Placement of a 12-year-old girl in secure accommodation in May 2019. Child D and her family were well-known to services and there was a history of criminality, mental health issues and drug and alcohol misuse in the family. There were concerns about previous neglect and non-protective behaviour from her mother and sexualised behaviour from her sibling and a section 47 enquiry was undertaken in respect of both children. Children's social care received a multi-agency referral form in May 2017 raising concerns that Child D was a victim of child sexual exploitation. By March 2019, Child D was frequently going missing, was involved in criminality and reported misusing substances. Throughout her life, Child D disclosed several instances of rape and sexual abuse. In May 2019, Child D was found almost unconscious and intoxicated in a local park. She was admitted to hospital and children's social care were informed. Following this, Child D was accommodated in a secure residential placement where she remains under section 20. Ethnicity and nationality not stated. Findings include: Child D's aggressive behaviour may have impacted on professionals' perspective and response to the case; despite being on a child protection plan, outcomes did not improve for Child D; and there appears to have been a lack of cohesion in care planning. Recommendations include: analyse themes and trends from return home interviews to inform service provision; consider developing a strategy to manage highly complex and high-risk cases; review escalation around the legal gateway process.
      
 Title:  Multi agency local learning review: Child D: learning theme: repeat missing episodes between 2017 and 2019: “if you take me home, I’ll just go missing again”. LSCB: Dudley Safeguarding People Partnership Author: Su Vincent Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Author: Su Vincent: Designated Nurse for Safeguarding Children     Multi Agency Local Learning Review Child D Learning theme: Repeat Missing Episodes between 2017 and 2019   “If you take me home, I’ll just go missing again”       Page 2 of 11  Contents 1. Framework of the review: ................................................................................................................... 3 2. Rationale for undertaking this case review ........................................................................................ 4 3. Background to the Case Review .......................................................................................................... 4 4. Scoping period .................................................................................................................................... 6 5. Findings ............................................................................................................................................... 6 6. Analysis ............................................................................................................................................... 8 7. Conclusion ......................................................................................................................................... 11 8. Recommendations ............................................................................................................................ 11                        Page 3 of 11 1. Framework of the review: 1.1 Working Together to Safeguard Children 2018 contains the statutory guidance for undertaking Child Safeguarding Practice Reviews (CSPRs) when a serious child safeguarding cases has been reported. These are cases in which:  • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed 1.2 Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice.  1.3 Issues might appear to be the same in some child safeguarding cases but reasons for actions and behaviours may be different and so there may be different learning to be gained from similar cases. Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families. 1.4 Some cases may not meet the definition of a ‘serious child safeguarding case’, but nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near miss’ events. Safeguarding partners may choose to undertake a local child safeguarding practice review or another form of review in these or other circumstances. 1.5 The aim of this Local Learning Review (LLR) is to identify improvements that can be made to better safeguard children and to prevent, or reduce the risk, of recurrence of similar incidents. 1.6 The review will undertake a rigorous and objective analysis of what happened and why. It will consider whether there are systematic issues, and whether and how policy and practice need to change. It should be noted that the review is not being conducted to hold individuals, organisations or agencies to account as there are separate processes for this. 1.7 Dudley Safeguarding People Partnership (DSPP) is a joint overarching body, with the remit to monitor and improve safeguarding activity for children and adults. It brings together senior officers from the key agencies and agreed significant partners to ensure there is a focus on transformation by providing strong leadership and guidance to all of its partners, identifying the strategic priorities on a yearly basis and determining the desired outcomes in respect of safeguarding activity and practice.  The DSPP has strategic oversight of the work across both the Safeguarding Children Partnership and the Safeguarding Adult Board, which in turn drives the work of the sub-groups to improve outcomes.  Page 4 of 11 2. Rationale for undertaking this case review 2.1 The subject case was initially chosen at random from a number of cases selected to be reviewed as part of a Multi-Agency Case File Audit (MACFA) planned for May 2019 focussing on children under the age of 12 going missing.  2.2      On the return of a completed audit tool, it was recognised that Child D was cause for serious concern and a meeting was held in mid-April 2019 with senior leaders to consider immediate intervention in order to safeguard the child and progress the case prior to the MACFA.  2.3       The meeting included senior representation from Children’s Social Care, Police, Social Work Manager, IRO and the DSCB Business Manager. The meeting concluded with all in agreement that a secure residential placement would be identified.   2.4       This would be the second attempt to place this young person in a secure placement, as an accommodation had previously been identified in November 2018, but had not been progressed, as the placement was not signed off in time leading to the loss of the placement and drift and delay with the case. A further secure placement was sought in May 2019, however Child D was found intoxicated in a park prior to a placement being identified. She was subsequently transferred to a secure placement a week following the incident.  2.5       Following the sharing of information and discussion at the above noted meeting, it was also agreed that the case met the threshold for a referral into Serious Case Review sub group for the consideration of an SCR.  2.6       The case was discussed at SCR sub group on 2nd May 2019, where it was initially agreed that the case did reached the threshold for an SCR. However as scoping information had been requested and received from partners for the forthcoming MACFA, it was identified that there was already a wealth of information regarding the case.  2.7 As is required, the outcome and decision from the SCR subgroup was discussed with the National Child Safeguarding Practice Review Panel, who agreed for a local review to be completed, and published in accordance with Working Together 2015 statutory framework.  2.8 It was agreed that the DSCB Business Manager and Designated Senior Nurse would prepare a report in order to ensure that the learning and recommendations could be disseminated in a timely manner. 3. Background to the Case Review 3.1      Child D is 12 years of age and has been known to services for a number of years. She lived with her father in a neighbouring borough for much of her early years. There appear to have been some issues around potential neglect (persistent head lice, infected eczema, bedbug bites).  3.2       In the earlier years, Father engaged with the Early Help (formerly CAF/Child Concern) process and parenting appeared to improve. He appeared to work closely with the School Nurse and attended Child Concern Meetings.   Page 5 of 11 3.3        Child D was also “on the SEN register”1 at her primary school.  Her behaviour at school was causing concern at this point and a copy of the SEN statement was shared with appropriate agencies to ensure that they were aware of her learning disability.  It later transpired that at this time Child D had disclosed that she had been sexually abused by a family friend at the age of 7. A strategy meeting was held and mother appeared to be sceptical that the event actually occurred. There were concerns around previous neglect and non-protective behaviours from mother. It was felt that she could not safeguard Child D. There were also concerns around her sibling’s sexualised behaviour in the home.  3.4       It was agreed to undertake a joint Section 47 enquiry in respect of both children.  There was insufficient evidence to investigate the perpetrator as name, date of birth and timescales of the incident were not provided. This raised significant concerns in relation to Child D’s mother around why she was not providing the information required in order to investigate the alleged disclosure.  Therefore a multi-agency meeting was required to implement plan of intervention which is in the best interest of the child to ensure she is not put at further risk.  3.5 Child D reportedly had a close relationship with her father. At some point, he re-married and declined any further contact. It is unclear when the relationship broke down and the circumstances that led to the rift but since that time, Child D has resided with her mother and her mother’s partner.  3.6      The family reside in a privately rented two bedroom property which is also home to Child D’s 16 year old brother E who has severe ADHD and his girlfriend. Also in the property is Child D’s 24 year old brother F and his girlfriend. F is known to the Youth Offending Team. Due to the limited space within the property, Child D and her mother sleep top and tail on the sofa.   3.7      From records, it is known that Child D had a number of physical fights with her brother and at some stage was moved to live with her grandmother in November 2018. However Child D’s two maternal Uncles also resided at grandmother’s house. Both misuse alcohol and substances. Dudley Children Services have been involved with the family since 15th March 2013, following an NSPCC referral (National Society for the Prevention of Cruelty to Children) that raised anonymous concerns that parents are dealing drugs at property.  The referrer alleged that this took place when children are in the property. 3.8        There is an extensive history of criminal activity and police involvement with the family. This includes Child D, her brother E and her mother. All have been recorded as both victims and suspects of crime. Child D has been arrested for assault, theft and criminal damage. She has also reported being the victim of a number of sexual assaults including rape.  Child D was reviewed in the SARC and the case was filed as no further action under code 16. 2  3.9       The Anti-Social Behaviour team have also been involved with the family as in 2016 and 2017 there were reports of the children verbally abusing neighbours, using drugs and  1 Forerunner of the Education, Health and Care Plan (EHCP)  2 This means that there was an identified subject but that evidential difficulties prevented any prosecution.   Page 6 of 11 an incident in which it was alleged that E sexually assaulted the child of a neighbour who was of a similar age.  3.10       Children’s Social Care received a Multi-Agency Referral Form (MARF) in May 2017, when Child D was just 11 raising concerns that she may be a victim of CSE. Following this referral, a number of agencies became involved with the child. She was discussed at a number of multi-agency fora including  • Young People at Risk of Sexual Exploitation (YPSE) • MASE • CMOG • CP Conference • Safer Estates • Adolescent Response Meeting Child D and the family were supported by a number of agencies including Child and Adolescent Response Team (CART), School Nursing, Housing, Youth Offending Service, Barnardos, PRU, CAMHS and adult mental health services. In May 2018, Child D disclosed a sexual assault in Birmingham by a 15 year old who she met online. Child D was assessed at the West Midlands paediatric SARC and counselling was recommended. She had previously been referred to CAMHS for behavioural issues but demonstrated only limited engagement. Child D has been subject of a Child Protection Plan since 2018.  3.11     In March 2019 there are a number of police logs including a report by police that mother had “lost control” of Child D and that she did not impose appropriate boundaries.  Child D was frequently going missing and involved in criminality. Also that month Child D disclosed that she had been raped the previous month by persons known to her. She reported that she had been drinking alcohol and smoking cannabis. Later that month, Child D was found wandering around Dudley town centre and police used police protection powers to safeguard her as she stated she intended to continue to abscond.  3.12     In April there was a report that Child D had observed her boyfriend stabbing someone and at the end of May she was found significantly intoxicated and virtually unconscious in a park by a member of the public who called for an ambulance. She was admitted to hospital and Children’s Social Care were informed.  Child D was accommodated in a secure residential placement where she remains under Section 20 of the Children Act 1989.  4. Scoping period 4.1  It was agreed that the scoping would commence when the first concerns around potential CSE was identified and a MARF submitted in May 2017 up to the time that Child D was placed in secure accommodation in June 2019. Any pertinent information outside of the scoping period would be included to give context to the review.  5. Findings 5.1 It was clear from the information shared at both the MACFA and the SCR sub group that Child D has been causing concern for a number of years. She has lived within a  Page 7 of 11 very complex family dynamic with elements of abandonment. Her father who she appeared to have a good relationship, declined any further contact with her following his remarriage.  Her mother also sent her to her maternal grandmother’s following the fights she had with her brother.  5.2 It should be acknowledged that Child D is 13 years of age and remains in a secure unit for her own protection.  There is a long family history of criminality, mental health issues, substance and alcohol misuse and anti-social behaviour. All of which will impact on the children’s health and wellbeing. There is also evidence of sporadic engagement and lack of commitment from mother within the mental health records with both Child D and E.  5.3      Whilst mother has completed a Triple P parenting programme, it does not appear to have developed her parenting capabilities or improved outcomes for the children. She does not support her daughter to engage with CAMHS and does not appear to be able to set boundaries for her children. Both of her older children have been involved in criminal activity and she was unable to keep Child D safe when she repeatedly went missing (There have been over 30 reported missing episodes). Mother appears not to understand the impact that Child D’s behaviour and episodes of missing has on her safety.  5.4       There is evidence of disguised compliance with mother reporting to professionals that she cannot make Child D engage with the support offered. She has not reported Child D missing on a number of occasions. There have been several missed CAMHS appointments, where mother has not taken her and evidence from the MASE meetings and police that Child D is suspected of having links to local gangs. There have been a total of 11 alleged sexual offences against Child D reported since the age of 7.  5.5        Child D demonstrates aggressive and violent behaviour both towards her family and occasionally towards professionals. She has assaulted a number of people including a young person with hyper mobility issues and has subsequently been arrested and in some instances charged. She has caused criminal damage in a local shopping centre and stolen property from unknown victims and also stole from her mother’s bank account. Child D’s older brother E also has a criminal history and a history of mental health issues and severe ADHD.  5.6        Child D was referred to CAMHS in July 2018 due to her inability to settle at school and anger issues and her perceived peer pressure from her friends. She has a poor level of engagement and missed numerous appointments. Child D had started to self-harm and had previously disclosed suicidal ideation. Child D did engage when she attended for her mental health assessment but walked out when questioned about her sexual relationships in the context of CSE. It was agreed that Child D should be assessed for possible ADHD, however she refused to attend the appointment. It was around this time (February 2019) that Child D’s risk of CSE was increased from medium to high following a MASE meeting, which identified that she was extremely vulnerable in regards to her friendship groups, possible gang affiliation and risk of being sexually exploited. 5.7        Both Child D and her brother E had been subject to a number of school exclusions. Child D was permanently excluded in December 2018 due to her deteriorating behaviours. The school were aware that she was missing on a regular basis and at high  Page 8 of 11 risk of CSE. They were aware via the MASE meetings that she was travelling out of the Dudley area (particularly to Birmingham). In total there are over 30 missing episodes, however this may be underreported as it would appear that Child D’s mother did not report them all as she had reportedly been threatened by Child D. Child D was temporarily accommodated at a Pupil Referral Unit (PRU).  It was agreed that staff at the PRU would consider a EHCP but it is unclear if this was completed. According to YOS Child D had refused to attend a re- integration meeting as she has stated that gang members were hanging around the PRU. 5.8  Child D’s risk of CSE was recognised by professionals and she was discussed at a number of multi-agency fora. Safety plans were developed but although support was offered it was often declined.  Professionals tried hard to engage with Child D but she was very difficult to manage and often refused to comply.  Professionals also recognised that Child D had been groomed.  Child D reported to a support worker that she preferred to engage with people older than herself. 6. Analysis 6.1    There were abandonment issues in Child D’s life. She was sent to live with her grandmother following a series of physical fights with her brother. She also reported that she was very upset following the breakdown of her relationship with her father, following which her behaviours deteriorated. There is no evidence that the relationship was ever re-established. Abandonment as a child is a recognised phenomenon and is a proposed behavioural or psychological condition that results primarily from the loss of one or both parents, or from sexual abuse. Abandonment may be physical (the parent is not present in the child's life) or emotional (the parent withholds affection, nurturing, or stimulation)3. A child abandoned by a parent or caregiver may have mood swings or anger issues and later in life these behaviours can alienate potential partners and friends. A child's self-esteem can also be affected by lack of parental support and fears of further abandonment can impair a person's ability to trust others. Child D clearly demonstrated these behaviours which resulted in her putting herself in risky situations in order to receive attention and affection.  6.2 In May 2018, Child D reported that she had been raped the previous month by a 15 year old who she had met online. At the time she would have been 12 years of age. She was reviewed in the Paediatric SARC and demonstrated low level indicators for CSE. The case was not progressed due to issues around evidential difficulties.  6.3       When Child D reported a further alleged rape that occurred in April 2019 (again a month after the event) she was still only 12. She gave the police officer the name of the alleged suspect, however police encountered difficulties contacting her following the incident and she refused to be ABE (achieving best evidence) interviewed. She was reported to be “exceptionally rude to her mother and all who encounter her”. As the incident was outside of the forensic timeframe it was felt that a forensic medical examination would have been of limited benefit.   3 Black, C. (2010) Understanding the Pain of Abandonment: Living with repeated abandonment experiences creates toxic shame. Psychology Today.  Page 9 of 11 6.4       Both of the sexual assaults occurred when Child D was under the age of 13. 4 The second assault in March 2019 was not progressed as Child D refused to engage with the police or offer any further information. In a previous SCR, a young person who reported a sexual assault did not feel that her allegations were taken seriously because of her behaviours and presentation. It is not clear what Child D’s thoughts were as there is very little evidence of her thoughts and feelings following the incident. Child D’s aggressive behaviour and presentation may possibly have impacted on professional’s perspective and response to the case.   6.5  Child D went missing on a very regular basis. Some of these were not reported by mother and each time she was returned to her mother’s care. In March 2019, she went missing 11 times within one month. When police found her in the town centre, she stated that she had every intention of absconding again if she was returned home. It is very clear that she was “voting with her feet”. There is no evidence within the information received that any professional asked Child D what she wanted. It was clearly evident that mother’s parenting skills were sub optimal and that she could not keep Child D safe. It would also appear that mother was scared of Child D. She had also struggled to parent her older children who are both involved with drugs and criminality. Mother’s brothers also misuse alcohol and drugs and Child D may have been exposed to this whilst residing with maternal grandmother. At the time that Child D was going missing, return home interviews were not being undertaken for children under the age of 13. Following the recommendation from the MACFA, this was addressed and all children who now go missing are offered a return home interview regardless of age.   6.6  Eight broad areas of adversity have emerged as key factors related to multiple adversities and negative outcomes for children and young people: ▪ poverty/debt/financial pressures ▪ child abuse/child protection concerns ▪ family/domestic violence ▪ parental illness/disability ▪ parental substance abuse ▪ parental mental illness ▪ family separation/ bereavement/imprisonment ▪ parental offending/anti-social behaviour.              Adverse childhood experiences have a marked impact on children and young people both when young and also as they progress into adulthood. Child D has experienced at least five of the identified areas of adversity. Despite being subject to a Child Protection Plan, outcomes did not improve for Child D who was repeatedly returned to the family home to experience further elements of family dysfunctionality and inadequate parenting with limited or no boundaries.   6.7 Child D was a young person who had been on the brink of care and/or a custodial sentence for some time. Her criminal activity was escalating and despite being discussed in a number of arenas, outcomes did not improve and ultimately she was  4 Statutory rape laws in the UK are based on the premise that an individual is legally incapable of consenting to sexual intercourse under the age of 13 until that person reaches a certain age. The law mandates that even if he or she willingly engages in sexual intercourse, the sex is not consensual.  Page 10 of 11 placed in secure accommodation. Cashmore (2011)5 asserts that children and young people who have progressed deeper into the juvenile justice system are more likely to have experienced abuse and neglect, have mental health problems and be developmentally delayed. Child D demonstrated some of these responses however the response from CSC identified that no referrals had been received regarding potential abuse. There was also no evidence of legal gateway/planning when the CSE and Child Protection plans were not working.  Whilst it is always preferable for children to remain in the family home, there are occasions when this is just not possible. Consideration should perhaps have been given to removing Child D from such a toxic household at an earlier point.  6.8 Despite being known to numerous agencies, there appears to have been a lack of cohesion in care planning. The meetings at which Child D was discussed do not appear to have been integrated to develop a holistic assessment in order to inform future plans. Child D had been permanently excluded from school which would have increased her risk of further missing episodes and subsequent exploitation. It is not clear that mother’s disguised compliance was clearly recognised. She stated to police and health professionals that she “could not force” Child D to engage, however, she was only 12 years of age at the time which would suggest that her mother could not safely parent her and had not developed the appropriate strategies in order to manage a troubled adolescent.  6.9 It would be helpful to have a forum where such highly complex cases can be discussed and managed as part of the escalation process. Currently Dudley have an Adolescent Risk Management Panel (ARM), which reviews those high risk cases which are demonstrating concerning features and are not progressing. The membership consists senior leaders within Children’s Social Care (including commissioning), Police and Health and aims to develop and implement a collaborative approach that ensures that the most vulnerable young people are identified and offered the best support possible to meet their complex needs. Whilst currently the panel discusses children and young people between the ages of 11 and 18, this could be developed in order to address issues around transition into adulthood.  6.10 The GP records report that Child D demonstrated “significant delay in expressive language” as a younger child. There is no evidence that there has been any recent assessment of her cognitive ability despite being subject of a SEN plan when in Primary School. The school confirmed that academically Child D was working at approximately age 7 years for all subjects and whilst she had learning needs and an Individual Support Plan in place, she did not have a formalised Education, Health, and Care Plan (EHCP). The school have recognised that this was a missed opportunity to offer appropriate support. If Child D struggles to articulate her feelings, this may cause frustration which could contribute to her anger and behaviour and may impact on her ability to recognise the impact of her behaviour and her risk of being exploited. It may have helped if Child D had one single, constant support worker, who could have built up a lasting relationship with her and who Child D felt she could trust.   5 Cashmore, J (2011) The link between child maltreatment and adolescent offending: Systems neglect of adolescents. Australian Institute of Family Studies  Page 11 of 11 6.11 Since being in secure accommodation, Child D has developed a close relationship with the small cohort of staff and they have reported that she is “a delight”.  7. Conclusion 7.1      Child D was not an invisible child. She had been known to numerous agencies for a number of years. She resided in a toxic household where there were a number of safeguarding concerns and had endured a number of adverse childhood experiences.    7.2 Her childhood has been marked by exposure to substance and alcohol misuse, anti-social behaviour, criminality, sexual abuse and parental inadequacy. Child D has grown up without normal parental boundaries and was in effect out of parental control and yet there is no evidence that care proceedings were considered and when she made a disclosure of sexual abuse occurring at the age of 7, the case was filed as no further action.    7.3 Whilst the risks of CSE to Child D were recognised, the wider contextual safeguarding elements do not appear to have been considered holistically and appeared to have been managed in silos until the case was discussed at ARM panel and the decision made to identify a secure placement.  7.4 The voice of Child D was not clearly heard regarding the reasons for her not wanting to go home and her feelings about the alleged sexual assaults. Whilst a number of agencies were trying to support and engage Child D, they were not always successful.  8. Recommendations • Themes and trends from return home interviews to be collated and analysed and used to inform service provision  • Consider the development of a strategy to manage highly complex and high risk cases possibly linking with the ARM panel and the escalation process via Contextual Safeguarding Sub Group.  • To progress the bid for funding to implement the “Strengthening Families: Protecting Children Programme”.  • To consider the impact that permanent exclusions have on children and young people already at risk of abuse and exploitation.   • To review escalation around the legal gateway process.   