Executive summary of a review into the death of Christine, aged 17 years, on 12th March 2012, at the hand of her sister's ex-boyfriend, Michael. A friend of Christine was also murdered and her sister kidnapped. Michael tried to flee the country but was caught and sentenced to serve a minimum of 34 years. Christine had been known to children's services since 2007 and was living in supported independent living at the time of her death. History of: challenging and risk-taking behaviour; drug and alcohol use; going missing from home; suspected child sexual exploitation (CSE) by older men; and disclosures of domestic abuse made against an ex-boyfriend. Makes single and multi-agency recommendations, including: awareness raising of CSE risks to young people, particularly those over the age of consent; extending the NHS safeguarding supervision to involve staff from GUM clinics who see patients one-to-one; and an action plan for addressing domestic abuse between young people.
      
 Title:  Serious case review executive summary: Christine LSCB: Wakefield and District Safeguarding Children Board Author: Pat Cantrill 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.                                    Wakefield and District Safeguarding Children Board     Serious Case Review Executive Summary     Christine       2   1. Introduction    Reasons for the Serious Case Review  1.2 Chapter 8(9) of Working Together to Safeguard Children 2010 requires a Local Safeguarding Children Board to undertake a Serious Case Review whenever a child has died and where abuse or neglect are known or suspected to be a factor in the death.   1.3 The purpose of a Serious Case Review is:   • To establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children  • To 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; and  • To improve intra- and inter-agency working and better safeguard and promote the welfare of children.  Scope and process of the review  1.4 On 14th March 2012, the Independent Chair of the Wakefield and District Safeguarding Children Board (WDSCB) made the decision to hold a Serious Case Review Panel to consider the circumstances of Christine’s death.   1.5 This Serious Case Review Panel met on 11th April 2012 and recommended that the case met the criteria for a Serious Case Review. The Independent Chair of the Wakefield and District Safeguarding Children Board subsequently made the decision to undertake a Serious Case Review.  Terms of reference  1.7 The Serious Case Review Panel identified the following specific lines of enquiry:  • Was the level of vulnerability and risk to Christine fully understood by the different services within an organisation and effectively communicated between different services and to partner agencies?   • Were Michael’s level of vulnerability and the extent of the risk he posed to others fully understood by the different services within agencies and effectively communicated between these different services and to partner agencies?   • Was the level of risk to Christine effectively communicated during the transition from children’s services to adult services?  • Was the level of risk posed by Michael effectively communicated during the transition from children’s services to adult services?  3   • When Christine or Michael failed to engage fully with services provided were services sufficiently persistent in promoting engagement or were there missed opportunities?  • Did the services within agencies have effective procedures to deal with non-engagement or non-attendance and were these procedures followed?   • When different services within agencies became involved with Christine or Michael, were their histories sufficiently explored and understood to enable these services to fully understand the vulnerabilities and risks?   • When Christine returned to Wakefield in February 2011 from an out of area placement did the Safeguarding and Family Support Directorate effectively share information with partner agencies in health to enable them to provide adequate support?   • Did the services effectively communicate with Christine and Michael in a way that they could fully understand? Were there any missed opportunities to communicate more effectively?  • Were there any missed opportunities to share information effectively with partner agencies?   • Did practitioners use line-managers or supervision to effectively discuss any concerns that they had about Christine or Michael?   • Is there any evidence of practitioners being overly-cautious or inhibited due to cultural issues?  • Was appropriate action taken in line with West Yorkshire Procedures in relation to any concerns about possible child sexual exploitation?   • Is there any evidence that a focus on the issues of possible child sexual exploitation impacted negatively on the identification of other risks?   Time Period  1.8 This Serious Case Review has covered the period from 1st January 2011 to the date of Christine’s death.   1.11 The independent author of the Overview Report is Professor Pat Cantrill. Professor Cantrill has led a number of high profile Serious Case Reviews. She has considerable experience in cases of domestic abuse and child sexual exploitation. Professor Cantrill is a Visiting Professor at Sheffield Hallam University and the University of Lethbridge in Canada.   2.  Case Summary   Christine  2.1  Christine became known to specialist safeguarding services in 2007. At this point, concerns focused on the following issues:  4   • Challenging behaviour within the home • Risk-taking behaviour • Use of alcohol and drugs • Going missing from home • Association with older males and possible Child Sexual Exploitation   2.2 Christine was made subject to a Child Protection Plan in 2007 as a result of these concerns. However despite intervention by professionals, these problems escalated and in December 2007 Christine was accommodated by the Local Authority initially at a local children’s residential unit and then in a foster home.   2.3 Whilst in foster care these concerns lessened and Christine returned home to live with her mother in August 2008 with support from professionals. However in November 2008 the situation deteriorated and Christine was again accommodated by the Local Authority.  2.4 Between August 2008 and February 2010 Christine was placed with foster carers but experienced a number of placement changes as a result of challenging behaviour and concerns relating to risk taking behaviour, going missing and suspected sexual exploitation. In February 2010 the decision was made that it would be in Christine’s best interests to be placed in a therapeutic residential placement outside the Wakefield district.   2.5 A settled period followed however in December 2010 Christine, then aged sixteen, indicated a desire to leave her placement. A decision was subsequently made to support Christine to live independently in a flat in February 2011.  2.6 After this point, concerns about Christine’s welfare again began to increase. She appeared to become increasingly hostile to professionals and had stopped attending college. She disclosed that she had experienced domestic abuse from her ex-boyfriend.  2.7 Christine remained in this placement with support however concerns persisted and in July a local police officer reported concerns about adult males visiting Christine’s flat and possible use of drugs at the property.  2.8 Christine indicated her intention to return to Wakefield in August 2011 stating that she was being harassed by local males. After her return to Wakefield she was placed briefly in bed and breakfast accommodation before moving with her agreement to experienced supported lodgings providers.  2.9 Whilst in supported lodgings, concerns about Christine’s welfare persisted. In particular, these concerns centred around suspected drug and alcohol use, periods of absence from the placement and possible sexual exploitation.  2.10 In December 2011 partly as a result of requests made by Christine herself and partly as a result of concerns about the impact of Christine’s behaviour on other resident young people, the decision was made to support Christine to move from supported lodgings to supported independent living in a flat in central Wakefield.   2.11 Professional support continued after Christine moved to this supported tenancy however despite frequent visits from professionals, concerns remained. There were several complaints from neighbours about noise from Christine’s tenancy and frequent visitors to the property.  5  Professionals continued to hold concerns about drug use and suspected sexual exploitation although Christine denied this. In March the parent of a friend contacted the Local Authority and informed them of concerns about possible sexual exploitation and in addition another young person also raised similar concerns.    2.12 On several occasions, Christine had expressed concern about the welfare of her older sister due to domestic abuse and threats by her older sister’s boyfriend, referred to in this Serious Case review as Michael. Professionals had met with Christine’s older sister on several occasions and offered advice and support in relation to domestic abuse and alternative accommodation. Christine’s older sister subsequently separated from her boyfriend.  2.13 On 12th March 2012 Christine was murdered in her flat by her older sister’s ex-boyfriend. A young female friend of Christine was also murdered. Christine’s older sister was kidnapped and the ex-boyfriend made an attempt to flee the country.  2.14 After Christine’s older sister escaped, she was able to raise the alarm. The adult male referred to as Michael was subsequently arrested.   Michael  2.15 Michael first became known to agencies in Wakefield in October 2007. He was an unaccompanied asylum seeker who had fled Afghanistan.   2.16 Although he claimed to be fifteen years old, an age assessment was undertaken in line with guidance and his age was assessed at sixteen years.  2.17 Michael was initially placed in a local hotel however after a suicide attempt, he was placed in a local authority children’s residential unit in November 2007, where it is believed that he first met Christine’s older sister.  2.18 In March 2009 Michael moved from this residential unit to a multiple occupancy supported tenancy, where he received support from the Local Authority.  2.19 The Independent Overview Report provides a detailed account of the services and support provided to Michael until the incident in which Christine and her friend were murdered in March 2012.  2.20 Michael has since been convicted of the murder of Christine and her friend. He has been sentenced to serve a minimum of thirty four years in prison.  3.  Conclusions and Learning   3.1  This Serious Case Review has identified a number of areas of good practice including the degree to which some professionals were persistent in attempting to support and guide Christine in an effort to reduce risk.   3.2 The Serious Case Review has also identified missed opportunities to protect both Christine and her older sister and to assess the risk posed by Michael.  3.3 The Independent Overview Report identifies learning for agencies in the following areas:  6   • Working in partnership to identify risk and to safeguard and protect teenagers  • Domestic abuse and in particular, abuse within teenage relationships  • The provision of services to young people who are placed outside of the local authority area  • Identifying and reducing the risk of sexual exploitation   • The provision of mental health services to young people in crisis  • The provision of accommodation to vulnerable young people and particularly young people who are leaving the care system  • The process of age assessment of unaccompanied asylum seeking children and the need for these to be reviewed in the light of new information  3.4 Prior to the completion of this Serious Case Review, changes have already been made in relation to the delivery of services to young people and care leavers.   3.5 These changes include the review of mental health services provision in the district and new systems to support the allocation of independent accommodation to care leavers as well as the development of a local Child Sexual Exploitation Strategy and Action Plan and new multi-agency arrangements to tackle child sexual exploitation in the district.  3.6 Following the completion of this Serious Case Review a detailed action plan has been developed to enable the implementation of the recommendations that have been made for agencies. This action plan will be monitored by the Safeguarding Children Board.  4. Recommendations    The Mid Yorkshire Hospitals NHS Trust  4.1 The LSCB member for MYHT will provide the LSCB with an action plan indicating how awareness of the risk factors for child sexual exploitation will be communicated to staff. This will specifically include risks to children of over the age of consent.  4.2 The LSCB member for MYHT will ensure that all staff within the GUM service who work with children and young people in 1:1 situations are included in the Trust Safeguarding Supervision Policy.  4.3 Raise awareness of purpose and function of Looked After Health Team with specific consideration to Increased Vulnerabilities  SPECTRUM Community CIC  4.4 To develop a care pathway for Young People accessing Spectrum Community Health Services who misuse substances.  4.5 Educational programme will be extended for CASH outreach nurses to include: mandatory  7  training related to substance misuse and qualification as a non-medical prescriber.  4.6 The Named Professional Safeguarding Children will amend the Safeguarding Supervision Policy (2011) to include that  prior to an arranged Safeguarding Supervision session Outreach CaSH nurses will identify which young people are currently open on their caseload at:  • Child Protection Level • Child in Need Level • ‘Looked After’ Children • Any case identified by the CaSH outreach nurse has having poor multi-agency working.  4.7 The Executive Lead for Safeguarding (Spectrum) will provide the LSCB with an action plan indicating how awareness of the risk factors for child sexual exploitation will be communicated to staff. This will specifically include risks to children of over the age of consent.  South West Yorkshire Partnership Foundation NHS Trust  4.8 The CAMHS referral process should be strengthened   • There will be clear criteria with regard to what constitutes an urgent referral • Standards will be developed for responding to urgent referrals  • The referral documentation used by agencies should be reviewed to ensure that it elicits the information required to ensure the child or young person gets the right service at the right time. • A clear care pathway should be agreed outlining a Childs journey in CAMHS once a referral is made, (including potential for disengagement) through to effective and safe discharge or transition.  4.9 An examination should take place of how complex cases and cases and multiple repeat referrals are managed and a pathway and process developed to ensure effective outcomes for children and young people.   4.10 The development of a system and process should include multi professional consideration of cases where children and young people are identified as vulnerable or identified at risk.  4.11 That a review and analysis of risk, its assessment and management in the CAMHS service is undertaken, this should include:  • What is understood about risk assessment and management in the CAMHS service and in particular what is understood by the different professional groups?  • The assessment tools used , including specific tools for specific issues(CSE for example)  • The quality of assessments undertaken, including regular reassessment at key points of child’s journey(inclusive of discharge planning)  • Are the risks identified translated into the care packages provided to children and their families?   This will result in clear recommendations for practice; recommendations will be incorporated into a risk management appendix for the Clinical Risk Assessment and Management Policy for  8  South West Yorkshire Foundation Trust.  4.12 That a targeted programme of learning and development takes place in relation to Child Sexual Exploitation (CSE).This will include identifying and recognising the signs of CSE in young people and training staff to undertake specific risk assessments related to CSE and heighten the awareness of communicating the identified risks.  West Yorkshire Police  4.13 West Yorkshire Police to review the process of domestic violence notification to the Police Safeguarding Units with respect to timeliness and management oversight  4.14 West Yorkshire Police to ensure that all cases that meet the criteria for MARAC are referred in a timely manner  WDH  4.15 To review the current lease arrangement and working protocol between WDH and Wakefield Council (Vulnerable Adult Services) for the provision of temporary accommodation.  CRI Rebound  4.16 To ensure that the background history of young people who access the service, in particular any previous or current safeguarding concerns, is identified and recorded.   When a young person indicates that they do not wish information to be shared with their social worker, this must always be explored with them to identify the reasons for this and they must always be advised of the exemptions to confidentiality.  4.17 The working relationship between Rebound and SPECTRUM should be strengthened.  WMDC Safeguarding and Family Support Services   4.18 The current review of the organisational structure within Safeguarding and Family support should establish clear lines of accountability and responsibility within the Leaving Care Service, for both management of staff and for service users.  The Leaving Care Team should also establish a system to notify partner agencies when a young person eligible for services moves into or returns to the Local Authority area.  4.19 The Strategic Group looking at Domestic Abuse should ensure that it develops an action plan to address Domestic Abuse between young people.  In the meantime there should be an exercise to identify the scope and scale of DA between service users within the Leaving Care Service resulting in a clear action plan to address the needs of both the victim and perpetrator.  4.20 The way in which age assessments/risk assessments are conducted in respect of unaccompanied asylum seekers should be considered in line with new national guidance and the local training already commissioned.  This should emphasise the expectations that age and risk assessments should be reviewed to ensure currency.  4.21 To develop a new mechanism for the multi-agency discussion of cases where the plans that have been made for an individual young person are not being achieved and where the young person is still at risk. This system should be applicable to any young person including LAC and  9  Care Leavers and should allow for reflection, review and also challenge of the intervention of each agency.   WMDC Youth development and Support Service  4.22 The YDSS will ensure that all staff are clear about their responsibilities for undertaking assessments, planning interventions, sharing information and recording all information.  4.23 Changes to be made to YDSS recording practices that include:  • All records to be held electronically  • Managers to agree the correct assessment and planning tool for each service area and communicate this to relevant staff  • Managers to ensure they have access and can use the range of electronic databases used by the staff they supervise.  4.24 Information sharing consent forms that are signed by young people to be updated to ensure they contain clarity on how risk management and safeguarding impact on confidentiality and have an annual review built into them.    4.25 Supervision arrangements to be amended to ensure the following.  • The supervision template prompts the manager to:  � ensure information sharing consent forms are in place and renewed annually for all open cases. � an assessment and plan is in place for each case � ensure that issues of risk management, safeguarding, inter-agency working and information sharing and wider family concerns are considered in relation to each case where relevant. � ensure that follow-up action previously agreed has been completed. � record whether the interventions discussed have been undertaken within the required standards and policy and practice guidance. � ensure the case recording is of a sufficient standard.  • Quality assurance of line manager supervision to take place in line with Family Services policy and Service Manager to follow up deficiencies identified by the audits.  4.26 Targeted Youth Support Services to establish a case planning forum that quality assures the assessment, planning and review of all TYS cases.          