Death of a 17-year-old boy as a result of multiple stab wounds. Learning is embedded in the recommendations. Recommendations include: seek assurance that there are formal processes to collect and analyse data around fixed or permanent exclusions and managed transitions; undertake a review of the themes and patterns of behaviour which constitute a 'persistent breach of school behaviour policies' and provide evidence of the effectiveness of approaches used to prevent exclusions for those who are overrepresented and at risk of exclusion from education; undertake work to understand young people's experience of alternative provision in the borough, especially young people with complex needs, being exploited/at risk of exploitation or who are disproportionately affected by exclusions; undertake a consultation process with Black and ethnic minority children, practitioners, community groups and families to understand the reluctance to engage with early help services and devise an action plan which addresses the barriers; undertake a review of referrals received, support offered and take-up of services for ethnic minority groups; and assurance that school behaviour policies have clear guidance and a definition of 'persistent breaches and school exclusion' and that they are based on guidelines provided by the DfE regarding behaviour and discipline in schools.
      
 Title:  Local thematic child safeguarding practice review: Young Person SC. LSCB: Sandwell Children’s Safeguarding Partnership Author: Gillian Ming Date of publication: 2023  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.                           1  Local Thematic  Child Safeguarding Practice Review: Young Person SC                                     INTERNAL REVIEWER: GILLIAN MING 2  CONTENTS     Page:  1 Introduction  3 2 CSPR Process 4 3 Background to this Local Review 5 4 Identifying Meaningful Local Learning 7 5 National Context  9 6 Sandwell’s Strategies to Prevent School Exclusions     10 7 Research Findings on Alternative Provisions 13 8 Section Summary and Recommendations  14 9 Exploitation and Disproportionality in Sandwell 15 10  What is known about Sandwell’s Response to Exploitation and Section Recommendations 18 11 Report Summary  22 12 Recommendations 25 Acronyms and References 26  3  1. Introduction The reason for undertaking this Local Child Safeguarding Practice Review  1.1 This Child Safeguarding Practice Review (CSPR) was directed by Sandwell Children’s Safeguarding Partnership (SCSP) following a serious incident notification and Rapid Review Panel meeting regarding a 17-year-old young person, identified as being of Black Caribbean heritage, who for the purpose of this review will be referred to as ‘SC’. SC was found with multiple stab wounds in a street in Sandwell and later died as a result of the injuries sustained.   1.2 An 18-year-old male who was known to the victim was arrested and charged with murder the day after SC died. There does not appear to be a clear motive for the murder, however both SC and the perpetrator had suspected links to gang activity, and in SC’s case there had been previous concerns he was at risk of being exploited. The suspect was subsequently convicted of murder and imprisoned.  1.3  Both the victim and the alleged perpetrator were known to multiple services across Sandwell, including youth justice services, education, health, children’s social care and the police. In the year preceding this death, there were increases in police reported incidents and SC was known to ‘Horizons’, the local Exploitation Team, and had been reviewed at a Multi-Agency Child Exploitation (MACE) meeting; a meeting developed as part of the local contextual safeguarding pathway to drive effective multi-agency intervention and support.   1.4 The intention of this report is not to go into specific details of SC’s life, or to analyse multi-agency engagement at key points of the young person’s journey. The scoping information received from agencies to inform the rapid review process was scrutinised in detail and provided an insight into agencies’ involvement at key points of SC’s life which agencies in Sandwell are well sighted on and areas for learning or improvements have been monitored for progression through formal action plans.   1.5 This review will follow the conclusion of the Rapid Review Panel that learning from this case was best considered as part of a broader thematic review and examine the national notion found from much research and the rising concerns about how ‘some ethnic groups are marginalised by the systems’, the overrepresentation of ‘black boys excluded from mainstream education’ and the connecting links to child exploitation and criminal activity for these young people.    1.6 The decision of the Rapid Review Panel, as endorsed by the SCSP and agreed by the National Panel, sees an innovative approach to undertake this review by asking the Child Exploitation Board (CEB), a  subgroup of the SCSP, to lead and complete a thematic review of systems and structure in the areas stipulated which will not include an examination of agencies’ practice in a specified time leading up to the incident, as this was covered and satisfied by the Rapid Review process.  1.7 The review meetings were led by the Chair of the CEB, with representatives and contributions from the statutory and relevant partners, as well as attendees from Sandwell Community and Voluntary Organisations (SCVO), all the agencies who 4  were known to provide direct services and/or support to children and families across Sandwell.   1.8 The report was compiled and authored by the Safeguarding Partnership Manager who had no prior involvement in the delivery of services to SC. The report is designated as a Local Thematic Child Safeguarding Practice Review and complies with the local and national requirements for undertaking such reviews, including notifying the National Panel, DfE and Ofsted of the date the report will be published 7 working days beforehand. 1.9 The Child Exploitation Board leading this review would like to thank all those who have been involved in this review: the openness and reflections have been invaluable.   2. The CSPR Process used for this review   2.1 The National Child Safeguarding Practice Review Panel has agreed with the decision of the local Rapid Review Panel for this to be undertaken as a ‘thematic review’ focusing on the following two distinct areas:  A. The disproportionality of cohorts involved in exploitation (in particular needs to address how black children are seen and perceived by the youth justice system and the safeguarding systems, particularly in the context of exploitation and gang activity). B. A spotlight review of the cohort of children known as being exploited  or at risk of exploitation linked to school exclusions, CME, and/or have an EHCP/SEND which will lead to raising awareness of more targeted intervention and strengthen processes.   2.2 The approach in undertaking this thematic CSPR included forming two Task and Finish groups: • The School Exclusion Group – spanning primary and secondary school years, and the association/ links to exploitation   • The Disproportionality Group - response and intervention for some groups, i.e. young black adolescents.  2.3 Leads for each group were nominated for their associated seniority, knowledge and involvement in the specific areas noted above. Information was scrutinised in the groups and later compared against the findings of similar reviews, research and literature.  2.4 The groups were merged to analyse the findings and conversations extended to aid a true and honest reflection as to whether there is evidence of black boys having higher numbers of exclusions from mainstream education, being subsequently connected to child and criminal exploitation, being marginalised by the systems and overrepresented in receiving heavy/harsh sanctions.   2.5 The final task for the groups was to elevate the system and practice challenges and the required responses from agencies in Sandwell to ensure equal access, opportunities and support to those children and their families; to identify what improvements and changes are required in order to be more confident and 5  assured that all agencies are collectively working together to bring about the required change; and to agree the recommendations that are considered to make the changes happen.   3. Background to this Local Review   3.1 This thematic review seeks to examine structures and processes that should be equally applied to all children, rather than a review of agencies’ practices. With this, the Child Exploitation Board sought to reach SC’s parents to gain their view and contribute to this review in terms of their experiences of the educational systems, and access to services and support for SC. However, no response was received and more recent attempts to reach the family and share the findings of the review again were met with no reply.    3.2 In undertaking this CSPR process, the Child Exploitation Board was mindful that this report was to be written in a style which acknowledges the wealth of work currently underway by partners across the borough in relation to exploitation, alongside the impact of what happened to SC, his family, friends, the local community and the many professionals who knew him and other young people in similar circumstances.  3.3 SC became known to Children’s Social Care at the age of 8 months due to concerns about neglect and drug misuse in the home where he lived. These concerns remained prominent as reoccurring themes in numerous safeguarding referrals made throughout SC’s life.   3.4  At age 8 years, SC was referred to the Behaviour Support team (now known as the Special Advisory Teacher Team: SEMH) by primary school who were struggling to manage his disruptive and challenging behaviour. This continued and at aged 10 years there was a managed move to another primary school which lasted for only 2 months before SC was dual registered with the original primary school and a local PRU.   3.5 At age 11 years, SC returned unaccompanied from a trip abroad owing to his mother having been detained, resulting in SC being cared for by father and close relatives.    3.6 When starting secondary school, SC was placed in small nurture classes with no more than 15 students and received mentoring for one hour per week. SC struggled to concentrate and exhibited challenging behaviour which led to frequent periods in isolation.   3.7 Mother returned before SC started in Year 8. Early in the term, following aggression towards staff and others, SC was temporarily moved to an alternative education provider. At the end of this short-term provision, SC did not want to return to the original setting. This was supported by mother and so home tutoring was paid for by the school until a smaller mainstream school was found.   3.8 SC was enrolled at another secondary school during Year 9 where he remained until the end of Year 11 and finished his education, obtaining one GCSE in Maths. Attendance at points when he was wearing an electronic tag was high at 97% 6  however, once the tag was removed, attendance dropped to 74% by the time he left Year 11. SC was referred for post 16 options to Connexions, however at the time of the incident SC was NEET.  3.9 At age 14 years, SC was the subject of a Child Protection Plan (CPP) under the category of neglect and the increased involvement in criminal activity, county lines and unreported missing episodes. After 9 months, the case stepped down from CPP to Child in Need, closing a few months later.      3.10 SC was also involved with the Youth Justice Service for 2 years from age 13 years and during that period received three Youth Referral Orders for assault, robbery and violent disorder. During the same period, SC was given an Intensive Supervision and Surveillance Order (ISS) which included an electronic tag and curfew and, although successful, a further final Youth Referral Order was issued shortly afterwards.  3.11 Through the lens of WMP, there are 16 incidents logged against SC; the majority see him being an ‘offender’. Records date back to SC at aged 11 years when a Child Abuse Non-Crime was recorded with suspicions of familial  links to gangs and increasing concerns regarding SC’s association with older teenagers and deteriorating behaviour. Later in the same year, SC was linked to anti-social behaviour in the neighbourhood.  3.12 Between the ages of 12 to 16 years, SC was arrested at least six times and received charges for assault, attempted robbery, possession of Class A drugs (heroin), violent disorder, common assault and malicious wounding, some of which related to county lines. During the same period, there were also allegations/suspicions of further crimes with insufficient evidence to pursue or prosecute.   3.13 As a victim of crime, SC reported an assault to WMP on one occasion and was recorded as a victim of trafficking for exploitation when he was found in London.   3.14 SC presented at A&E 6 times between the ages of 11 and 15 years – one of these visits was with facial injuries having allegedly been assaulted and another with a leg injury reportedly occurring when jumping over a fence. At age 12 years, SC saw his GP and requested help with anger management. From this SC was referred to CAMHS and offered counselling.    3.15 There is much evidence to suspect many years of neglectful and compromised parenting with exposures to parental offending behaviour including shoplifting, drug misuse and trafficking; domestic abuse; potential poor parental mental health, and lack of adequate supervision.   3.16 On at least two occasions, Mother was escorted via ambulance to A&E due to mental health related incidents and, following a referral for a mental health assessment, Mother was found to be suffering with depression and anxiety stemming back over 10 years.   3.17 The background covered so far offers a brief account from what was ascertained at the Rapid Review meeting, where Mother is depicted to be the main and most significant carer. However, SC’s father did have a role but, as is evident in many 7  reports post serious safeguarding incidents, less is known about fathers, and in some cases there seems to be an acceptable absenteeism or very little information about the role and involvement of fathers.    4. Identifying Meaningful Local Learning  4.1 In reaching the decision and shaping the direction of this review, the Rapid Review Panel reflected on the significant progress and developments to understand the real nature of criminal exploitation across Sandwell. This includes through the Horizons (Exploitation) team, the interface and involvement of partner engagement, the exploitation process around the Exploitation Hub and MACE processes, which were developed and tailored to more effectively ensure intervention and prevention for CCE is tracked and managed, and the linked actions around those identified as at risk of exploitation. 4.2 The Rapid Review Panel was able to identify the strengths in partnership working and a ‘drive to make a difference’ from the enthusiasm, dedication and commitment of the Horizons team and partners to engage with young people, as was the case with SC. There was also evidence of the support provided to children and families across all forms of exploitation, which the Rapid Review Panel felt demonstrated a ‘true’ commitment and drive to reduce the risk to Sandwell’s children and young people identified as being at risk of exploitation.  4.3 The Rapid Review Panel considered recent/current local activities to combat child exploitation, recognising that child exploitation is an area of priority within the SCSP’s Multi Agency Safeguarding Arrangements (MASA) and in its structures in forming the Child Exploitation Board to lead and coordinate the work to protect children from all forms of exploitation.   4.4 Through the CEB, partners from across the borough and region join together to devise, monitor, improve and assure that the safeguarding systems and practice, and the arrangements to tackle child exploitation, are robust and well rooted in the coordination of ‘best practice’ models.  4.5 Sandwell is a member of the Contextual Safeguarding Local Authority Interest Network (LAIN) leading and championing the work devised by leading expert Carlene Firmin from the University of Bedfordshire across the multi-agency workforce. Sandwell has identified champions who have committed to attending events and incorporating principles of contextual safeguarding into practice across Sandwell’s partnership, ensuring there is understanding and approaches to respond to young people’s experiences of significant harm beyond their families.   4.6 Through the CEB, a self-assessment and action plan were the outcomes from the findings of the National Panel’s thematic CSPR published in March 2020 titled ‘It was hard to escape’. Sandwell’s response to this national review was initiated by the Independent Scrutineer where the report and recommendations were considered by members which showed:  • Of the learning areas covered in the report, Sandwell was able to correlate areas already included in the workplan or have the evidence that could satisfy the response required; this was mainly around identification of problem/areas/size/ neighbourhoods.  8  • Evidence to demonstrate which children are predominately affected by area; cohorts; minoritised ethnic groups and disproportionality • Sandwell was able to add context and detail for activities underway and linked to:  o Risk management across the frontline and understanding level of risk and plans o Having flexible services to respond to critical moments – (St Giles ‘a trauma informed youth work programme’ being established within the local hospital will be instrumental to this) o Agencies’ contributions  o Understanding balance of victims and perpetrators o Pattern of school exclusion and value of alternative provision  o How the MASA and scrutiny programme assist in focussing the work of exploitation  o Gaining the voices of children to inform response  4.7  There were 27 learning points in the report, from which there is work developed or underway in 20 (74%). Work is not yet planned in 7 areas, where activities do require further details on the basis of those recommendations which called for a National Panel and Government steer, additional resources and guidelines.    4.8 Partners in Sandwell also work closely with the West Midlands Violence Reduction Unit (VRU), which is instrumental in the activities and plans to tackle exploitation in the borough.  4.9 In March 2020, via the Secretary of State, Sandwell was called to provide evidence of activities being undertaking to tackle serious youth violence/exploitation in the borough. This followed being identified as one of 30 local authority areas with the highest numbers of young people harmed as a result of serious violence/exploitation.    4.10 Through the Quality of Practice, Performance and Assurance Subgroup of the SCSP, the outcome of a Multi-Agency Case File Audit (MACFA) in December 2020 focused on Child Exploitation and provided some evidence and assurance of the understanding of the local profile of exploitation including; issues, hotspot areas and level/appropriateness of interventions.  4.11 It was felt proportionate to utilise the existing work being undertaken to tackle exploitation as the format for this CSPR, as this will enable a wider systems-based analysis and response rather than a focus on the individual approach afforded to this family.  4.12 Whilst there was evidence of a strong partnership approach to tackle exploitation, with a strategy, workplan and pathways to support children and families such as SC being in place, it was also acknowledged that support at a much earlier stage is crucial, and work in raising awareness of the impact of adverse childhood experiences and how this can act as a push factor and increase a young person’s vulnerabilities to being exploited is underway in Sandwell.    4.13 Before moving on to the next section of this report, it is important to emphasise that agencies were able to demonstrate a footprint in SC’s journey where good practice was observed and equally, through reflecting on practice, a number of both single and multi-agency action plans are in place to drive system and culture changes to instigate positive improvements. Though in some areas, developmental work is at 9  the early stages, the drive, commitment and enthusiasm across partners in Sandwell was very evident.    5. National Context   5.1  SC would have been one of the estimated 50,000 children in the UK thought to be exploited, and his story tells of an organised criminal world which skilfully coerced, controlled and eventually harmed him with fatal consequences. 5.2 This Review wants to influence and affect the required change, through the lens of SC’s story, locally, regionally across the West Midlands, and nationally; challenging decision and policy makers and the UK Government to take proactive action.  5.3 There have been countless reports and articles over the past 3 or more decades that have drawn a direct connection between school exclusions, exploitation, knife crime and youth imprisonment. From a national perspective, the last decade or so has seen growing concerns in relation to the risk and harm faced by young people both at risk of and entrenched in exploitation.   5.4 What is overwhelmingly prominent in all publications viewed covering exclusions and exploitation is the disproportionate exclusion of black boys by schools, showing a stark over-representation of black young people in the youth justice system, with black children being at least four times more likely to be criminalised than their white British counterparts.  5.5 Equally, there have been countless reviews that have identified a significant disparity in exclusion from mainstream education amongst young black boys. A national priority review dating back to 2006 published by the Department for Education and Skills (DfES) titled: The Exclusion of Black Pupils “Getting it. Getting it right”1, where the findings are strikingly identical to the Timpson review undertaken in 2019 which, although some 13 years later, demonstrates that no positive progress has been made. The same issues are not just present, but the picture and position for this cohort of young people is even more dire now despite all the early indicators and intended strategies to bring about change.   5.6 There is evidence and published data suggesting that since 2005 the percentage of black young people in custody has doubled; currently almost 50% of the youth justice system is made up of young people from black and minoritised ethnic groups. What’s more, whilst the numbers for black young people entering the system is heavily increasing, the figure for white children is decreasing.   5.7 To a greater or lesser extent, all publications relating to school exclusion state, ‘excluded pupils are likely to be repeatedly involved in crime’ and provide evidence that suggests a strong correlative relationship between school exclusion, exploitation and youth violence (though it is generally agreed it is not necessarily causative).  1 https://dera.ioe.ac.uk/8656/1/exclusion%20of%20black%20pupils%20priority%20review%20getting%20it%20getting%20it%20right.pdf  10   5.8 A number of small-scale, qualitative studies were also viewed. All found that black pupils experienced differential treatment by teachers in the form of low educational expectations and a variance in reactions to behavioural transgressions.  5.9 In autumn 2018, the Department for Education (DfE) commissioned an independent literature review on behalf of Edward Timpson CBE to enhance the understanding of the continued disproportionate exclusion of certain pupils from English schools. This included Black Caribbean boys, children with special educational needs or disabilities (SEND) and those eligible for free school meals (FSM). The DfE examined the data further via logistic regression analysis, which showed that while controlling for other factors including background, children from some groups (such as black Caribbean children) are more likely to be excluded than white British children, while children from some other groups (such as children from an Indian background) are less likely to be excluded.  5.10 There was a common factor seen in information viewed in that they all set out to focus on the children who are more likely to be excluded and to find the reasons that apply to each group. Many of the issues, risk factors and preventative strategies overlap and apply to more than one group. Simultaneously, many children can be categorised in different ways and can fall under multiple risk factors, for example poverty, ethnicity, challenging backgrounds and SEND.  6. Sandwell’s Strategies to Prevent School Exclusions   6.1      The task group for education aimed to assist in identifying whether or not there is                          disproportionate exclusion for children of certain ethnic groups and review the                                         position for black boys; including the type and effectiveness of any preventative             approaches used to avoid exclusion and pupils’ engagement in and experiences             of the exclusions process.  6.2 Information collated from the ‘School Exclusion Task Group’ considered the range of approaches across both primary and secondary school years to prevent school exclusions, where there are known/suspected association/links to exploitation.  6.3 What was gleaned from this group is that Sandwell Local Authority supports children/young people who are at risk of permanent exclusion through offering in-school preventative work as well as alternative solutions such as managed transitions. Sandwell LA recognises that a permanent exclusion has a negative impact on a young person’s life chances.  6.4  The DfE guidelines and statutory regulations around permanent exclusions and suspensions are followed within Sandwell schools and the Fair Access and Exclusions Team work with both schools and parents to ensure that statutory processes are followed. It was also shared that Head Teachers and Governing Bodies have the power to exclude a pupil and this should be for serious or persistent breaches of the school’s behaviour policy; and/or where allowing the pupil to remain in schools would seriously harm the education or welfare of others. Exclusions should be used as a last resort.  11  6.5  Sandwell has established a ‘Fair Access and Exclusions Team’ to oversee and to ensure that schools follow the law and process regarding permanent exclusion and parents and students know their rights to appeal a decision through an independent review. Where possible, the team will support students, parents and the schools to find alternative solutions to a permanent exclusion. Solutions include on-site support from the Preventing Primary Exclusions team (PPE), preventative placement at an Alternative Provision / Pupil Referral Unit, or a managed transition to another school. If the pupil has an Education, Health and Care Plan, an emergency annual review meeting should be called with professionals working with the child/young person to discuss change of SEN and possible change of provision.   6.6 However, even though schools and personnel in the education directorate are well informed of the statutory processes, some multi-agency partners are not aware of the statutory regulations around permanent exclusions, suspensions and use of alternative strategies such as managed transitions as well as how this translates to the rights of children, parents and schools. 6.7 In addition to this, it was not possible to demonstrate how multi-agency partners were consulted or invited to be involved/mediate when alternative strategies are being considered prior to ‘serious breach or persistent breaches of the school’s behaviour policy’; and where possible, mediatable interventions could possibly enable pupils to remain in schools.   6.8 Data on permanent exclusions and suspensions within Sandwell shows a steady reduction in permanent exclusions and suspensions over time up to 2020/21. It was noted that the impact of Covid and subsequent lockdowns have had an impact on figures for both 2020/21 and 2021/2022. This has impacted more on suspensions as students transitioned back into school following long periods of being at home and the impact that has had on their social, emotional and mental health needs. There have also been new expectations on Covid safe behaviour placed on both schools and students.   6.9 The data presented shows that the majority of children considered by the Fair Access Panel were from a white British background, however, what the data could not provide was the figure for children from a black and minoritised ethnic heritage who received fixed or permanent exclusions and those considered for managed transitions. Nor was data available for children of a black and minoritised ethnic background with an EHCP and SEND. What the data did show was some evidence of the impact of strategies used to support pupils at risk of permanent exclusion, with the numbers of pupils who were permanently excluded from school steadily reducing.  6.10 It was shared that in both the Primary and Secondary sectors, Sandwell had fewer students permanently excluded than their regional and statistical neighbour comparators.   6.11 The number of permanent exclusions and suspensions each school makes in Sandwell is monitored through Quality Standards and Performance meetings on a half termly basis. These meetings are attended by Head Teacher representatives as well as LA Officers from School Improvement, SEND, Attendance Service as well as the Fair Access and Exclusions Team. Each school is rag rated and additional support is offered to “red rag rated” schools if they are flagged as meeting the following criteria: Primary Schools: 6 or more 12  suspensions and/or 2 or more permanent exclusions. Secondary Schools: 61 or more suspensions and/or 3 or more permanent exclusions.  6.12 However, the team were unable to produce data on ethnicity / disproportionality due to a new casework management system being introduced and capacity issues within the team. This will be resolved through training and support from the data intelligence unit. 6.13 In Sandwell, there are clear strategies to support students at risk of permanent exclusion. The BLISS strategy in Primary schools supports the identification of pupils at risk of permanent exclusion. The majority of pupils will receive support from the Special Advisory Teacher for Social, Emotional and Mental Health (SAT SEMH) and the Preventing Primary Exclusions Team (PPE) in order to prevent exclusions. This was said to aid the identification of any special educational needs. The PPE team provides onsite support for 6 weeks modelling successful strategies to school staff to support children. Schools can refer to the pupil referral unit for a preventative placement or arrange a managed transition (through the Fair Access Panel). 6.14 In Secondary schools, the SAT SEMH Team and Fair Access and Exclusions Team work closely with school pastoral leads to collaboratively reduce permanent exclusions and suspensions. This work is mainly done through individual casework via the Fair Access Panels and development days. Multi agency presence and involvement is increasing at these panels through the attendance of Community Police, VRU and the Horizons Team, with significant work undertaken to develop supportive actions.   6.15 Data on exclusions is analysed and used to identify gaps and next actions for development at Fair Access Management Board. Regular development days are held with schools, alongside action research projects to inform practice. For instance, research was conducted around supporting successful managed moves/transitions which then led onto practice; this was to ensure that transitions are well planned, students have a ‘trusted adult’ to support them and their family and both schools are well informed throughout the process.   6.16 Managed Transitions are seen as a ‘fresh start’ opportunity and Sandwell’s involvement in the national research and pilot project on managed transitions led to the employment of the Secondary Reintegration Team as part of the Fair Access and Exclusions Team to support transition. It is too early to see the impact of the team due to being established less than a year ago and it remains under review. 6.17  However, it is noted that although all schools are asked to organise managed moves/transitions through Fair Access Panel, some schools will still organise moves for themselves e.g. multi-academy trust schools may make their own arrangements. There is also a lack of consistent data around managed transitions/moves which needs to be addressed. Multi-agency partners are not always invited or attend planning meetings around supported managed transitions; this includes social workers who may be involved with the child and family. This is an area of concern and does present a significant gap in the system.  6.18  The process for students with an Education, Health and Care Plan (EHCP) who are at risk of permanent exclusion and those also linked to the statutory processes for SEND is that schools are advised to hold an annual review of the 13  EHCP before exclusion, so that a multi-agency discussion can be held with the student, parents and school about the needs of the pupil and the provision stated in the plan. The outcome of the annual review might be that the plan is amended to show how the student’s needs have changed and this may also impact on provision provided. Pupils with EHCPs at risk of exclusion are seen as a priority.   7. Research findings on Alternative Provisions (AP)   7.1      There are different models and approaches that describe ways and provision             types to respond to excluded pupils including children showing the need for            multiple and complex support. However, evidence of impact and the effectiveness            of these varying approaches was limited.  7.2 Much of the literature reviewed reflects on the role and added value of AP, with many of the studies suggesting pupils are positive about AP and the teachers, and report feeling safer, more engaged and happier than in their previous experiences of mainstream education, even when their academic outcomes were low. There were, however, some research papers in which pupils reported negative aspects of their experience of AP: these included feeling isolated, not having choice around whether to attend AP, not being able to study specific subjects or courses and often low academic outcomes. Young people attending AP in Sandwell did not contribute to this review and this may be an area to explore further.      7.3 When looking at research and reviews on managed moves/transitions, the findings in all studies viewed found that as these were voluntary agreements with no statutory template or guidance governing them, success could only be seen in those areas where local authorities are integral to and facilitating the process and ensuring collaboration and accountability across schools. Sandwell’s involvement in the research paper commissioned by the DfE, ‘Timpson Review on exclusions and alternative provision’ (2019), was recognised for good practice.  7.4 In collating and comparing the information presented by Sandwell Education Directorate and the findings from research studies, there are indicators of managed moves in Sandwell having some of the components found in research to aid success, including:   • There is a clear agreement between the excluding and receiving institutions  • Inter-personal relationships between staff and pupils and among pupils are prioritised  • The process is transparent; with all parties involved understanding what is happening; and decision-making includes the child’s views  • It was also clear that although the implied or explicit threat of exclusion cannot legally be used to encourage or force a managed move, the research reviewed indicates that this does occur.  7.5 Researchers also recommended that managed moves should be based on well-defined protocols; collaboration across schools and other local stakeholders; treating children as central; and focusing on pupils’ strengths.      14  8. Section Summary   8.1 Sandwell has used this task as an opportunity to review the existing approaches and processes used to prevent school exclusions. In comparing Sandwell’s approach to other models for this review, what was very apparent was the strong view that structures coordinated by local authorities, such as the case in Sandwell, were seen to have more impact and have the fundamental basis for success.    8.2 The data to demonstrate how these approaches applied to different ethnic groups, in particular black boys, was not available in Sandwell. What was shared was the fact that the majority (over 70%) of children considered by the Fair Access Panel were from white British background, however, there was no other data to review for children from a black and minoritised ethnic heritage who received fixed or permanent exclusions or those considered for managed transitions, including those with EHCP and SEND.  8.3 Although the Education Directorate was unable to produce any data on the breakdown of exclusions and managed transitions for ethnic groups, according to figures published by the Department for Education (DfE), it can be assumed that that the education system in Sandwell will mirror the inequalities evidenced in other areas and in the countless reports, including that undertaken in Sandwell and noted in the Criminal Justice System.   8.4 To better understand the local picture and position of fixed and permanent exclusions and managed transitions in particular for young black boys in Sandwell, the availability of data would have enabled this review to cover some of the salient points; that is, the review was unable to ascertain:  • The position and rate of school exclusions/managed transitions for the cohort of young people involved in the review of pupils of different ethnic groups and other disproportionately excluded groups   • What approaches are taken specifically to prevent exclusions for those overrepresented and to engage where they are at risk of exclusion in education  • Evidence of the effectiveness of the approaches used and how these differ by school type (mainstream/special/AP) and phase, between primary and secondary for the groups included in the review • What gaps are there in the current support to groups of pupils that have been identified as having links to exploitation, criminality and having high exclusion rates   • The differences in how pupils and their parents / carers from disproportionality groups engage in the independent review process following an exclusion, and their experience of that process.  Recommendations for Sandwell Education Directorate   • Strengthen the knowledge of statutory partners and local citizens around the statutory regulations and law around exclusion from school. 15    9. Exploitation and Disproportionality in Sandwell   9.1 From the ‘Disproportionality Task Group’ a glimpse of what is known was pooled together with the findings referencing the work undertaken across Sandwell including that by the Criminal Justice System, indicating that in Primary School education, white British children are 10% more likely to achieve expected standards in reading, writing and maths than black Caribbean children. By the time the two groups reach A-levels, white British students are more than three times as likely to achieve higher grades than black Caribbean students.  9.2 Research shows that for some black young people their first negative experience of a punitive authority was in primary school, where they experienced escalating disciplinary sanctions and high rates of school exclusion instilling them with a negative mind-set about teaching and learning. This then continued into secondary school and can be seen in some cases as the initial starting point for later criminalisation.  9.3   Exploring further the notion and seeking evidence to satisfy the key lines of enquiry as to whether disparities exist for young black boys in Sandwell youth offending systems in the context of exploitation and gang activity, information collated and provided showed evidence of work and activities being undertaken and developed in Sandwell, and emphasised this area being previously reviewed and consistently monitored by the Sandwell Youth Justice Team (formerly Youth Offending Service).   9.4 A study undertaken by the Youth Justice Board on racial disparity titled “Journey of the child” in 2019 found that although black children are a small percentage of the overall number of children aged 10-17 in England in Wales (data showing over 5 million – 2011 census only just over 200,000 were black young people - roughly 4.3%):  • Black children are 4 times more likely to be arrested than white children. • Twice as likely to live in a deprived neighbourhood • They are half as likely to receive a caution for an offence than their white peers • Yet twice as likely to be sentenced to custody  • Improve use of data systems to record managed moves/transitions and disproportionality data. Discuss with Synergy Steering Group reporting formats and training for staff. • Strengthen knowledge and contribution of statutory partners with supporting managed moves / transitions so that holistic support is provided to the student and their family. • To implement a formal process to monitor the data around exclusions for particular cohorts of children to ensure all groups, including those who are particularly vulnerable, from black and minoritised ethnic groups, subject of EHCP or SEND, have fair and equal access to education. • Introduce a process which enables early recognition and appropriate mediatable intervention for behaviour characteristics that can lead to persistent breaches of school’s behaviour policy.  16   9.5 David Lammy explained that although difficult to evidence, there is a growing debate that ‘unconscious’ or ‘implicit bias’ may play a part. This is a relatively new field of study which examines the risk that individuals act upon prejudices that they may not even be aware of. Senior figures in the CJS have called for an increased focus on tackling unconscious bias.   9.6  It was difficult to challenge the data outlined in the countless reports and with the national data presented that racial disparity exists and is evidenced for children from ethnic groups and particularly so for black Caribbean boys who then are highly visible in criminal exploitation and in the youth justice system.    9.7 The findings from this group will build on from the national context around disproportionality including the findings of the Lammy Review in 2017, which was followed up by Sandwell partners, forming action plans and activities after the 2018 HMIP (Her Majesty’s Inspectorate of Probation) Inspection where it was determined that further work was required in the area.   9.8 Looking at the data provided by Sandwell partners to explore whether or not disproportionality exists within local systems for ethnic groups and particularly for black Caribbean boys, and starting with Early Help, the following was found:  • Nearly half of all young people (43%) referred to Early Help in Sandwell between January and September 2021 were identified as being from an ethnic minority background,  • 14% of white British children would have consent denied or withdrawn by a parent for Early Help support. This is in comparison to 23% of children from a non-white British ethnic background. • In relation to a child being supported and ending a Team around the Family support plan with positive outcomes – this was 19% for those with a white British ethnicity compare to 27% for those from ethnic minority backgrounds.   9.9  Thus, in summary, a child who is non-white British is more likely to be denied Early Help support by their parent or guardian but where parents utilise the support the outcomes achieved are greater.  9.10 In terms of a programme delivered via Black Country Women's Aid  (BCWA), data provided from April 2020 to March 2021 showed, of 13 referrals received from across the 4 Black Country local authority areas for support from the ‘Our Future’ (one-to-one mentoring & counselling support for young people), 46% (6) were from Sandwell. This is a positive story as this suggests that Sandwell was the highest referrer for this group of young people, demonstrating accessing and connecting to community-based services which are often better placed to engage and work with some young people. Schools were seen as making the majority of these referrals. 69% (9) were from the 10 – 15 years old cohort, with all other ethnicities being 40% of the cohort in this age range.  A small data sample from BCWA showed that 58% of black males withdrew (or parents withdrew consent) from the ‘Our Future’ one-to-one support compared to the overall average from all other groups. This adds to the theme seen from Early Help, in that Black (Caribbean/African/Other) backgrounds have a higher incidence of withdrawing support compared to other groups.    17  9.11 In relation to disparity, West Midlands Police convene local Scrutiny Panels to look at specific police activity – such as the use of youth or adult cautions, or the use of Stop and Search powers – and to invite feedback from the community as to whether the outcomes are fair and proportionate given the (anonymised) circumstances.    9.12 A recent addition to police investigation outcomes in 2021 is the option of finalising a crime report with evidence of intervention, education or diversion for a suspect in cases where the investigation would otherwise not lead to a charge or caution. This means that work can be conducted to deter offending without necessarily criminalising a suspect, including youth suspects. In the case of offenders under 18 this would also require a referral to the youth offending service to identify a suitable intervention. This outcome is additional to existing out of court disposal options, such as community resolutions where offenders have admitted their involvement.   9.13 In respect to the local hospital trust, how injuries presented in A&E by young people, including knife crime, are managed is an area where data analysed evidences that disproportionality does exist. Work is currently underway to approach things differently in terms of how data is captured so it is more meaningful to both understand and shape effective responses.   9.14 It was shared that incidents meeting the threshold for referrals to children’s social care for knife crime aren’t always made due to various challenges faced within the Emergency Department, mainly from a lack of professional curiosity around how an injury may have occurred.    9.15  It was recognised that staff in A&E are trained to look at a case from a medical model and will focus on the injury and treatment; very often a young person will not give the right explanation of how an injury may have happened, with an intent to avoid further service involvement.   9.16 There were other challenges in extracting data from the IT system and being able to extract information recorded as free text.   9.17 Another challenge faced was with young adults who self-discharge, as well as some of the young people being placed on adult wards rather than an adolescent ward, especially the 16 to 18-year-old age group. A system is currently in place where a daily report is run on all 16 -17-year olds to see if they are in the acute setting and daily contact is made with the ward to make sure safeguarding has been explored.  9.18 Partners in Sandwell are at the early stages of exploring partnership working with ‘St Giles’, a trauma informed youth work organisation that has established a Youth Violence Intervention programme in hospitals, working alongside clinical staff and young people as victims of serious assault with a ‘revolutionised approach’ aimed to reduce serious youth violence which includes employing case workers who have a ‘lived experience’ of youth violence thus making them more credible to engage this vulnerable cohort of young people.  9.19 Specific to exploitation, Sandwell Children’s Trust (SCT), the provider organisation for children’s social care services in Sandwell, in partnership with 18  stakeholders, launched the Horizons Team in October 2018 to work specifically with young people who are under 18 years old and are open to SCT where there is a medium and/or high risk of exploitation.  9.20 Horizons described a clear and effective pathway linking early indicators through to statutory interventions. Some organisations had a good understanding of the pathways and others didn’t, it was also acknowledged that the pathways are under constant review and improvements have been identified to ensure equal understanding from the perspective of all organisations.  9.21 All agencies receive some level of training to increase understanding, awareness and engagement relevant when working with children where contextual exploitation is known or suspected, and across SCT, all staff are said to receive a series of briefings on exploitation, including the responses.  9.22 Through Horizons, all children found following a missing episode are offered a Return Home Interview (RHI), in addition, due to the 72-hour national timeframe for undertaking RHI, staff from each service, including out of hours (EDS) have received training and can complete Return Home Interviews. Although this offers young people a choice, preference is usually to speak with their allocated worker after returning from being missing.  9.23 The Sandwell Safeguarding HUB launched in May 2019 is a monthly meeting currently chaired by the SW NPU Chief Inspector from West Midlands Police. The HUB membership consists of statutory and non-statutory partners and was created by SCT, to replace CMOG (CSE & Missing Operational Group) within the scope of Contextual Safeguarding. The HUB feeds directly into the Strategic Child Exploitation Board (CEB). The HUB provides oversight and management of children and young people deemed to be at high risk of exploitation, through the Child Exploitation Risk Assessment. Additional MACE meetings manage Medium risk cases and below. This is an information sharing meeting to aid progress for those young people subject of interventions and safeguarding. The meeting is victim focused and separate sections of the agenda enable escalation of risk linked to exploiters and locations where barriers to partnership intervention exist.   9.24 The Horizons Team has developed and facilitated a bespoke staged training course for the SCSP training programme, delivered training to all Foster Carers regarding exploitation, worked alongside the Targeted Early Help Service (COGs) to create champions within each locality and attend team meetings upon request to discuss the service. The team also attends the Designated Safeguarding Leads (DSL) meeting for education and has co-delivered training with police to police colleagues.  10. What is known about Sandwell’s response to Child Exploitation and Section Recommendations  10.1 An external review of the Horizons services undertaken by Camden in 2021 provided positive feedback, however noted improvement points largely to how information is gathered through Return Home Interviews and the partnership contributions through the Contextual Exploitation Safeguarding HUB.  19  10.2 Camden examined the MACE process and identified that High risk young people being discussed only in the HUB meant that young people with Medium or Low risk levels were more heavily scrutinised operationally than those who are deemed to be High risk. This had also been identified by the Head of Service for Exploitation. The HUB has since returned to its original functions and high-risk young people are now allocated adequate space and time through MACE meetings to ensure effective and well-coordinated plans. The HUB is focused on barriers and strategic influence to overcome these.  10.3 Owing to this change, all young people deemed to be at High risk of exploitation were presented in a multi-agency arena where MACE plans are informed by and contribute to Child in Need plans and are reflective of contextual risks, meaning that children’s needs are not considered in isolation but there is a more joined up approach and this aids in understanding and managing risks for some of our most vulnerable young people. This enabled involved professionals to gain greater collaborative insight into the risks for the young people they are working with and also enabled parents, carers and young people themselves to take part in these meetings, reporting to have felt the benefit from hearing the concerns collectively and feeling they are being ‘worked with’ rather than ‘done to’.  10.4 Comparing Sandwell’s approach to tackle child exploitation to the research findings, and particularly for this review how black boys in Sandwell known to have associations and/or displaying indicators suggestive of exploitation, the following was found; displaying breaches/persistent breaches of school behaviour policies, therefore at increased risks of fixed, permanent exclusions, or pushed towards managed transition; may have signs and behaviour patterns associated to adverse experiences, compounded by exposure to  mental health problems, substance/domestic abuse, poverty and social inequalities.   10.5 Disproportionality is a national issue and evidence is available to suggest that this has been a reoccurring priority area for the UK Government dating back to 1995, with all reports concluding with some elements of being complicated and difficult to unpick, whereas fundamentally disproportionality is about how boys and girls from minority ethnic groups are treated unequally by systems that should be equally applied to all.    10.6 Disproportionality has been a key priority area in Sandwell’s Youth Justice plan for the last 2-3 years with an aim to try and understand the local issues channelled through the Youth Justice Partnership. Work has been done to understand the trends in school exclusions for black boys, including patterns of behaviours, and regularly reviewing data and raising awareness locally. It would be useful to know what progress has been made, what actions are being taken and, more importantly, what difference is being made to support a future which eradicates disparity that exists for ethnic groups.   10.7 In addition to what has been gathered from partners on where they are on the journey to understand disparities across the services, the Youth Justice Team (formerly Sandwell Youth Offending Service) and Horizons have gone through the same journey of understanding school exclusions, links to exploitation, county lines and understanding the increasing risks to vulnerable children.    20  10.8 Adding context to the data reviewed and the work currently underway in relation to disproportionality in Sandwell, what was observed was that Children in Care (CIC) of black Caribbean or black African heritage had up to 4 placement moves over a 12-month period, and this is higher than other groups.   10.9 The data for the young people specifically around disproportionality within the local exploitation and the youth justice system showed the ethnicity breakdown based on the young people supported through the MACE process (Medium risk) or the HUB (for High risk).   10.10 This showed a higher percentage of young people who are white British being supported in the lower end MACE process, with only 3 black young people supported in this arena – this was 5% of the MACE cohort and therefore lower than the representation of the community.   10.11 Looking at the same cohort in the HUB management arena for those children considered to be at higher risk of exploitation the narrative changes; of only 18 young people supported at this higher level, 33% were white British - meaning 67% of the cohort were from minoritised ethnic backgrounds – of which, 39% of this cohort were black young people which is 6 times over represented in comparison to the general population.   10.12 In the out of court disposal arena (pre-court intervention space), disproportionality was already evident. Black or mixed heritage males made up 24% of the cohort and only 12.9% of the demographic and therefore are twice as likely as their white counterparts to be brought into a YJS arena. However, this becomes even more concerning as we move into the custodial arena, where there were only 9 custodial sentences given to 6 young people by the Courts in 2020 and over 50% of these custodial sentences were dealt to black young males despite their 6.5% representation in the general population. White young males received 11% of the custodial sentences and Asian males were 11%   - which for both is half the representation of their demographic in the community.   Further analysis of these 6 young people noted that: For ethnicity and exclusion: • 1 is identified as white British – (16%) o having 8 fixed term exclusions  • 3 recorded as black British: (50%) o 1: 19 fixed term and 1 permanent exclusion o 1: 12 fixed term and 1 permanent exclusion o 1: 8 fixed term and 2 permanent exclusions • 1: Bangladeshi – (16%) o 7 fixed term exclusions • 1: Kosovan – (16%) o 8 fixed term exclusions Of the 6, 5 were noted as having a learning needs (EHCP or SEND) as: • 1: white British (20%) • 2 black British (40%) • 1: Bangladeshi – (20%) • 1: Kosovan – (20%) 21   • In 4 of the 6 cases there was more than 1 missing episode, and in 2 cases (both black British) numbers of recorded missing episodes were 110 and 134. • All of these have been known to the partnership for exploitation concerns with 67% managed at the HUB Level (or equivalent) • All of them have been open to Children’s Social Care with 4 of the 6 being deemed children in care at some point in their childhood journey (although it does need to be noted that if they were remanded to a YOI awaiting sentence then they would be given automatic child in care status).  10.13 Having a criminal record can hold back young people from having a different future to aspire to – a recent study showed that half of employers would not consider employing someone with a criminal record. But over the past five years 22,000 minority ethnic children have had their names added to the national police computer database. This increases their risk of re-offending, when they feel there is no positive alternative pathway for them.  10.14 Though this report provides a snapshot and summary of the areas examined, the results are consistent with the national findings also viewed and as recent as October 2021, following a thematic inspection into the experience of black and mixed heritage boys in the youth justice system, HMIP published another report where the findings capture data analysed of those black boys on statutory court orders and states:    • 60% of this cohort has been excluded from school – the majority permanently excluded  • Almost a third had been victim of criminal exploitation  • Half the boys had experienced racial discrimination  • A third were subject to CP or CIN processes  • A quarter were classed as a child with some form of disability.   10.15 In the report, the chief inspector Justin Russell stated, ‘The boys whose cases we looked at had complex needs, and opportunities to support them earlier, outside of the youth justice system, had often been missed’. This is no different to closing statements made in other similar reports.    10.16 In summary, the findings from the Disproportionality group do not differ to what is known nationally, in that racial disparity exists and was found in the cohort of black boys known in the exploitation and youth justice arena.  For most members of the Disproportionality group, this was not a new revelation.   10.17 What has been very evident in this group is the importance of data capture. If ethnicity is not recorded or data is unable to be interrogated, then we are unable to fully understand the scale and or nature of the problem or what is underpinning this disparity. NHS partners have already made a recommendation to improve how their data is captured to better understand this issue in the health arena, as well as in planning to work in partnership with ‘St Giles’ to bring a Youth Violence Intervention programme into the hospital trust.   10.18 While the group could not disagree with the national data presented that racial disparity exists, the view of how this compares in Sandwell shows this to be a 22  local issue requiring local strategies, however a national steer is crucial if there is to be any chance for true and meaningful change.    Recommendations for the CEB • Ensure there are mechanisms which enable data on ethnicity to be routinely and consistently collected and analysed to inform and influence the work and action plan to progress of the CEB and evident in the workplan. • Routinely monitor the work and progression of YJT in action plan for addressing Disproportionality (as part of their Youth Justice Plan).   11.  Report summary 11.1 All research viewed for this review evidences that black people are disproportionately impacted by a complex combination of factors including poverty, low expectations, unconscious bias, discrimination, language barriers, mistrust of support services, higher risk of school exclusions, victimisation, exploitation and criminalisation. What was really lacking was a true understanding on the scale and nature of disproportionality for all cohorts of children and the importance of connecting certain patterns of behaviours and characteristics in the primary years as indicators for later exploitation and criminalisation.   11.2 Although school exclusions in Sandwell have been steadily declining for a number of years, nationally the numbers are increasing, with the most vulnerable children most likely to be excluded. Excluded children are said to be four times more likely to be from the poorest families with up to 8 out of 10 of them having a special education need or disability; and at least one in two will have a recognised mental health need.  11.3 It is therefore not surprising to learn that black pupils are significantly over-represented in pupil referral units and being over three times more likely to be permanently excluded compared with their white British counterparts. As an example, a black Caribbean boy eligible for free school meals who also has special educational needs (SEN) is 168 times more likely to be permanently excluded than a white British girl without SEN and not eligible for FSM, according to statistics.  11.4 The question of how exclusions have become so unequal is met by having an educational system which openly marginalises children who do not conform to majority norms. Data available from the 1960s shows that black Caribbean students have been over-identified as having SEN, and pupils with SEN have been disproportionately excluded. The labels used to describe these groups in the 60s as “educationally subnormal” (ESN) and “maladjusted” were disproportionately applied to ‘disadvantaged’ black pupils; in reality, it could be argued that whilst these labels may have been revoked, how these groups are treated by the system has not.  11.5 Black children are twice as likely to live in low-income households compared with their white counterparts. The poorest black households were predicted to 23  experience the biggest average fall in living standards by 2020, equating to a real-terms average annual loss of £8,407.  11.6 Household and community disadvantage are associated with outcomes that are, in turn, linked to exclusion, including emotional, behavioural and mental health difficulties, and under-developed language and literacy development. Children with multiple disadvantages require increased support in school but are instead more likely to be excluded.  11.7 The Institute for Public Policy Research (IPPR)’s recent report ‘Making the Difference’ estimates that close to 100 per cent of children who are excluded have mental health difficulties, researchers found that 1 in 2 excluded pupils experience recognised mental health problems, compared with 1 in 50 pupils in the wider population. Estimates suggest this might be as high as 100% once undiagnosed problems are taken into account. Meanwhile, government data has shown that only one in a hundred children who have been permanently excluded from mainstream schools go on to receive five good GCSE grades. 11.8 The government published its Race Disparity Audit in October 2017, a collation of data showing black-white disparities in a range of lifelong outcomes, including educational attainment, labour market participation, health, wealth and treatment by the criminal justice system. These outcomes are all related, and school exclusions can act as a key link in a chain of risk leading to adverse consequences throughout an individual’s life, for example, pupils officially excluded from school at age 12 are four times more likely to be in prison by age 24.  11.9 David Lammy MP is quoted as saying, “The relationship between pupil referral units [a type of alternative provision maintained by the local authority] and the criminal justice system has become symbiotic, and the rise of exclusions is creating a pipeline of young people into our prison system, with no fiscal or moral case to go on like this.” 11.10 By and large, partners in Sandwell have been bold, transparent and self-critical in undertaking this review, and have demonstrated a wealth of positive initiatives to monitor the situation with attempts and alternative approaches consistently applied in some areas. Despite what can be seen on the surface, the picture does not show anything new, the findings are consistent with every other paper viewed on the area, none had a different story or disagreed or contradicted the findings from other reports all telling the same story. 11.11 The one interesting and differing approach viewed was not surprisingly from the lens of Sandwell’s Horizons Team, having a model which advocates for young people with young people using teachable moments in discretionary points, secondly increasing awareness with a language session including the use of language and how powerful language can be. “Cultural Identity” is a component in the Horizons risk management plan which looks at how cultural identity impacts on young people and exploitation, working with families, giving them a better understanding of exploitation, ensuring more engagement and more effectiveness around the plan. However, Horizons also recognised that more is required and are striving to do more than adding culture and identity into assessments, but equally 24  consistently seeking to understanding how it shapes a family and their experiences.   11.12 This Review finds nothing different to other reviews, studies and reports viewed, with evidence of structures in Sandwell to address school exclusions, however this did not go as far as looking at exclusions rates by ethnicity or have a focus on disproportionality. This omission in itself identifies a gap in the system and a line of sight to young black males such as SC, whose complex needs provided opportunities for early support way before the need for statutory and youth justice involvement; this early intervention, requiring parental consent and cooperation, is frequently missed for some ethnic communities.  11.13 It can be summarised that from the wealth of reviews and literature studies undertaken, all with the same findings, none have been able to offer solutions that have made a difference. By continuing with these reviews and coming up with the same outcomes and recommendations which produces no sustainable results, it is difficult not to imagine a picture of a dire future for young people such as SC should inequalities continue to escalate at the same pace.  11.14 The continued lack of steer, specific legislation underpinned by statutory guidance and framework means that it is left to local authority areas to identify, prioritise and drive improvements through local systems. It is unfortunate that the good practices cited in many reports were not followed through with recommendations that introduces a statutory framework imposed on all local authority areas to comply.  11.15 The recommendations from this review seeks to stimulate open and honest conversations amongst local and national strategic leads, as though this review recognises that pockets of good practice exist, these are all arranged at local levels and varied in attention, resources, application and impact. The lack of a statutory framework means the structures needed for meaningful and sustainable change over time will further add to the inequalities currently experienced by some groups based solely on ethnicity.     11.16 A final thought has to reflect back to SC and his journey compounded by ‘neglectful and compromised parenting’ travelling through a system where the early signs/indicators of his escalating complex needs are repeatedly addressed under the code of ‘persistent breaches of school’s behaviour policies’, then ask the question: where were his chances? What are the chances for young people such as SC, and will society ever be ready to make changes that can really make a difference?             25  12. RECOMMENDATIONS 1.  SCSP to seek assurance from SMBC that there are formal processes to collect and analyse data around fixed or permanent exclusions and managed transitions. The system must be able to differentiate cohorts of children including by ethnicity, as well as those who are vulnerable, receiving additional support via Early Help/Social Care, YJT and children subject to an EHCP or SEND.   2. SCSP to task SMBC to:  a) undertake a review of the themes and patterns of behaviour which constitutes a ‘persistent breach school behaviour policies’ and provide evidence of the effectiveness of approaches used to prevent exclusions for those who are overrepresented and at risk of exclusion from education. b) undertake work to understand young people’s experience of alternative provision in the borough, especially young people with complex needs, being exploited/at risk of exploitation or who are disproportionately affected by exclusions. This should explore their experiences through processes which may be applied differentially, or experienced differentially, or through outcomes which are quantitatively different for different ethnic groups. c) to ask the Education Directorate to strongly consider including in its processes for schools that before decisions are made on whether to exclude a vulnerable pupil (either permanently or for a fixed period) the Headteacher should consult the DSL and where necessary contact a ‘Group Head’ to evaluate risks and to plan how to ensure the child is kept safe from significant harm during the exclusion. 3. SCSP to seek assurance from Sandwell and West Birmingham NHS, and a report detailing: a) the action plan to address the disproportionality identified through the recent review of the hospital data on ethnicity.  b) the actions taken to ensure referrals are made to Children’s Social Care in all cases where young people have presented at A&E with injuries which could indicate serious youth violence, including injuries/wounds from a knife and wounding implements.  4. SCSP to task the Early Help Partnership to undertake a consultation process with black and ethnic minority children, practitioners, community groups and families to understand the reluctance to engage with Early Help services and devise an action plan which addresses the barriers. 5. SCSP to task Black Country Healthcare Foundation Trust to undertake a review of referrals received, support offered and take-up of services for ethnic minority groups. The findings and any plans to address to be reported and monitored through the Sandwell Safeguarding Health Partnership. 6. SCSP to task the QPPA subgroup with gaining assurance from the Education Directorate that school behaviour policies have clear guidance and a definition of ‘persistent breaches and school exclusion’ and that they are based on guidelines provided by the DfE regarding behaviour and discipline in schools. 7. SCSP to write to Ofsted, the Secretary of State for Education and the Minister for Children, Families and Wellbeing sharing the findings from this report which endorse the findings from the Timpson Review (2017) and Lammy Review (2019) and fully support the need for Government to take action and introduce regulatory standards for local authorities to comply to reduce inequalities and disproportionality which evidently exist in systems, structures and organisations across the UK.          26  Acronyms Used  AP – Alternative Provision CAMHS – Child and Adolescent Mental Health Service CCE – Child Criminal Exploitation CSE – Child Sexual Exploitation CME – Children Missing Education  EDS – Emergency Duty Service EHCP - Education Health Care Plan GBH - Grievous Bodily Harm HMIP – Her Majesty’s Inspectorate of Probation  MACE – Multi Agency Child Exploitation NEET – Not in Education Employment or Training PRU - Pupil Referral Unit SEMH – Social Emotional Mental Health SEND – Special Educational Needs Disability SWNPU - Sandwell Neighbourhood Policing Unit WMP – West Midlands Police YJS – Youth Justice Services YOI – Youth Offenders Institute   References: • The Youth Violence Commission: Interim Report (2018) • The London Assembly Education Panel (2018)  • The Timpson Review of School Exclusions (2018) • Examining the Educational Background of Young Knife Possession Offenders by the Ministry of Justice (2018) • Serious Youth Violence (2018) by The Home Affairs Committee • Back to School: Breaking the Link Between School Exclusions and Knife Crime (2018) by All Party Parliamentary Group on Knife Crime • Health Equity in England: The Marmot Review 10 Years on (2020) by Institute of Health Equity  • Making the Difference: Breaking the Link between School Exclusion and Social Exclusion (2017) by the Institute for Public Policy Research (IPPR) which in its  • The Lammy Review (2017) - An independent review into the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System • https://www.ethnicity-facts-figures.service.gov.uk/education-skills-and-training/absence-and-exclusions/pupil-exclusions/latest • https://publications.parliament.uk/pa/cm5801/cmselect/cmjust/306/30609.htm • https://www.unison.org.uk/motions/2019/black-members/black-children-and-exclusions/ • https://irr.org.uk/wp-content/uploads/2020/09/How-Black-Working-Class-Youth-are-Criminalised-and-Excluded-in-the-English-School-System.pdf • https://www.bbc.co.uk/news/education-53516009 • https://www.bbc.co.uk/news/uk-england-bristol-50843354 • https://publications.parliament.uk/pa/cm5801/cmselect/cmhaff/57/5702.htm • https://dera.ioe.ac.uk/5410/1/RR616.pdf • https://www.dianeabbott.org.uk/news/speeches/news?p=102413 • https://www.westmidlands-pcc.gov.uk/pcc-to-meet-with-teachers-to-discuss-rising-levels-of-school-exclusions/ • https://www.lbhf.gov.uk/sites/default/files/section_attachments/adam_serious_case_review.pdf  