Fatal stabbing of a 15-year-old boy while intervening to protect another young person during a robbery in 2019. Concern about the family had escalated throughout 2018 particularly in relation to Joe and his sister being at risk from criminal and sexual exploitation. Learning themes include: the family context; understanding and managing risk; partnership working; and management oversight. Recommendations for the Partnership include: agree, implement and monitor the impact of a relationship-based, trauma-informed practice model across all agencies which includes an approach to working with fathers; review the current training and development opportunities regarding disabled children, to ensure professionals are clear about the threshold for access to services and the impact on parents of caring for a disabled child; review its approach to the provision of services which create diversionary activities and resources to mitigate the 'pull' of exploitation; engage the council in a review of and relaunch of the Young People at Risk Strategy to specifically incorporate a review of existing Child Protection systems in relation to extra familial harm and a transitions protocol for children moving from primary to secondary school; reinforce the early help and social work practitioners' understanding of their 'key worker' role through training, development, and supervision; agree a model approach to supervision and training across all agencies that supports the development of professional curiosity in all practitioners to ensure a greater understanding of the lived experiences of children; and Children's Social Care should develop a protocol with Housing Providers which clarifies processes and thresholds for housing transfers on safeguarding grounds.
      
    Serious Case Review No: 2022/C10212  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   Child C Summary LCSR final for publication 2024  1    Young Person “Joe” Child Safeguarding Case Review Author: Jane Held February 2022         Child C Summary LCSR final for publication 2024  2   Introduction:  To protect the identity of all involved in this case, all names, location details etc have been changed. This report summarises the learning from a detailed review of the death of a fifteen year old boy, Joe, and of his and his older sister, Kayla’s circumstances. The Review was conducted following Child Joe being stabbed and killed. It was considered that this was related to criminal exploitation, however, the police investigation and criminal trail made clear that the fatal incident was not gang or CCE related. Sadly, Joe was stabbed while intervening to protect another young person during a robbery.  The local Safeguarding Case Review, (SCR),  agreed to continue with a learning review due to the complexities of the family life. Terms of reference for the review are attached as Appendix 1. The review was led by an Independent Reviewer and covered a significant number of years of this family’s life together.  The detailed learning was further considered and summarised for publication in line with the requirements for publishing Child Safeguarding Practice Reviews on behalf of the Safeguarding Children’s Partnership. This was completed by a second independent reviewer. During this second stage action was already underway to address the learning from the detailed review, by those individual agencies involved, and collectively as a safeguarding partnership. All family names in this report are pseudonyms. Background and family circumstances: Joe was the second oldest member of a large family. The children lived primarily with their mother and sometimes their father. The whole family was for a long time in receipt of some limited early help services, health care services, and school support, as well as police involvement. Neighbour disputes and healthcare concerns about a younger sibling, Dylan, were the primary concerns for much of that time. Additional and specific support services were considered, to meet the needs of individual children, but were not always followed up or provided. For most of Joe’s life his mother was in effect a single parent, and under serious stress, as a result of Dylan and another child’s health conditions, Kayla’s poor emotional health, poor overcrowded housing and constrained finances as well as ongoing problems with school attendance, behaviour and offending. Little was known (or explored) by professionals about Joe’s father although he was actively involved with the children’s lives and appeared to move in and out of the household. Social Care first became involved in November 2017. Concern about the family escalated throughout 2018 particularly in relation to Joe and Kayla, both of whom were seen to be at risk from criminal and sexual exploitation. All the siblings were made subject to Child Protection Plans for 8 months that year, and at the end of the year they were stepped down to Child in Need Plans.  Child C Summary LCSR final for publication 2024  3  As concerns about Joe increased, he was made subject to a Child Protection Plan, although his siblings remained on Child in Need Plans. Joe became increasingly involved in serious offending. Joe was killed in 2019. At the time of his death, he was subject to a Youth and Rehabilitation Order, with intensive supervision and surveillance support and a 3-month electronic tag following proceedings involving a range of serious offences. The attack which led to his death was unrelated to these. Joe’s family’s views: The loss of Joe for his parents and siblings, who clearly loved and cared for him deeply, has been traumatic and cannot be underestimated. Joe’s mother and grandmother met with the reviewer and were open and reflective about what happened. They helpfully and generously hoped that, by contributing, there may be some impact on practice for other children in similar situations to Joe.  They felt that there needed to be a much greater understanding by professionals of their child’s vulnerability to exploitation and a more robust and joined up approach to working with him. They also said that there needed to be more focus on the risks to Joe within the community, rather than an over-focus on the family’s capacity to protect him in the home. This was never an issue in their view. They felt agencies could have worked more closely alongside the family to protect Joe and that a more open and collaborative approach would have better safeguarded him.   In addition, they felt strongly that Joe and other young people like him, would have been less vulnerable to exploitation if there were more extra-curricular opportunities available to them which would counter the impact of grooming and exploitation on them.  Their views concur with some of the findings of this summary, in that practitioners focussed on the family context as the source of the problems rather than addressing the social context (involving criminal exploitation and associated sexual exploitation) that Joe and his sister were part of. Joe’s story: Joe’s first ten years were marked by the regular arrival of more siblings, and a range of family issues which occasionally came to the notice of various agencies but rarely led to any purposeful interventions to address the emerging issues. These included marital disputes, occasional episodes of mental ill-health for Joe’s mother, very short-lived social care involvement and regular police involvement, (primarily related to neighbourhood disputes and Joe’s father’s attitudes), as well as changes of primary carer and increasing levels of family stress.  Dylan’s birth increased the stress in the household due to his complex medical needs. The primary school provided very high levels of support to the children, and the NHS system was actively involved in relation to Dylan. Additional support from children’s services to assist given Dylan’s disabilities was requested by a health visitor but did not materialise. Joe’s older sister, Kayla responded to the level of family stress by struggling with her mental Child C Summary LCSR final for publication 2024  4  health and was referred to CAMHS for support. Joe had 6 A&E attendances in his first 10 years, which, with hindsight was another indicator of how stressful family life was. Kayla and Joe were close to each other and provided mutual support.  As is often the way Kayla’s transition to secondary school, followed by Joe a year later meant a significant support to them both, (the primary school) was lost. Concerns about both , escalated quickly. Kayla experienced significant bullying and was transferred at her mother’s request. She found the second school difficult too, began to absent herself, and transferred to a third school. Very quickly after that she was permanently excluded. Joe too was struggling at secondary school receiving his first fixed term exclusion within 2 months of starting. After a further 8 exclusions and a very high level of detentions he was permanently excluded and moved to a pupil referral unit (PRU) following an incident of assault and robbery for which he was found guilty. This began a pattern of serious and disruptive behaviour by Joe with 349 incidents in the first 18 months there. These included violence, drug use, numerous police call outs, inappropriate comments, and obstructive behaviour. His attendance was also poor. He was clearly struggling with school, and with life more generally by this point.  His older sister was transferred to the same PRU. The two siblings constantly got into trouble “protecting” each other. Kayla’s attendance was poorer than her brother’s and it clear that both young people were unable to regulate their behaviour or respond to the structures and routines school offered. Their home and social lives were challenging, and they were involved in a range of activities and behaviours that were clearly risk factors for even greater involvement in exploitation, social media bullying and threats, assaults, and criminal behaviour, including sexual exploitation.  Despite their mother and grandmother’s concerns, and interventions by a range of professionals, as well as regular police involvement, things continued to deteriorate for them both. The PRU decided they could no longer meet Joe’s educational needs and he was effectively out of education from that point until his death. Kayla remained at the PRU in ever deteriorating circumstances until she ceased attending completely. Both young people by this point were living with volatile, frightening and often violent or abusive social lives, which increasingly spiralled out of their own control. Numerous professionals were involved with the family, and, in particular with Dylan, Joe and Kayla. There were many opportunities for professionals to come together and think about the family in context over this period. Unfortunately, attendance at the many meetings that were convened as well as the focus of those meetings varied enormously, leading to a lack of consistency or coherence in understanding the lived experiences of each family member, and in particular the underlying distress for Kayla and Joe.  Matters escalated very rapidly after a major incident when Joe was arrested. Joe told his mother he was threatened with a gun a week before his arrest, as he was involved in serious drug related criminal behaviour and said he was afraid. This was a time of extreme pressure for the family. So much so that Kayla overdosed (but did not inform her mother or others until sometime after the event ) as things had become intolerable for her.  Child C Summary LCSR final for publication 2024  5  Apart from police action to flag the family address in response to their understanding of the enhanced risk following Joe’s arrest, there appears to have been limited local multi agency or even single agency consideration and planning for when Joe returned home from remand. This was despite the feedback from Joe and from his mother that he would be unsafe if he returned, and he needed to be living elsewhere.  Joe and his sister Kayla had difficult lives, from an early age. As their lives became more distressing their behaviour became increasingly challenging. Very few professionals managed to engage with either of them sufficiently well to understand what their lives were really like or build sustainable relationships with them to help them understand and address what was happening to them. Interventions were characterised by limited information sharing, limited follow through from one meeting to the next, incident based, short term, reactive plans based on inadequate information, and limited assessments of the social and community context the young people were living in.  This meant from very early on in the young people’s lives coherent practical and structured support to help mother and the wider family cope was not put in place. Latterly there were limited, co-ordinated, or coherent plans to identify and address the underlying causes for what was going wrong before the deterioration reach crisis point. In addition, professional attention was on managing behaviour and on placing too much responsibility on family members rather than seeking to address the root causes of and mitigate the risks faced by both young people. The National and Local Context: Joe’s murder took place in the context of a national growth in the number of vulnerable young people being involved in criminal and sexual exploitation, linked, in the main, to the supply and distribution of drugs. Deaths of young people related to ‘gangs’ and criminal exploitation have been the subject of intense media scrutiny and increasing concern and reflection by professionals. The focus of child protection and safeguarding work more recently has had to adapt to address contextual safeguarding issues outside the family context and within the wider community. Research related to contextual safeguarding, and the associated practice issues informed the full review as did the report published by the National Child Safeguarding Practice Review Panel in 2020.1 At the time of Joe’s death, the authority, along with several other Local Authorities, had high rates of young people involved in crime and being exploited. The findings in the national research informed the development of a specific strategy in the Authority designed to address the issues. This sets out clearly those factors (such as poor educational outcomes and school exclusion, early experiences of poor parenting and parental separation and early involvement in aggressive/ bullying/ violent incidents) which can increase the risk of young people being involved in criminal exploitation. The Strategy and the Action Plan to apply the strategy were published early in the year of Joe’s death but the timing means it did not have an impact on practice in relation to Joe or his siblings. Since Joe’s death, significant work has  1 “It Was Hard to Escape”: Safeguarding Children at risk from criminal exploitation. Child Safeguarding Practice Review Panel 2020 Child C Summary LCSR final for publication 2024  6  been undertaken in the authority to better address the needs of young people at risk of exploitation.  Key Themes from the Review: The review has identified five key themes which merit further consideration by the safeguarding partnership if agencies are to work more effectively in the future to both prevent and where necessary to safeguard children and young people at risk of exploitation.  These themes appear in many reviews especially those involving criminal and sexual exploitation and underpin the need for multi-agency practice to be well informed and confident about recognising and managing contextual safeguarding concerns and underpinned by research and training. There were opportunities in the early phase of the children’s lives to better understand the pressures the family were under and to offer more effective, more co-ordinated, and more accessible support. If professionals had been more able to effectively engage the family in these early years, the subsequent experiences may not have been so acute, though of course this could not have been guaranteed. It is also important to bear in mind that the cause of Joe’s death was not directly linked to intra or extra familial harm.  In the second phase of agencies involvement with the family, when the risks of exploitation of Kayla and Joe were becoming more evident, there were opportunities again to come together to both fully understand the lives of the children and to plan more effectively to reduce the risks they were living with. However, despite the very large number of professionals involved [ and perhaps because of this] information sharing and joined up assessment, insight, reflection, and planning was much less effective than it could have been. Opportunities to really engage with, listen to, build trusted relationships with, and understand the children’s lives appeared to have been missed. The focus instead was on the family’s responsibilities and was not perceived as helpful by family members. The family context: There were many risk factors emerging during Joe’s primary school years which if taken together would have justified significantly greater levels of early help. Joe and his sister had strong enduring bonds and family relationships, but they lived in stressful and challenging circumstances. The family context was rarely considered by those engaging with them, and the focus was less on relationships of support and trust and more on expectations and responsibilities.  Joe was one of 6 children all relatively close in age, including one with significant additional needs. They were cared for by their mother, supported by grandmother with sporadic involvement from the children’s father. Very little was known about father, who appeared to live elsewhere, with other children involved. The first real engagement with him by professionals was in the summer of the year Joe was killed. There is little sense that the family was seen as a whole or any understanding that the children’s day to day lives were informed by their relationships with their parents and siblings and by what was happening with them.  Child C Summary LCSR final for publication 2024  7  In addition, the birth of Dylan with very significant health needs placed huge additional pressure on the family, emotionally and practically, reducing mother’s capacity to be available to her other children, and placing caring pressures on the children themselves. Key services such as early help, specialist disability services or young carer support were not made available.  Throughout Joe’s life his family lived in an inadequate and overcrowded home. Their housing circumstances were particularly acute following Dylan’s birth, whose additional needs alone would have merited transfer to a larger property. Despite requests for better housing over many years the housing situation was not resolved until the year Joe was killed.  Other stress factors for the family related to the school challenges that Kayla and then Joe faced as they moved from a very supportive primary school setting to secondary school. The part played by any school, is vital to children’s ongoing safety and can enhance a professional networks’ understanding of children’s wellbeing. In this instance the primary school was the only substantial and consistent support service in the family’s lives. When that safety net was removed things deteriorated very quickly. Non-attendance and school exclusion adds significantly to the risk for vulnerable young people and both were major issues for Joe and Kayla. In the second part of the young people’s lives, the focus of agency involvement was on Joe and Kayla, but in the main they were being seen by different professionals, whose liaison with each other was limited. Kayla’s degree of emotional distress was not fully identified or recognised. She first displayed this during her transition from primary to secondary school and she tried to kill herself by overdosing three times in total. The exploitation she was involved in, her worries for Joe and the pressure on her family must have been very distressing for her. Sadly, the information that Kayla was sharing about her brother did not raise questions for professionals about how she knew these things and what else she might be involved in.  Despite attempts by many professionals to engage mother, there was in general a focus on her ‘capacity’ to meet all of the children’s needs, with limited analysis of the very real obstacles to her being able to do so. There does not appear to have been very much, if any, consideration given to the realities faced by mother of caring for her children, or of how difficult it is for a parent to counter contextual risks as these emerge in the lives of adolescents, who are already vulnerable given their family circumstances. Overall, the picture is of two young people significantly out of control, caught up in conflict, bullying, criminal behaviour, sexual vulnerability, and retributions within their peer group, all set against a family context where their mother was managing a great deal of stress and pressure and their father’s presence was intermittent and possibly unreliable. Sadly, there was ‘a tunnel focus’ from professionals on the individual behaviours rather than why the behaviours were occurring and what they said about the lived experience of the children. The need for greater curiosity about the meaning and causes behind specific behaviour is a key point in practice with young people. Child C Summary LCSR final for publication 2024  8  Understanding and managing risk Although this was a family in need of significant support from early on, the emerging concerns about the safety and wellbeing of Kayla and Joe were contextual, relating to their school, peer group and neighbourhood. Although their vulnerability was understood to a point, it appeared to be a challenge for the professional network to respond to these risks, outside a traditional family and parental capacity framework. Almost from the beginning of his time in secondary education, Joe’s behaviour was indicative that he was at risk through his interactions with his peers. There were ongoing and serious concerns about his behaviour inside and outside of school, incidents of bullying,  aggression, fighting and arrests. These risk indicators were not seen within a contextual context but were viewed as   difficulties in and of themselves. In addition, the detailed story of Joe’s life demonstrates the gradual and systemic exploitation (or grooming) of him over a period of years by others external to his family context.  At the time there was a need for a contextual safeguarding framework to be more robustly established in in the authority and for professionals to be equipped with knowledge and expertise about ‘what to do’ with and for young people like Joe. In addition, although specific risks related to Child Sexual Exploitation were, to a degree, recognised there is little evidence that these were conceptualised collectively by professionals as risk indicators for gang associated young people.  The sexual exploitation of “gang associated” girls [ and sometimes boys] by their peers is now well documented and understood. CSE is often carried out alongside other forms of exploitation related to the drugs market. It appears that as the concerns about Joe escalated, the very real risks that Kayla was exposed to, faded somewhat into the background. It is highly likely that both Joe and his sister were known to and being exploited by the same group of people. For the most part, they were treated separately by professionals and the opportunity for agencies to come together and think about how they both fitted into their wider peer group was missed. Even though some work continued with Kayla, there was little collective thinking and planning for her specifically in the last year or so of agency involvement.    It is also well evidenced that for black boys and girls growing up in gang affected areas, there is a greater vulnerability to their being criminally exploited, particularly if there are additional risk factors related to early trauma and subsequent school exclusion or non-school attendance. Professionals working with children and young people need to be extremely wary of making assumptions about young black & ethnic minority people and gang involvement, but it is important that professionals are aware of the possibility of increased risk to young black & ethnic minority people living in areas where the drug trade may be operating. Holding these risks in mind may help professionals to be more alert to the risk indicators for this cohort of children and to intervene earlier in their lives.  Mapping of a young person’s peer group as a joint agency exercise is now fairly common in contextual safeguarding. In the case of Joe and that of Kayla, mapping their peer group in this way is likely to have created a much better understanding of the links between Joe and Child C Summary LCSR final for publication 2024  9  Kayla and between them and their peers. It would have helped to contextualise the pattern of ‘bullying’, assaults and recriminations that were frequently being seen at the PRU and helped to develop a more integrated and effective response to the risks the young people were exposed to.  All these issues of risk identification and management are covered in the Authority’s new strategy to address criminal exploitation and violence, but it is unclear how much awareness professionals working with Joe and Kayla in the year Joe was killed had of that relatively new strategy. It is also unclear how good a grasp professionals had of the nuanced interaction between context, ethnicity, culture and community and the differential levels of risk of exploitation faced by vulnerable young black children and young people. These differential risks require differential approaches to support individual young people into alternative pathways.   Partnership working Over the course of Joe’s life 12 agencies representing at least 22 individual services, were involved with him and his family. Within each of these there was the involvement of numerous professionals, some of whom were involved with the whole family but many of whom were primarily concerned with only one or two of the children at any one time. Many of these individuals were all involved at the same time without liaison with each other. The impact on the family and on Joe was inevitably difficult. There were considerable demands made to “engage” with some or all these individuals, many of whom were not sufficiently aware of the detail of the involvement of others. The family was judged by each agency as to their compliance and limited notice was taken of how overwhelmed the family was or how difficult it was for the young people to trust and make relationships with those wanting to help them. As things got more serious there may have been opportunities for all professionals to come together and consider what relationships were most effective and which professionals could perhaps take on more of a leadership role in developing relationships through which change could happen, but these were not recognised. Nor was the intelligence held across agencies shared well enough, analysed properly, or dealt with holistically. The large number of professionals involved meant that there were few situations when all those involved came together and used the time to think about the whole family. Attendance at TAFs, Child Protection and Child in Need meetings was variable, and information was often not shared, was misconstrued or, on occasion, lost. These gaps in information sharing and joint planning meant that the stresses within the family and the contextual harm experienced by Joe and his sister were not recognised sufficiently early and pro-actively assessed and managed.  Linked to the above there is some specific learning to be gained from looking at the statutory safeguarding framework and how this was used to recognise and manage risk in relation to the contextual harm the children were suffering. There are significant challenges in using what is traditionally a child protection framework designed for management of risk to children within families, to one which can also support the safeguarding of children at risk Child C Summary LCSR final for publication 2024  10  within their wider context. In Joe’s case none of the individual forms of professional’s meetings (Team around the Family, Child Protection Conferences and Core Groups and strategy meetings) were sufficiently multi-agency in membership, considerations, or plans, and they were guided (and limited) by the process requirements for that particular intervention approach.  These challenges have been recognised within updated statutory and guidance frameworks, which continue to rely on a consistent set of safeguarding and child protection processes and procedures, regardless of the origin of risk, but which do demand that investigation and analysis considers the child’s wider context and involves a wider set of safeguarding partners.  Similarly in relation to the issues of risk and exploitation the application of the Authority and agencies missing procedures and the work of the historic exploitation panel were both insufficiently holistic in their use, level of multi-agency functioning, and apparent impact. Management oversight The concerns about partnership practice and understanding of risk above, by definition, reflect on the quality of the management grip and leadership support available to frontline staff, particularly in terms of the need for analysis, reflection, and challenge in the supervisory relationship. Ideally supervision is an opportunity to pause and reflect about what the practitioner is reporting and to bring expertise and distance to their practice. Though there is evidence of the family and in particular Joe and Kayla being discussed in supervision settings across the network, there is limited evidence of this supervision being an opportunity to bring some curiosity to the practitioner’s narrative about the family.  There is also some learning here regarding accountability for decision making. There are several examples of decisions being made in multi-agency forums which were either not followed or were changed by the supervisor or manager. While this may have been a reasonable decision by the relevant manager, it would have been helpful to all professionals for there to be greater clarity about where accountability and decision-making lay, and what collegiate responsibility rested within multi-agency meetings.    There is also some very clear learning about the need for a shared approach to working with families and for a frame of reference which provides for the impact of trauma and the value of working in a relationship-based way to support recovery and change. A supervision framework which placed greater emphasis on understanding what was behind the behaviour of the various members of the family, may have made a significant difference to the subsequent understanding and planning for appropriate intervention.   Good practice There are some examples of good practice. The support of the whole family by the children’s primary school and the support given to Dylan, was exemplary and highly valued by the family. It is notable that each child’s life became much more challenging after their Child C Summary LCSR final for publication 2024  11  transition to secondary school. There are several other examples of individual workers doing what they could to support Joe and Kayla.  The referral for Multi Systemic Therapeutic work with the family was a positive decision and a recognition that Joe’s parents would need intensive support if they were going to be able to counter some of the risks their children were living with. The referral of the case to a Family Support Worker to attempt to resolve the housing issues late in Joe’s life led ultimately to a much better understanding of the family’s situation and to very belated action being taken regarding housing. The Family Support worker was tenacious in her approach and worked hard to ensure that the family’s situation was understood, and action was taken. A Child Abduction Notice issued by the police was a good example of criminal exploitation disruption activity and the referral of Joe to the National Referral Mechanism was a recognition that he was seen as a victim of criminal exploitation rather than purely a perpetrator of crime. Each of these interventions were helpful but in the absence of a coherent overall approach over several years to support the family, identify the risk factors that made Joe more vulnerable to being exploited and address the cultural context of criminality and exploitation that Joe and his sister were exposed meant the work of professionals resulted in less impact than if it had been part of a more coherent approach. Summary of Key Learning Points Though there is clear evidence of considerable individual professional commitment to supporting this family, there was a need for greater multi agency ‘grip’ of the issues far earlier in Joe’s life and for greater curiosity about what lay behind the presenting behaviours of the children. This meant that opportunities to intervene and support change were often missed. There was a need for more thinking about the family as a whole unit, including a need for greater understanding about the children’s lived experiences and their relationships with their parents, each other, and their social context.  From the outset of professional involvement with the family, there were opportunities to intervene and provide support, which, if they had been successful, may have helped the parents and the children to bring about some change. Professionals underestimated the pressures and stresses in the family and the impact of these on all the family members. For Joe’s mother in particular her failure to meet all expectations placed on her was often construed as neglect and evidence of poor parenting rather than as evidence of the overwhelming demands being made of her. It is clear from her contribution to the review that she understood what the problems were and her own limitations in addressing them. There was also a need for greater curiosity about and involvement with the children’s father and Joe’s extended family. There may have been opportunities for the whole family to find solutions to some of the family’s challenges themselves but without sufficient professional curiosity, this could not happen.  Child C Summary LCSR final for publication 2024  12  Further, an over focus on ‘traditional’ family based safeguarding work, where Joe’s mother’s perceived capacity to protect the children informed the planning, meant that the significant risks located in the children’s wider social and cultural environment were underplayed and could have been better understood. When the risks to Joe and his sister did become more evident to the extensive professional network, there were gaps in information sharing and planning, leading to an approach which needed to be more coherent and consistent to be successful.  While the large number of agencies and professionals involved was a measure of professional concern about the children, this created its own challenges, exacerbating the difficulties with joined up intervention. The new strategy designed to address these contextual safeguarding issues was developed and implemented across the system outside of the timescales and issues affecting Joe’s life.  Following Joe’s arrest in the year he died, the need for the professional network to come together and consider the risk to him as well as the wellbeing of the whole family was acute, but this did not happen, effectively.  This does not of course mean that Joe’s murder could have been prevented. It does raise however, the need for a much more robust multi agency response to incidents of significant risk in contextual safeguarding cases in the future.  Recommendations for the Local Safeguarding Children Partnership.  The family context: That the Partnership builds on the training and work already done and in development to agree, implement and monitor the impact of a practice model approach across all agencies which is relationship based and informed by an understanding of the impact of trauma on individuals and families. This approach should ensure that professionals are supported to pro-actively engage families and where the real need for practical support is prioritised.  That the Partnership develops within the approach cited above, an approach to working with fathers, that ensures their full involvement wherever possible in assessments, planning and intervention. That the Partnership reviews the current training and development opportunities regarding disabled children, with a view to all professionals becoming clearer about the threshold for access to services for disabled children, the impact on parents of caring for a disabled child, the role of SEN services and EHC plans and the need to escalate and advocate for children as necessary.  That the Partnership reviews its approach to the provision of services which create diversionary activities and resources to mitigate the ‘pull’ of exploitation.  Understanding and managing risk and Contextual Safeguarding Practice: That the Partnership engages the council in a review of and relaunch of the Young People at Risk Strategy to specifically incorporate the following:  Child C Summary LCSR final for publication 2024  13  ➢ A review of existing Child Protection systems as they relate to risks from extra familial harm   ➢ A review of the existing panels covering contextual harm across all agencies with a focus on how they manage contextual risk and harm , including the degree to which corporate and wider agencies are involved in the management of those risks  ➢ The management of contextual risk and harm.  ➢ Comprehensive and integrated inclusion of risk to girls from contextual harm ➢ A transitions protocol for children moving from primary to secondary school and how effective information can be shared in relation to contextual safeguarding  Partnership working: That Children’s Services reinforce through training, development, and supervision the role of the early help and social work practitioners in understanding their ‘key worker’ role, in particular relation to holding the ring on the whole professional network and ‘gripping’ the overarching plan for the child/children.  That the Partnership reviews current systems for coordinating, evaluating, and testing the effectiveness of multi-agency training. That Children’s Social Care develop a protocol with Housing Providers which clarifies processes and thresholds for housing transfers on safeguarding grounds.  Management oversight That the Partnership agrees a model approach to supervision and training across all agencies that supports the development of professional curiosity in practitioners [including teachers] leading to a more comprehensive understanding of the meaning behind children’s behaviours and a greater understanding of the lived experiences of children and their families, including the impact on parents and siblings of exploitation and contextual harm.    That the Partnership regularly monitors the development, the implementation and the impact of the work done to deliver on these recommendations.    Child C Summary LCSR final for publication 2024  14  Appendix 1 SAFEGUARDING Children’s REVIEW:                      TERMS OF REFERENCE 1. What learning is there from this case, in addition to learning already identified by agencies, that can inform the work of the Safeguarding Partnership? 2. Is there any evidence that this case involved neglect and acts of omission or organisational response.  3. What were the circumstances around Joe’s death? 4. Were appropriate mental health risk assessments completed and acted on when Joe was living in the community, and were escalation procedures followed? 5. What was the understanding of Joe’s safeguarding needs and were adequate protective and preventative arrangements made to address the risks in his life?  6. Were senior managers involved at points in the case where they should have been? What impact did management involvement have?  7. Were there any organisational and/or operational difficulties being experienced within or between agencies? 8. Are there any opportunities for joint learning from this case between Children’s and other agencies Services?  9. Are there any opportunities for learning from this case around community awareness and safeguarding?   