiences is to change it will need an absolutely clear and consistent message from the highest level of each of the agencies that if that experience is not be acceptable for our own children, it will not be acceptable for any children.   4.10 Could the harm to YP7 have been prevented or predicted? 4.10.1. As was the case with YP1-6, it is evident that the weaknesses in practice identified within this Review reflected not just the agencies’ approach to child sexual exploitation, but also to significant underlying problems within routine safeguarding practice. 4.10.2. There is little doubt that a radically different course of action than was taken in relation to YP7 was required from as early as 2004.  Had proper protective action been taken when YP7’s situation was first brought to CSC’s  attention, this would have provided: opportunities to better understand what was happening in her life; to identify a placement most suitable for her needs and with the greatest potential for a positive outcome; opportunities to address her significant    46 emotional and developmental difficulties; 11111111111111111111111111111111111111111111111111111   Most crucially it could have provided her with a place of safety.  4.10.3. There could be no absolute guarantees that YP7 could have been kept completely safe nor that the damage caused by her early negative experiences could have been reversed.  However, without decisive action it should have been clear that the outcome for YP7 was unlikely to be anything other than a negative one.  It was known by 2005 that YP7 was experiencing sexual exploitation and there was no rationale for considering that this would simply stop in the foreseeable future.  By 2008 it was painfully evident that YP7 was routinely exposed to significant risk of harm and that that harm could be catastrophic.   The corrosive combination of her life experiences clearly could not equip her to live independently, safely or in a way which allowed her basic needs to be met.   4.10.4. There were both strengths and weaknesses in the response of all the agencies.  However, the conclusion of this Review must be that CSC, the agency with the primary responsibility for protecting YP7 from serious harm failed to protect her from continuing harm.      47  5  MULTI  AGENCY RECOMMENDATIONS  5.1.  The individual management reviews for each of the agencies involved in providing services to YP7 have identified relevant recommendations for their own agencies as a result of this review and additional recommendations have also been included arising out of this Overview Report.   5.2. This Serious Case Review was completed within a matter of weeks of the  Serious Case Review in relation to YP1-6  who were also subject to child sexual exploitation.  A conscious decision has been made within this Review only to produce multi-agency recommendations which  focus on the  learning particular to YP7’s experience rather than in relation to each identified weakness in service, particularly when these are lessons reflected in the SCR for YP1-6.  RBSCB has clearly recognised that the learning from these two reviews needs to be linked together. 5.3. The multi-agency recommendations for Rochdale Borough Safeguarding Children (RBSCB) are therefore as follows: Recommendation 1: RBSCB to use the developing mechanisms for auditing and review of safeguarding practice, in order to identify evidence of improvement in multi-agency working, including the acceptance of the legitimacy and importance of inter-agency challenge. Recommendation 2:  RBSCB to assure itself that the role of agencies in decision making regarding specialist placements for young people with complex needs, is properly understood.  Further, that commissioning, whether joint or single agency, results in an appropriate range of options being available Recommendation 3:  111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 Recommendation 4: The RBSCB to undertake a review of its escalation policy and satisfy itself that that partner agencies have effective escalation policies which are used as intended. Recommendation 5:  The RBSCB to request a report from 111, CSC and Rochdale Borough Housing regarding the quality of accommodation available to vulnerable young people.  The report to  consider whether additional policy and procedures are required in relation to risk assessments being undertaken prior to placements and staff’s responsibility to report and take action on concerns.   A further recommendation has been made as identified within the schools IMR for the wider schools network:    48 Recommendation 6:  The leadership role of the primary and secondary head teacher representatives on the Safeguarding Board needs to be strengthened  in order to effectively deliver   key safeguarding messages to all head teachers in the borough through  the head teacher network meetings and in liaison with the Education  Safeguarding Lead.   Detailed responses and action plans with regard to the Multi-Agency Challenges and Recommendations become the responsibility of the Board.  6   INDIVIDUAL AGENCY REPORTS AND   RECOMMENDATIONS  Each agency through the production of its IMR has identified learning and provided recommendations for that agency.  A number of recommendations, relating to relevant areas of learning had already been made by many of the agencies as part of the SCR for YPs1-6 and therefore have predominantly not been repeated here.     6.1      CAFCASS: Children and Family Courts Advisory and Support Service  6.1.1. CAFCASS has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Service Manager, National improvement Service. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family, and  as such met the criteria for independence. 6.1.2. The Report was countersigned by the National Child Care Policy Manager who had no direct knowledge or involvement with the services provided to YP7. 6.1.3. CAFCASS provides advice to the courts and make provision for children to be represented family court proceedings.  CAFCASS had two periods of involvement with YP7.  The first when a Children’s Guardian was allocated to YP7 in relation to the Local Authority’s application for a Secure Accommodation Order. The second was in 2009, when a Children’s Guardian was appointed to represent ChildYP7 in the Care proceedings. 6.1.4. No recommendations have been made by CAFCASS in the light of learning already considered within the related SCR regarding YP1-6. 6.1.5. A recommendation has however been made by the Overview Report Author that: CAFCASS review the effectiveness of its practice in referring cases of current concern for a Serious Case Review in the light of this  Review.    49   6.2      Children’s Social Care: Targeted Services  6.2.1. Rochdale CSC has provided a chronology and Individual Management Review for this Serious Case Review. 6.2.2. The report has been prepared by an independent consultant commissioned by Rochdale MBC due to lack of capacity to provide an IMR author internally.  6.2.3. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family, and  as such met the criteria for independence. 6.2.4. The Report was countersigned by Assistant Director  who had no direct knowledge or involvement with the services provided to YP7. 6.2.5. CSC: Targeted Services provides a range of services to children who are assessed as “in need” or at risk of significant harm, including assessment at the point of referral, services for Looked after Children, after care and family support. 6.2.6. During the later stages of the Review it became apparent that significant information was missing from the CSC IMR.  Given the time constraints and the importance of maintaining independence, the Independent Overview Author reviewed relevant CSC files for YP7 in order to ensure that as complete a picture as possible was available for the Overview Report. 6.2.7. The recommendations for action for CSC are as follows: 1. CSC should further introduce measures to ensure that all practitioners working with young people have a good working understanding of the nature and dynamics of child sexual exploitation and are able to improve the quality of risk assessments.  2. CSC should ensure that  procedures, processes and review systems are in place to promote effective multi-agency planning in child sexual exploitation cases.  3. There should be a clear mechanism within CSC for the Strategic involvement of Senior Managers in organised child sexual exploitation scenarios.  4. CSC should have clear guidance on the management of extra familial child sexual abuse cases.  5. CSC should undertake regular case audits to ensure that the needs of children are at the core of work undertaken and based on the child’s journey.     50 6. CSC should have very clear standards and guidance about the circumstances, if any, in which non-qualified social care staff undertake qualified social worker tasks.  7. There should be regular auditing of files, with reports to the LSCB, on supervision within CSC. This should encompass the “challenge” role of supervision.  6.2.8 As a result of the learning arising out of this Review for and that of YP1-6 the following actions have been put in place by CSC:  The effective and early identification and addressing of child sexual exploitation is a top priority of local authority and is included in the Service Improvement Plan and the CSE Strategy which are report to the Children’s Safeguarding Board.  A new quality assurance framework has been developed and is in place.  This framework which uses auditing, direct observation and service user feedback to monitor the effectiveness of recognising and includes due regard to the issue of child sexual exploitation.  In addition, a constant theme of auditing activity focusses on historical information informing assessments, SMART planning and the extent the ‘voice of the child’ is evident in decision making and planning.   A revised supervision policy and guidance was launched in August 2013, which includes a programme of regular auditing activity by middle and senior managers to monitor the quality and effectiveness.   A learning workshop has been held for all managers responsible for the chairing of Child Protection Strategy Meetings and a good practice tools distributed.   A critical case briefing protocol and guidance has been issued to all managers/staff and implemented.  In addition a weekly caseload report is produced for all managers to monitor the workload of staff and ensure remedial action is taken where required.   A bespoke learning and development package has been produced for all practitioners and managers in recognition, assessment and response to child sexual exploitation and intra-familiar abuse.  Roll out has started and is a part of the mandatory induction programme for all news starters.  All children referred to Children’s Social Care are screened for risk for child sexual exploitation.  The development of a bespoke placement service for vulnerable young people who are at risk of CSE is being led by the Local Authority Commissioning Manager for Placements.     51 6.3      Children’s Services: Safeguarding Children’s Unit  6.3.1. Rochdale Children’s Social:  Safeguarding Children’s Unit Care has provided a chronology and Individual Management Review for this Serious Case Review. 6.3.2. The report has been prepared by an independent consultant commissioned by Rochdale MBC due to lack of capacity to provide an IMR author internally.  6.3.3. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family, and as such met the criteria for independence. 6.3.4. The Report was countersigned by the Head of Safeguarding  who had no direct knowledge or involvement with the services provided to Child A, B and C. 6.3.5. The Child Protection Unit Reviewing Service was responsible for providing Chairs for Child Protection  and Independent Reviewing Officers  for Looked after Child (LAC) Reviews  6.3.6. The recommendations for the Safeguarding Children Unit are as follows: 1. The IROs need clarification of their role and further development of their quality assurance role.  2. The specific role of the Reviewing Officers in “Strategy Meetings” should be clarified.  3. Management arrangements need to be in place to ensure that there is an appropriate escalation within the Reviewing Service, when there are concerns about safeguarding issues.  4. Children who have been or are being sexually exploited should be assessed as children in need or in need of protection and offered services to support them where appropriate.  5. Where there are ongoing child protection issues for looked after children, a CP Plan must be built in to the LAC Planning process and monitored through the Reviewing system.  6.3.7   The Safeguarding Children Unit has identified that within the timeframe of the Review and since, there has been a number of changes at the safeguarding children unit which correspond with recommendations made within the review.  A new agenda and template of minutes for conferences provides greater scrutiny of child protection cases and to the wishes and voice of the child or young person.  Advocacy  service for Rochdale children has been extended  to support children who are subject to child protection plans and the advocate has supported children to either attend conference or to have their views clearly stated. Reports from the advocate are produced with recommendations for the senior leadership team.      52  The unit has appointed a quality assurance officer who has introduced a new quality assurance framework to ensure that there is regular feedback from both conferences and from looked after reviews for, children and parents. The reports produced from this feedback are shared at senior management team meetings to ensure that gaps in service are addressed and themes are reviewed again at regular intervals to examine progress.  The unit has increased  ts capacity with the introduction of a team manager for the IRO and conference review service and three additional IRO’s to ensure that case loads reflect recommendations within the IRO handbook and IRO’s are able to greater  develop their quality assurance and challenge role.  The unit has introduced an escalation procedure in relation to child protection conferences and has reviewed the dispute policy for looked after children. Monthly reports of the escalations are produced and themes are identified and actions agreed via the senior management team.   The unit has carried out  a review of its business processes to ensure minutes are distributed within agreed timeframes  The new Greater Manchester Safeguarding Procedures have been adopted which clarify the role of the strategy meeting  6.4     Connexions Rochdale (Careers Solutions)  6.4.1. Connexions Rochdale has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Service Manager.  The author has had no operational responsibility in the case or any direct involvement with the Young Person and her family and as such met the criteria for independence.   6.4.2. The Report was countersigned by the Head of Targeted Services at Careers Solutions.   The countersigner had no knowledge or involvement of the services provided  to YP7 or her family. 6.4.3. During the course of this Review, the service provided by Connexions was transferred to Positive Steps.  Both companies have made a commitment to share the learning from the Review and the action plan will be taken forward by Positive Steps. 6.4.4. Connexions Rochdale provided Education/Training and Employment advice and support YP7 on a number of occasions.  The service included routine careers advice within schools as well as more individualised support.  6.4.5. The recommendations for Connexions/Positive Steps are as follows:     53 1.  Client intervention notes and information received from/passed on to other agencies need to be thorough and detailed to ensure other workers conducting future interventions have a clear understanding of clients’ circumstances.  Additionally it is vital that time is taken prior to an intervention to read previous contact details. 2. Where Advisers raise concerns about clients with their Line Manager, there needs to be a clear process of follow up of agreed actions being undertaken. 3. The need for an escalation procedure internally and externally which clarifies the process to be followed when liaising with partners.  6.4.6 The following actions have already been taken in relation to the learning from this review:    Team Managers conduct verification audits twice a year for each Adviser, which focus on ensuring documentation recording of client interventions are completed to required standards and this will include checking that where information has been received from or passed on to another agency, a key contact from that agency is identified and any agreed actions have been followed up.   The client database has in place an ‘alert’ system should there be issues that Advisers  need to refer to prior to conducting future interventions.    Although all Connexions Advisers received CSE briefings during July/August 2012 , CSE refresher training  is being arranged with RMBC for all Advisers during January 2014.   Positive Steps  has completed a programme entitled Safeguarding Month in which staff from all directorates within Positive Steps had to opt for up to 4 training sessions around safeguarding themes, one of which had to include the mandatory ‘ ensuring client safety’ session.  6.5     Early Break (Young People’s Drug and Alcohol Service)  6.5.1. Early Break has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Area Business Manager and Safeguarding Lead for Early Break East Lancashire.  The author has had no operational responsibility in the case or any direct involvement with the Young Person and her family and as such met the criteria for independence.      54 6.5.2. The Report was countersigned by the Chief Executive.   The countersigner had no knowledge or involvement of the services provided to YP7 or her family. 6.5.3. Early Break provided advice and support regarding alcohol and use to YP7 for three separate periods during the timescale.  .  6.5.4. No new  recommendations for Early Break have been made as the learning reflects recommendations that were made in the SCR for YP1-6, which were as follows:   Recommendation 1: Early Break to establish a formal process for the dissemination of learning from SCR  Recommendation 2:Early Break to review its current locality based process for recording and reporting of CSE. These to be recorded in one central place and the workforce to be updated on them.  Recommendation 3:Early Break’s workforce to reflect on their own organisational culture and how they also experience other organisational cultures in relation to CSE. Workers to also identify areas of tension and explore these in relevant supportive forums e.g. supervision  Recommendation 4:Early Break to establish clear escalation processes for safeguarding issues and complaints about other organisations  6.5.5. Early Break have identified that the following actions have been taken as a result of the learning arising from this Review and that of YP1-6:  Recommendation 1:  This process has now been established and serious case review information is now formally disseminated throughout service.  Recommendation 2: Workforce development undertaken on this and workers discussed locality based CSE processes. These are now recorded in a central place and this is reviewed with the workforce throughout the year. It is part of induction for new workers.  Recommendation 3:  This will remain an on-going process. Workforce development specifically undertaken on this with a focus on culture and areas of tension and how to resolve these or escalate.           55 6.6     GP Services Rochdale   6.6.1. GP Services Rochdale has provided a chronology and Individual Management Review for this Serious Case Review. 6.6.2. The report has been prepared by a GP Practice Lead for Child Protection.   The author has had no operational responsibility in the case or any direct involvement with YP7 or her family and as such met the criteria for independence.   6.6.3. The Report was countersigned by the Clinical Lead for NHS Heywood Middleton and Rochdale Clinical Commissioning Group The countersigner had no direct knowledge or involvement with the services provided to YP& or her family. 6.6.4. GP Services were provided to YP7 for much of the period of this review, however there are some gaps in information as a result of missing records and also for periods while YP7 was living out of the Borough. 6.6.5. Three recommendations for action  have been made for GP services in Rochdale  as follows: 1:   The Pan Manchester Protocol for the management of Sexually Active Young People under the age of 18 years needs to be distributed to all GP surgeries in the borough with audit to be completed after six months to ensure that policy is embedded into practice. 2:  Training in CSE and child protection for GPs needs to be reviewed to ensure that key risk indicators are recognised and the role of the GP is emphasised.  Recognition of  child abuse as a differential diagnosis also needs to be included.  Safeguarding training for Gps needs to be audited to ensure that it is changing clinical practice. 3:  GPs must receive training in CAF and understand their role to initiate its implementation for children and young people who require additional support. 6.6.6. The following information has been provided regarding actions taken as a result of this Review and that of YP1-6: 1. The Pan Manchester Protocol for management of sexual activity in young people below the age of 18 years has been distributed to all GP services in the borough and has been included in the GP training programme  2. Training for GPs now includes CSE as part of level 3 single agency training        56 6.7  Greater Manchester Police  6.7.1. Greater Manchester Police have provided a chronology and Individual Management Review for this Serious Case Review. 6.7.2. The report has been prepared by a Senior Review Officer.  The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence.   6.7.3. The Report was countersigned by the Head of the Public Protection Division who had no direct knowledge or involvement of the services provided to YP7 and her family. 6.7.4. The IMR concluded that there were no new lessons for the Police arising out of this Review that had not already been recognised in regard to the SCR for YP1-6 and therefore the recommendation remained the same: Recommendation: That the Head of Greater Manchester Police Public Protection Division ensures the continued participation of GMP in Project Phoenix and ensures that all agreed recommendations or directives arising out of the project are implemented by Greater Manchester Police within a realistic time scale.     6.7.5. Subsequent to further reflection, Greater Manchester Police concluded that more detailed recommendations were required in relation both to YP1-6 and YP7 as follows: 1. CSE and safeguarding children to remain as a priority for GMP and included in the Rochdale divisional delivery plan to support the PCC Police and Crime Plan. 2. To ensure all staff are trained to a minimum required standard and are aware of local safeguarding board procedures.  3. Provide all new operational staff working in Rochdale with induction training in CSE and multi-agency safeguarding children procedures. 4. GMP to commit to developing and maintaining the Sunrise Team and to work proactively with the RBSCB to ensure a cohesive approach pending any final agreement and implementation of Phoenix within Rochdale. 5. GMP to re-emphasis the escalation process for the review and professional challenge of CPS decisions.   6. Ensure all officers investigating CSE within the Sunrise team have suitable accreditation within this specialism including the training and development as child abuse investigators. 7. GMP to ensure that there is a clear structure of supervision and monitoring and quality assurance of CSE investigations.    57 8. Senior Leadership Team to ensure that roles are understood to deliver the Rochdale multi-agency CSE strategy to prevent, protect and prosecute. 9. To develop and implement a toolkit of CSE prevention and disruption activities which can be monitored, evaluated and shared as best practice to ensure continuous improvement.  6.7.6. Greater Manchester Police have taken a range of actions as a result of the learning from this and other Reviews. GMP’s Rochdale Divisional Commander chairs the RBSCB child sexual exploitation Sub group whose work includes:     Establishing a Cohesion Unit to build confidence and increase awareness within the community including the concept of ‘World Cafes’ which encourages our diverse community to take responsibility to tackle CSE.  Includes other initiatives such as Accreditation for Taxi Drivers and designated Safeguarding Officer from the Rochdale Council of Mosques.     Implementing Operation Noric, the aim to tackle CSE by proactive means. It involves regular weekday and weekend evening and night time work visiting high risk offenders, hotspot locations and conducting visits to young person's identified as being at significant risk of harm. Both uniformed and plain clothes officers working in conjunction with social workers, housing, fire and licensing enforcement officers, HMRC and VOS. 6.7.7. Other specific actions  taken by GMP as a result of the learning identified in this Review include:   Training and awareness to all Rochdale police officers, PCSOS and police staff involved in operational policing.  Police officers are now fully embedded in the commissioned multi-agency sunrise team.  There is a clear structure of supervision, monitoring and quality assurance of CSE investigations.  There has been development and implementation of a CSE prevention and disruption toolkit which can be monitored and evaluated and shared as best practice to ensure continuous improvement.  The Rochdale Senior leadership team are fully involved in safeguarding and hold key roles in order to support and drive CSE strategy to prevent, protect and prosecute.  A monthly performance scorecard has been developed to monitor performance.  Police members of the RBSCB are fully involved in the development of Project Phoenix and fully involve the wider partners.    58   6.8     Pennine Acute NHS Hospital’s Trust  6.8.1. Pennine Acute NHS Hospital’s Trust has provided a chronology and Individual Management Review for this Serious Case Review. 6.8.2. The report has been prepared by the Named Doctor for Safeguarding, North Manchester General Hospital.  The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence.    6.8.3. The Report was countersigned by the Head of Safeguarding.   The countersigner had no direct knowledge or involvement with the services provided to YP7 and her family. 6.8.4. Services were provided to YP7 by 4 hospital departments: Accident and Emergency, the Children’s Ward, the Medical Emergency Unit and the Obstetric Department. 6.8.5. Three  recommendations for action were made by Pennine Acute NHS Hospital’s Trust: 1. Development of documentation proforma and training, prompting assessment of social history  2.  Recognition procedures to be reviewed in A & E and MEU, Training and awareness raising within PAHT A/E and MEU departments to reinforce responsibilities for 16-17 year olds under the Children Act 1989. 3. Safeguarding education to be designed, developed and piloted that is grounded in non-technical skills and human factors including employment of simulation and observation of error and threshold exercises that are grounded in non-technical skills concepts 6.6.7. The following actions have already been taken in relation to the learning from this Review:   CSE briefings programme extended to include 2 extra dates in Dec.  Documentation proforma to prompt assessment of social history has been developed and is being piloted in Rochdale Urgent Care Centre.  Following a staff survey the proforma has been amended and the pilot has been extended.  Records will be audited in Dec with a view to rolling out the proforma to the rest of the Trust in 2014.  Level 2 and Level 3 safeguarding training (children and adults) has been revised to strengthen emphasis on the care and responsibilities towards children and young people.  Learning Lessons bulletin has been developed for YP7case.    59  Specific sessions re: YP 7and the learning lessons bulletin will be delivered to all A/E and the UCC depts. during December.  A DVD highlighting the story of a pregnant teenager has been developed as a ‘patient story’.  The story is in the words of the patient herself and highlights what help and what hindered her journey from childhood to parenthood in extremely difficult and abusive circumstances.  . 6.9     PENNINE CARE NHS FOUNDATION TRUST (Community and Mental Health Services)  6.9.1. Pennine Care NHS Foundation Trust (community and mental health services) has provided a chronology and Individual Management Review for this Serious Case Review.  6.9.2. The report has been prepared by an Independent Author with a substantial background in nursing, health visiting and  midwifery and 14 years experience as a Named nurse for Safeguarding children. Named Nurse for Safeguarding Children for Oldham Borough for Pennine Care NHS Foundation Trust.  The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence.    6.9.3. The Report was countersigned by the Acting Head Safeguarding Chidren.   The countersigner had no direct knowledge or involvement with the services provided to YP7 and her family. 6.9.4. The recommendations for action for Pennine Care NHS Foundation Trust are as follows:  1. A single agency procedure for child sexual exploitation to be developed and ratified in line with any multi-agency procedure and implemented.  This should include a clear pathway for referrals and for sharing intelligence with the Sunrise Team. This should be compliant with the Trust policy for electronic transfer of personal identifiable of data. 2. Record keeping training and a records audit of the Crisis Intervention Team records to be undertaken to ensure that they meet statutory, legislative and Trust safeguarding requirements for clinical documentation. 3. That a standard operating procedure be developed, ratified and implemented to ensure prompt transfer of records for Looked After Children. 4. Health visitors to be reminded of their duty of care to mother's, whose babies have been removed into foster-care at birth, with regard to assessing individual cases of the need for parenting support and maternal post-natal mental health and well-being. This should be in line with the local and the National    60 Commissioning Board: Greater Manchester Area Team Health Visiting Service Specification. 5. That the supervision arrangements provided to the Crisis Intervention Team be reviewed and evaluated to include:  managerial function;  learning and development function;  the opportunity to evaluate and reflect on the effectiveness of action being taken in complex cases;  the opportunity to resolve professional differences (mediation). 6. The safeguarding children competency framework for all staff identified as level 3 (Royal Colleges of Paediatrics and Child Health Intercollegiate document, 2010) be harmonised across Pennine Care NHS Foundation Trust and implemented. 7. All staff to be reminded to use the Safeguard Incident Reporting system in line with PCFT policy to escalate differences of opinion that cannot be resolved in relation to critical decisions concerning the care of children and young people, as well as their line manager and Named Nurse. 8. Training needs analysis of CIT staff to be undertaken in relation to safeguarding children. 9. CIT staff to demonstrate awareness and understanding of the Trust’s Safeguarding Children Policy and the multi-agency safeguarding children policy.Two further recommendations have been made by the Overview Report Author: 10. Pennine Care NHS Foundation Trust should collate factual information and examples of their concerns about the threshold at which Children’s Social Care take action in cases of sexual abuse.  The information to be presented to the Board in order to contribute to work currently being undertaken regarding thresholds. 11. Pennine Care NHS Foundation Trust should review the accessibility and responsiveness of services provided to the survivors of sexual abuse in the light of this report. 6.9.5 The IMR identified that the following actions have already been taken in relation to the learning from this and related reviews:  1. The "Step by Step" guide for children at risk of sexual exploitation (DfE, 2012) has been circulated to all health practitioners.  2. A records audit tool has been developed to ensure the CIT records  meet statutory and legislative requirements in relation to safeguarding (audit to be undertaken in December 2013).  3. The Crisis Intervention Team has attended record-keeping training.     61 4. Health visitors have received briefings in respect of their duty of care to mother's, whose babies have been removed into foster-care at birth, with regard to assessing individual cases of the need for parenting support and post-natal mental health and well-being.   5. A single safeguarding children competency framework has been developed and disseminated; staff awareness raising has been completed.  6. All staff have been reminded to use the Safeguard Incident reporting system in line with Pennine Care NHS Foundation Trust policy to escalate differences of  opinion that cannot be resolved at practitioner level.  7. The Safeguarding Children’s Team has undertaken a structured appraisal of the safeguarding learning needs of the Crisis Intervention Team staff.  8. Crisis Intervention Team staff have engaged in a safeguarding session with the Safeguarding Children’s Team to review and discuss the Trust’s and multi-agency safeguarding policies and procedures.  6.10 1111111111111111111111111111111111111111  6.10.1. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.2. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111  6.10.3. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.4. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111.  6.10.5. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.6. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111      62 6.11     RMBC Strategic Housing Services   6.11.1. RMBC Strategic Housing Services has provided a chronology and Individual Management Review for this Serious Case Review in relation to the Homelessness Advice and Housing Option Service. 6.11.2. The report has been prepared by An Access Officer at the Homelessness Advice and Housing Options Service.   The author has had no operational responsibility in the case or any direct involvement with YP7 or her  family and as such met the criteria for independence.   6.11.3. The Report was countersigned by the Homelessness Services Manager.   The countersigner had no direct knowledge or involvement with the services provided to YP& or her family. 6.11.4. Advice was offered to YP7 and the services working with her on a number of occasions, including referral to a range of accommodation provision.  The RMBC service also provided YP7 with emergency accommodation, in particular by 1111111111 where she lived intermittently for several months. 6.11.5. Three  recommendations for action  have been made for Rochdale Strategic Housing Service  as follows: 1. Improve awareness of safeguarding issues across the service 2. Empower and encourage staff to be confident 3. Improve internal processes 6.11.6  The IMR identified that the following actions have already been taken    in relation to the learning from this and related reviews: Recommendation1:  CSE Awareness Briefing delivered to a Housing Strategy meeting using the materials provided through RBSCB  Lessons Learnt Staff Training Event held              Recommendation 2  All staff have been issued with new service standards including standard reporting to colleagues and line managers  Recommendation 3  All pregnant customers to be notified to Family Support Worker – this has been embedded as part of our Assessment process.    6.12 Schools (RMBC Children’s Services, Early Help & Schools)     63 6.12.1. RMBC Children’s Services, Early Help & Schools have provided a chronology and Individual Management Review for this Serious Case Review. 6.12.2. The report has been prepared by  the Senior Education Welfare Officer Safeguarding.  The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence.   6.12.3. The recommendations made for Schools (RMBC Children’s Services, Early Help & Schools)arising out of this Review are:  1.   New protocols and guidance to be written and issued to all schools on the required recording standards for pupil files(all education and child protection)  2.   Development of a borough wide protocol for the transfer of relevant information at transition between designated staff within mainstream education and post 16 provision.  3.  Ensure that the signs and symptoms of CSE are understood and responded to by staff in school settings.  CSE awareness-raising to be incorporated into single agency safeguarding training delivery.  4.  The CAF to be embedded as an early intervention assessment tool in all schools.  6.12.4. Information has been provided regarding actions taken as a result of this Review.   1  Briefings have been provided to both Primary and Secondary Headteachers.  A regular designated Leads network meeting set up each term with a standing time reminding them of recording standards.  Guidance being written to incorporate best practice for recording standards and filing of records..  Safeguarding training now also includes reference to record keeping.  2.  Protocol has been made available on the intranet and has been highlighted at the designated leads meetings and briefings.  The impact to be assessed through moderation activity and sampling.  3. Safeguarding training packages have been revised to include and reflect CSE.  4.  The numbers of CAFs being opened by schools and the quality of CAFs are increasing and are now being monitored for quality and appropriateness.      64 6.13    111111111111111111111                              6.14     HEYWOOD, MIDDLETON AND ROCHDALE PCT   (COMMISSIONING)  6.14.1. The Primary Care Trust responsible for commissioning has provided a Health Overview Report encompassing the three individual IMRs.  6.14.2. The report has been prepared by the Designated Nurse for Safeguarding Children. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence.  6.14.3. The report was signed by the Executive Board Nurse. The countersigner had no direct knowledge or involvement with the services provided to YP7 and her family.     65 6.14.4. No further recommendations for action have been provided for  Health Commissioners in the light of relevant recommendations for YP1-6.    66  Name of SCRP chair assuring quality of overview report  Audrey Williamson  1 Endorsement by LSCB Name of LSCB Chair   Jane Booth Date of LSCB endorsement of overview report 17th Dec 2013   Signed on behalf of LSCB:           Position:  Independent Chair of Rochdale SCB    Author:    Sian Griffiths      67  BIBLIOGRAPHY & BACKGROUND READING  Brandon, M et al ( 2008 ), A Biennial Analysis of Serious Case Reviews 2003-05, Department of Children Schools and Families. London. Brandon, M et al (2009), A Biennial Analysis of Serious Case Reviews 2005-07, Department of Children Schools and Families. London. Brandon, M et al (2010) A Biennial Analysis of Serious Case Reviews 2007-09, Department of Children Schools and Families. London. Brandon, M et al (2012) A Biennial Analysis of Serious Case Reviews 2009-11, Department of Children Schools and Families. London. Calder, M ed (2009):  Sexual Abuse Assessments Dekker, s (2006):  The Field Guide to understanding Human Error Department of Health (2001);  Private Fostering: A cause for concern. Finkelhor, D (1986)  A Sourcebook on Child Sexual Abuse HM Government (2010) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London  NICE public health guidance 28  updated April 2013 NSPCC (2010)  Children and young people disclosing sexual abuse: An introduction to the research Munro, E (2008):  Effective Child Protection Munro, E (2011):  The Munro Review of Child Protection (Dept of Education) Ofsted (2008) Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008 Reder,P., Duncan, S. and Gray, M. (1993) Beyond blame: child abuse tragedies revisited Wilson and James (2007) The Child Protection Handbook Woods, D et al (2010)  Behind Human Error         