Death of a 15-year old boy in May 2018. Archie was fatally stabbed by another young person. Archie arrived in the UK in 2014 with his mother and lived with his adult sister and three older siblings until mother's return in 2015. Enrolled in a different school to siblings' due to lack of places. Death of adult sister in a house fire had a traumatic impact on Archie. His behaviour in school began to deteriorate and moves to new schools were unsuccessful, resulting in periods where Archie was home educated. Detained for shop lifting; other offending quickly escalated. Frequent episodes of missing from home; involved in gang culture, controlled and exploited by older associates; known to the criminal justice system and youth justice; subject to a Child Protection Plan. Archie was of African Caribbean heritage. Learning is embedded in the recommendations but also includes: impact of bereavement must not be underestimated. Recommendations include: when a parent elects to home educate their child, the local authority should seek reassurances that the child is receiving a balanced education, including a home visit for an assessment by a trained professional; local authority must develop and communicate a clear escalation process for children not on school roll; ensure there are structures in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and organised crime groups; clear referral route for vulnerable young offenders; implement Child Protection conferences that assess risk and develop plans in line with increased understanding of contextual safeguarding.
      
 Title:  Serious case review: Archie: final report. LSCB: Sheffield Safeguarding Children Board Author: Mike Cane Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1    Serious Case Review  Archie    Final report         Independent Author: Mike Cane Published: February 2020  2 His mum’s memory of her child….  My son was a cheerful, energetic and happy child! His powerful voice of laughter filled the rooms in our home with joy.  His big eyes could penetrate and know when something was wrong.  His football coach remembered him as a hardworking, passionate and reliable football player. He loved going to Sunday school and was an active participant in helping out. He had a big heart and a giving spirit that was expressed in so many ways to his family and friends. He was my calm! Forever missing his presence and innocent attitude. Forever missing his hugs and kisses. Forever missing his immeasurable smile.  Forever missing the Happy Go Lucky Child who lived his life fearless!  Gone, but not forgotten, Loved forever            3 Contents: 1. Introduction 2. Methodology and Terms of Reference 3. Brief Synopsis 4. Family Involvement 5. Analysis 5.1 General Comments 5.2 An understanding of the educational arrangements in place and the support offered to Archie and his mother 5.3 The involvement in and influence of gangs including any evidence of criminal exploitation 5.4 An understanding of Archie’s offending behaviour and attempts to tackle or address this 5.5 Specific Agency Issues 5.6 Responses to episodes of ‘missing’ 5.7 Support Archie received in relation to the bereavement of his sister 5.8 An analysis of the Child Protection Plan and its effectiveness 5.9 Support offered to his mother (for example housing, police, health, education, courts, social care) 6. Findings and Recommendations 7. Glossary     4 1. Introduction 1.1 In May 2018 a young man was fatally stabbed in Sheffield.  He was taken by ambulance to hospital but, despite the efforts of medical staff, he sadly died an hour later. Archie 1 was aged 15 at the time of his death. 1.2 The death of any child is a tragedy. Sheffield Safeguarding Children Board and all organisations involved in this review offer their sincere condolences to Archie’s family.  1.3 Chapter 4 of Working Together to Safeguard Children 2015 states that Serious Case Reviews and other case reviews should be conducted in a way which:  Recognises the complex circumstances in which professionals work together to safeguard children.    Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did.   Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.   Is transparent about the way data is collected and analysed.   Makes use of relevant research and case evidence to inform the findings. Following consideration by Sheffield Safeguarding Children Board it was recommended that this case met the criteria for a Serious Case Review and this decision was endorsed by the Independent Chair of the Board in June 2018. 1.4 Sheffield Safeguarding Children Board appointed an Independent Author for the review. Mike Cane is a retired senior police officer. During his career he led homicide enquiries and investigations involving the deaths of children. As the Head of a ‘Protecting Vulnerable People’ department he was the police representative on a Local Safeguarding Children Board and Child Death Overview Panel in the North East. Since leaving the police service, Mr Cane has completed a number of Serious Case Reviews and Domestic Homicide Reviews as both an Independent Chair and an Independent Author. He has no connection to Sheffield and has never been employed by any of the organisations involved in this review. 1.5 A Serious Case Review Panel was established to oversee the review with representatives from;   Children Young People and Families, Sheffield City Council      Sheffield Housing and Neighbourhood Services   Youth Justice Service, Sheffield City Council  Commissioning, Inclusion & Learning, Sheffield City Council                                                             1 ‘Archie’ has been used as the pseudonym for the subject of this review, with the agreement of his family  5  South Yorkshire Police  Sheffield Clinical Commissioning Group (CCG)  Sheffield Children Hospital NHS Foundation Trust (Acute Services)  Sheffield Children Hospital NHS Foundation Trust (Community Services)  Sheffield Futures 1.6 The Independent Author, Mike Cane, attended all panel meetings.  2. Methodology and Terms of Reference  2.1 The Review Panel agreed that the review should consider a period from September 2015 through to the date of Archie’s death on 24th May 2018. Agencies that had been involved with Archie between those dates were asked to provide chronologies and brief reports of their involvement including any relevant background information which pre-dated this time period.   2.2 In carrying out this review the Overview Author held a ‘Learning Event’ to which frontline staff and their managers were invited.  This helped to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took.  Another principle is that families should be invited to contribute to reviews.  The Overview Author met with Archie’s mother as part of this review.  Information she provided is included throughout the report where it informs the learning   2.3 The specific areas of focus identified by the panel were:  An understanding of the educational arrangements in place and the support offered to Archie and his mother.  The involvement in and influence of gangs, including any evidence of criminal exploitation.  An understanding of Archie’s offending behaviour and attempts to tackle or address this.  Responses to episodes of ‘missing.’  An analysis of the Child Protection Plan and its effectiveness.  Support Archie received in relation to the bereavement of his sister.  Support offered to his mother      6 3. Brief Synopsis 3.1 Archie aged 11 arrived in the United Kingdom with his mother in summer 2014, initially living with his adult sister and three older siblings when his mother returned home, before his family moved to the UK later that year.  Archie’s mother was fleeing an abusive relationship.   3.2 On arrival in Sheffield, he was enrolled by his elder sister into a local school where he started in December 2014.  This was not the same school as his older siblings or Archie’s mother’s or sister’s preferred choice but there were no places available at this school in his year group.   3.3 Archie’s adult sister died in a house fire in September 2015.   This had a traumatic impact on Archie’s life.  His mother became frustrated with agencies and reluctantly elected to ‘home educate’ her son.  This was not her preference, but she felt she had no option to avoid his isolation while awaiting a choice of new school. Archie began to miss significant amounts of education.  His behaviour and attendance deteriorated. 3.4 In December 2016, Archie was detained, along with a male of a similar age, at a department store. They had a concealed an item of clothing before attempting to leave. Police were called and both boys admitted to the offence of shoplifting. Restorative Justice was applied which included a condition to engage with the Community Youth Team when requested. This was Archie’s first direct contact with the criminal justice system. 3.5 In the following months, there was a rapid and significant increase in the level of offending involving Archie. The offences were serious and involved use of violence and carrying knives. He was frequently reported ‘missing from home’.  3.6 Archie began to associate with older boys and young men. He described these as his new ‘FAM’2. He became involved in gang culture. 3.7 In November 2017 an Initial Child Protection Conference was convened and Archie was made subject to a Child Protection Plan under the category of physical abuse.  He was still subject to a Child Protection Plan at the time of his death.   3.8 In May 2018, Archie was taken by ambulance to the Hospital Emergency Department with two stab wounds to his chest and sadly died as a result of his injuries. 4. Family Involvement 4.1 Archie’s family have been involved in this review. The Independent Author met with Archie’s mother to discuss her experiences and note her concerns and the contents of                                                            2 Street slang for ‘family’.  7 this report have been shared with her.  Her views and opinions have informed the report findings. His mother’s memories of him are shared at the beginning of this report. 4.2 Archie and his mother came to the UK around September 2014. His mother was very keen to get him and his siblings into school and tried to enrol them as soon as possible. After a few weeks his mother had to return to their home country to arrange a number of matters and she left Archie in the care of his adult sister. She recalls her adult daughter would send her photographs. These showed he was happy, but she does remember that some pictures showed holes in his uniform and she believed he had been getting into fights. 4.3 His mother returned to the UK on a permanent basis around March 2015. She was disappointed that Archie had not been given a place at her preferred choice of school where his siblings attended but he did not seem to be having any major issues at that time with his education. He struggled a little with some English lessons but was good at Mathematics. She agrees with professionals’ observations of him at that time as ‘a very polite and respectful boy’.   4.4 Her older daughter died in a house fire in September 2015.  As well as the emotional loss, Archie’s mum had also relied heavily on practical support from her daughter. She acknowledges she ‘locked myself in my room and was not there for my children’. She did not feel able to give Archie any support and later apologised to him that she hadn’t been there for him during that difficult time. 4.5 His mother believes the bereavement he suffered at the loss of his sister (to whom he, in particular, was very close) affected his behaviour and he started to get into trouble. She accepts he had been disruptive but she was disappointed when the school placed him into ‘isolation’ just two days after his sister had died. The relationship between his mother and the school deteriorated and she removed him from the school roll to home educate. Archie began to miss a lot of school education, but his mum bought him books and other equipment. The lack of school attendance also impacted on him playing for a local football team which had close links to the school. She believes that inevitably ‘he began to hang around on the streets and go missing’. 4.6 On several occasions she went out searching for her son and found him with older boys or young men. She remembers he would usher her away and she believes he was trying to protect her. 4.7 He began to get into trouble and his mother describes the situation as ‘something happening every day’. She recalls lots of different workers from Youth Justice, Social Care or Youth Work were trying to get him involved with different activities; but it was a bit like a ‘merry-go-round’ of different people arriving and then leaving. She thinks this impacted on him as he felt no one wanted to bother with him. He was disappointed that the ‘man who was going to take him boxing’ did not come back. His mother notes  8 that when they were in their home country, he had been on a programme called ‘Big Brother’ which supported him but he didn’t receive that sort of service in the UK. 4.8 He got into trouble on an almost daily basis and then didn’t attend his ‘probation’ appointments. His mother believes he soon realised he could get away with anything and that ‘nothing ever came of his actions.’ (Matters took so long to get to court that he just assumed he had ‘got away with it’.) She accepts his criminal behaviour rapidly escalated. She comments that ‘There were older boys out there on the streets getting him to do things for them’. 4.9 His mother had to give up work as it was difficult to leave him as he was at home all day and not in school. She was also suffering poor physical and mental health. His poor behaviour began to impact on his relationship with his siblings.  4.10 His mum concluded with the comment ‘I saw him change right before my eyes’. 5. Analysis 5.1 General Comments 5.1.1 Before considering each term of reference in detail, it is important to set the context for two areas of this review. These relate to the increase in deaths involving knives across the UK and the relatively new concept of ‘contextual safeguarding’. 5.1.2 The Office for National Statistics (ONS) provides data across the public sector. Their data illustrates that in the year to June 2018 there was an 8% increase in homicides within the UK. (30% of all homicides involved the use of a knife or sharp instrument) and that there has been a 38% increase in crimes involving the use of knives in just 3 years. Data provided by the NHS shows that the number of under 16s treated at hospital for ‘stab’ wounds has increased by 93% in five years. 5.1.3 These figures from the ONS and NHS set the context of a national issue which is disproportionately affecting young people and in particular young black men and boys. Work is now being undertaken at a government level to deal with the surge in knife crime. This review will focus on the detail relating to Archie’s experiences, but it is important that this detail is reviewed against this national context. 5.1.4 The second area to note is the development of contextual safeguarding. Again, details of specifics relating to Archie and Sheffield will be reviewed but this relatively new concept challenges all agencies in their approach to keeping children and young people safe within the child protection process, which are traditionally focussed on the home environment and working with families to improve lives. For teenagers there are additional challenges.  Carlene Firmin (2017) provides a national perspective:  9 Contextual Safeguarding is an approach to understanding, and responding to, young people’s experiences of significant harm beyond their families. It recognises that the different relationships that young people form in their neighbourhoods, schools and online can feature violence and abuse. Parents and carers have little influence over these contexts, and young people’s experience of extra-familial abuse can undermine parent-child relationships. Therefore children’s social care practitioners need to engage with individuals and sectors who do have influence over/within extra-familial contexts, and recognise that assessment of, and intervention with, these spaces are a critical part of safeguarding practices. 5.2 An understanding of the educational arrangements in place and the support offered to Archie and his mother 5.2.1 On arrival in the UK Archie was registered with a school (B) in Sheffield. The preferred choice was that family members attended the same school but there were no places available at this school (A) in his year group.  As new to the school system in the UK and new to Sheffield it would have been beneficial in settling Archie into mainstream schooling to be in the same school as his siblings. Although registration took place in the summer of 2014 Archie did not start at school B until December 2014, missing three months of his education. The review has not been able to determine the reason for the delay or whether Archie’s mother was provided information about appeal processes.  5.2.2 There were some minor discipline issues during his first two terms in school B but nothing that warranted a permanent exclusion. As a young person arriving from overseas it is not clear from records what, if any, assessment was made in relation to his language skills, educational ability or other factors that might assist or inhibit his integration. Staff in attendance at the practitioner’s event informed the review that no formal assessment was completed. He was said to have had a limited vocabulary but was described by staff as ‘a very polite, respectful boy.’ 5.2.3 In September 2015, Archie’s adult sister, who had also been his carer for his first period in the UK, died in a house fire. This had a major impact on him and his school experience.   5.2.4 The second application for a place at school C for Archie was accepted on 10th July 2016 but he did not start immediately and again it has been difficult to verify the reasons for this, although the headteacher of this school was of the view that Archie should have remained in his first school (B).  The opportunity to start at a new school just before the end of summer term (and potentially setting him some work or targets within the holidays) was lost. He had by now missed seven months of education. 5.2.5 Archie started at this second school 3 weeks into the September term in 2016 losing opportunities to integrate with his classmates and pick up on his learning.  It is also unclear if any assessment of his individual needs was carried out.  He was placed in a mainstream class and not a support unit. His behaviour and attendance were poor from  10 the start. Having missed the majority of the previous academic year, Archie may have struggled to study alongside his peers and this may have been one reason for his poor behaviour.   In addition, at the same time the family had re-located to another area of the city meaning that Archie was crossing the city on public transport (a significant and lengthy journey of around 90 minutes) to get to school.  His school attendance was poor and within a matter of weeks he was not attending school.  5.2.6 During the first term of the new school year in 2015, Archie’s behaviour deteriorated significantly. He had received two separate one-day exclusions and a large number of ‘yellow slips’ (these are linked to poor behaviour and are an indicator that he was repeatedly disruptive). 5.2.7 In early December 2015 his mother decided she would home educate him. This is her right as a parent: Section 175(1) Education Act 1996: “Responsibility for a child’s education rests with their parents. In England, education is compulsory, school is not”.   The education provision should be ‘efficient’ and ‘suitable’ but these are not defined in the Act. Local Authorities are ‘encouraged’ to provide support to parents who decide on elective home education. However,  Section 436A Education Act 1996 (as amended by Education and Inspections Act 2006) states: ‘Local Authorities have a statutory duty to make arrangements to establish the identities of children in their area who are not receiving a suitable education’.  5.2.8 Several weeks later his mother received a warning about his poor attendance. When she contacted the school, she was informed that because her email had not been signed her decision to home educate could not be accepted as an acceptable form of notification. Following this she wrote to the Local Authority by letter and received a standard reply relating to her obligations around her son’s education.   During the term the school had recorded Archie’s absence as including ‘authorised leave’, ‘education off site’ and a ‘managed move’ to another school (which was not completed). 5.2.9 The standard response to her ‘intention to home educate’ did not take into account her particular needs and was not an adequate response to the complex situation of this family. As a result of a long-term absence of a key member of staff in the Education Department at that time the matter was not given appropriate oversight and Archie was left with no education provision in place. His mother did not start to apply for a school place again until April 2016. By then, he had been out of any education setting for four months. She applied for a place at a new school with support from a MAST worker. 5.2.10 Although it is a right of parents to elect to home educate their children, there are national concerns about this choice of education. In February 2019, the Children’s Commissioner outlined her concerns on national television (Channel 4 ‘Dispatches’ programme broadcast 4.2.19). There are now over 60,000 children being home  11 educated within the UK. This figure has more than doubled in the last five years. Although in many instances, home education is a planned choice by parents, in the majority of cases home education starts after a dispute between the school and a parent. In particular, data shows that 22% of children who are home educated have Special Educational Needs. Figures provided from the Association of Directors of Children’s Services indicate between 11% and 51% (depending on Local Authority area) of children being home educated are already known to Children’s Social Care. 5.2.11 The Children’s Commissioner expressed her concerns at a trend of schools agreeing to parent’s requests for home education as an alternative to school exclusion. Electing home education does not provide the same level of support to a pupil who has been excluded from school.   5.2.12 A series of e-mails were exchanged between the Head Teacher and the Home Education Officer and although Archie remained on the school roll until February 2017 he never attended the school from late October 2016. He had only attended for a maximum of twelve days in the six months he was on their roll. 5.2.13 There are no records showing what support provision was available for a challenging young person within the school. There is no record of an ‘Attendance Officer’ home visit during that time. There is nothing to show if any professional at the school knew or did anything about the bereavement he had suffered. Nor does anything indicate what education provision was made for the three weeks he was recorded as Code B (educated off site). His offending behaviour, and with it his first contact with the criminal justice agencies, started in December 2016. Prior to that although he was a disruptive and difficult pupil he had not been involved in crime.   5.2.14 His experience within the mainstream school system in Sheffield can only be regarded as poor. 5.2.15 In contrast to the previous year, this time there was coordinated action from the Education Department at the Local Authority. The complex case manager raised Archie’s case at the fortnightly ‘Every child in education every day’ meeting. One action from the meeting was to write to School C to inform them that Archie should remain on their roll. 5.2.16 In February 2017, the complex case manager and attendance and inclusion officer carried out a home visit with Archie and his mother as they were concerned that he was not accessing any education provision. Another school was identified as a possible school for him. His education placement was also now the responsibility of the Youth Justice Service. Since his arrest and subsequent caution for a burglary offence, it was one of his conditions that he accessed education.  5.2.17 At a ‘Fair Access Panel’ in March 2017, Archie was allocated a school place at another school. Despite this he was never added to their roll and indeed never attended. With a  12 legal responsibility for the school to add a pupil to their roll on the day they are notified, or for the school to make representations within 5 days or appeal to the School’s Adjudicator within 15 days, (the Education -pupil registration- regulations 2006), the actions of this school are a concern.  In May, at another Fair Access Panel, the Head Teacher stated Archie was not suited to mainstream education, but the original decision remained in place. The Head Teacher of a large secondary school has a responsibility to educate pupils on their roll, but they also have a responsibility for the safety and welfare of other students and of their staff. The ‘stand-off’ between the Education Department and the school did nothing to help Archie. Other options such as a Pupil Referral Unit were not considered as he had never been excluded from mainstream education.   5.2.18 In September, Archie and his mother attended a meeting with the ‘Children Missing from Education’ (CME) officer to explore alternatives. The officer reports Archie did not engage well at the meeting.  The practitioner contacted the ‘Extended Curriculum Team’ (now re designated the ‘Progression Team’) who advised a risk assessment was necessary before any provision could be arranged. They were also going to make a referral to the ‘gang panel’.  5.2.19 In October during a meeting between several agencies, the decision was to make to request for a Child Protection Conference.  One key issue highlighted was that ‘Archie had now been missing from any education provision for 18 months’. 5.2.20 Between November 2017 and March 2018 further interventions were attempted by education professionals. These included offering possible alternative placements. Archie did not attend these placements. He was visited at home and discussed the ‘Not School’ provision and a computer was left. However, the family did not have an internet connection, so this was not feasible and the computer was returned. There was also a referral within the Youth Justice Service from the case manager to the education professional within Youth Justice. None of these were successful in re-engaging him. In May, an education professional met with Archie and agreed a way forward with an Education Welfare Officer looking at suitable placements and for the education professional to personally start work on Maths and English skills. The placements proved difficult to find. By this point there were so many other pressures within his life that any placement was unlikely to succeed. However, it should be recognised that there were determined efforts made by several committed education professionals. 5.2.21 In understanding the educational arrangements in place for Archie and the support on offer we can summarise:  There were delays from the very start in him accessing education. Even though his mother registered him in July 2014, he did not start at school until December 2014 and missed the first full term.  There are no records of any assessments undertaken when he started school. He had recently arrived in the UK from overseas and we understand that there had been some behaviour difficulties prior to his arrival in the UK.  An assessment of his  13 educational ability and his welfare and emotional needs would have been useful in planning a way forward. It does not appear a SENCO at the school was consulted.  Cultural issues were not considered (Archie was a teenage Afro-Caribbean boy) or specific arrangements made to support him (e.g. through NASSEA - Northern Association of Support Services for Equality and Achievement). Specialist services can provide advice around harder to reach BAME students in gaining access to quality education.  The bereavement of his sister was recognised by a pastoral lead at his first school. This was good practice and shows a level of connection with Archie. However, the subsequent response was not effective and this matter was never fully addressed. Such an event on a young person already exhibiting signs of poor behaviour was bound to have a negative impact.  His mother must share some responsibility in her inconsistency of stating she wanted to home educate him and then changing her mind. However, the Local Authority and the schools are the professionals and they needed to be more constructive and dynamic in their approach at a much earlier stage. Through a mixture of bureaucracy and staff absence, matters quickly deteriorated and Archie began to miss a significant period of his education. It was too easy for schools to acquiesce to his mother’s decision to home educate. Her decision had been made in frustration and there were insufficient services in place to support an effective home education.  There is a sense almost of a ‘stand-off’ between the Local Authority and the schools over alternative placements for him. This led to further delays and Archie missing even more education.  Whilst accepting schools have a duty to protect other pupils and their staff they also have a legal responsibility to educate a child on their school roll.  There is insufficient evidence of effective home – school links. The role of a pastoral professional from school staff, reporting back directly to the school would have paid real dividends in understanding his situation. There was a MAST (early intervention) worker supporting the family but their role was wider and education was only one factor in their work with the family.   There is evidence of some very committed practitioners working in education within Sheffield who explored several options to get him back into education.   It is to the credit of several education professionals that they never ‘gave up’ on Archie. However, these efforts were too late in stopping what had clearly become a downward spiral with him beginning to offend and becoming increasing drawn into a ‘gang culture’, in part due to his repeated absences from school.    14 5.3 The involvement in and influence of gangs including any evidence of criminal exploitation 5.3.1 HM Government’s ‘Serious Violence Strategy’ (April 2018) sets out the government’s intention on how to tackle the increase in violent crime within the United Kingdom. A key element of the strategy is the work around ‘gangs’ and the implementation of the ‘Ending Gang Violence and Exploitation (EGVE) programme. The strategy also explains the plans in relation to ‘County Lines.’ 5.3.2 County Lines is a major cross-cutting issue involving drugs, violence, gangs, criminal exploitation and missing persons. It can also include sexual exploitation and modern slavery. Criminal exploitation of children (and vulnerable adults) is a widespread form of harm that is a typical feature of ‘county lines’ activity.  5.3.3 Child criminal exploitation occurs where an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child or young person. The victim may have been criminally exploited even if the activity appears consensual. Factors that can increase a young person’s vulnerability include lack of a safe/stable home environment, social isolation, connections with other people in gangs, mental health issues and being excluded from mainstream education. 5.3.4 Recent research (2018) by OFSTED, HMICFRS and HMI Probation found that although much has been done by local partnerships across the UK to deal with Child Sexual Exploitation, agencies do not fully understand the scale or level of risk to children from other forms of criminal exploitation such as gangs, drugs or violence. 5.3.5 We know that much of Archie’s contact with professionals related to his association with older people. In January 2017, aged 13, he was in company with three other males, one of whom was 17 years old. The group stopped another young male and engaged him in conversation before threatening him with a knife and stealing his neck chain. In February 2017, whilst reported as ‘missing’ from home he was caught by police running from the scene of a burglary. He had committed the offence at 6.00am while in the company of a 20-year-old male. When he was searched by police he was found with a quantity of cannabis. In May 2017 he was stopped while in the company of an 18-year-old male and a 17-year-old female. Whilst the police submitted a child referral to Children’s Social Care in relation to the 17-year-old girl they did not do so in respect of Archie, who was only 14 years old, perhaps an indication of agencies not always recognising the risks of exploitation with teenage boys. 5.3.6 In April 2017 a meeting was convened to discuss the findings of a ‘speech and language’ assessment for Archie. It is a positive development that one of the findings of the assessment identified that he was ‘vulnerable to exploitation’. However, this does not seem to have evolved into action to protect him from that exploitation.   15 5.3.7 During a Social Care assessment in the summer of 2017, Archie was assessed as ‘involved in gang type issues’ but also assessed that he was ‘not at risk of significant harm’. With the other issues affecting his life, he was clearly open to exploitation by Organised Crime Groups (OCGs) and the assessment was therefore not sufficiently robust. Again, this is most likely due to professional’s lack of understanding of the exploitation associated with gang activity. 5.3.8 We know that an educational placement which had been arranged for Archie at a football club was cancelled by the club as their policy does not accept those ‘involved in gang culture’. Although it is understandable how a professional organisation does not want to attract crime and anti-social behaviour, the existence of the policy demonstrates how the assumption is one of criminality rather than exploitation.  5.3.9 Archie’s escalating involvement in crime shows how closely associated he was to gang activity within Sheffield. In addition to the drug dealing already mentioned, he: threatened to stab opponents; he was involved in a large fight with a group carrying weapons; he was in the company of several other males who chased teenagers into a car showroom and threatened the adults with a knife; he was part of a group (with older males) who entered a house, threatened the occupants, assaulted a female inside and stole the occupant’s drugs;  he was involved in a ‘drive-by shooting’ when he was in company with four other males (including a 19 year old and a 17 year old) and shots were fired at an address he was staying in.   5.3.10 Agencies did gather this information leading to interventions beginning. His Youth Justice case manager made a referral to the gang panel plus during a home visit a Social Worker stated their intention to refer to the ‘gang matrix’. It is unclear from records if these referrals took place, but Archie was never discussed at a gang panel and the review established at that time there was no direct route for professionals to refer directly to a ‘gang panel’ in Sheffield. The initial work of ‘scoring’ against a matrix was conducted by an analyst within the Police.  This appears not to have been fully understood by practitioners who may have referenced a referral but the existing systems at that time did not facilitate a referral by this route. 5.3.11 The police twice served ‘abduction notices’ on older associates of Archie, which was good practice. However, the officers realised these would be difficult to enforce, given his reluctance to stay away from his older associates and his mother’s apparent lack of control over him. The abduction notices needed to part of a wider concerted effort to safeguard him. 5.3.12 Archie often referred to his ‘FAM’ being ‘on the street’; an indication that family dynamics were not working and he was choosing to base himself with others outside the family home – many of whom were several years older than him. Lack of a stable home environment is a recognised factor in determining vulnerability to exploitation by gangs and criminal networks.  16 5.3.13 In summary there were indicators that he was being exploited. His involvement became more entrenched, placing him at greater risk of harm. There are several comments made by professionals of Archie expressing no regard for his own safety. When considering his carrying of knives, taking drugs from rival ‘dealers’, shooting incidents, assaults and threats to stab others it is clear he was at risk of ongoing significant harm.  5.4 An understanding of Archie’s offending behaviour and attempts to tackle or address this. 5.4.1 The government set out its aims for tackling youth offending in its Ministry of Justice publication ‘Review of the Youth Justice System in England and Wales 2016’: It advocates a societal shift so that from youth justice we see the child first and the offender second: “Almost all the causes of the child reoffending lie beyond the reach of the youth justice system. It is vital that health, education, social care and other services form an integrated multi-agency response to a child’s offending, but it is more desirable that these same services intervene with ‘at risk’ children and their families before their problems manifest themselves in offending.” 5.4.2 In just under a decade the numbers of young people entering the criminal justice system either by way of a caution or by a conviction has reduced by 79%. In 2007, 225,000 young people were dealt with by one of these sanctions. By 2015 the figure had reduced to 47,000. 5.4.3 The creation of Youth Offender Teams (YOT) in 1998 was in response to a growing sense that youth offending was not being dealt with in a systematic way. The strength of the youth justice system is in a locally based multi-disciplinary service. 5.4.4 The Youth Justice Service in Sheffield is a multi-disciplinary team comprising of a number of ‘case managers’ and other specialists within the team such as education professionals, CAMHS practitioners, a speech and language therapist, a health nurse, a housing officer and a substance misuse worker.   5.4.5 Although there had been a long-term issue with Archie’s regular school attendance this did not manifest itself in criminal offending until December 2016. He committed a shoplifting offence and subsequently received a ‘restorative justice’ sanction. This included a condition to engage with the Youth Justice Service when requested. This was the correct, proportionate response. It would keep him out of the criminal justice system but hold a sanction for him to think about his offence and the impact on others. 5.4.6 However, only two weeks later, Archie, then aged 13, was in the city centre at 10.30pm with three others including a 17-year-old when they threatened another youth with a knife and took his neck chain. The other three were arrested for robbery. Archie was not arrested as he was on the periphery but clearly associating with others which would  17 most likely get him involved in further offending. There were no referrals to Children’s Social Care regarding this incident or entries on police records to suggest his mother was contacted or advised about him being in the city centre late at night. 5.4.7 In February 2017, Archie had been reported ‘missing from home’.  Whilst missing overnight he was in the company of a 20-year-old male. They committed a burglary and were detained by police. When searched he was also found to be in possession of a small amount of cannabis. For this offence he received a conditional caution and, following an assessment by the Youth Justice Service, was required to undertake the following: address his offending behaviour and substance misuse, reintegrate with his education provision and enhance his victim awareness. The work is recorded by the Youth Justice Service as ‘completed’ with the caveat that his education placement was ‘pending’.  Given that he had missed so much education already this was a premature closure of the case and it should have remained open until the provision was secured and underway.  Although there were early signs of his vulnerabilities; with the exception of the education provision, the response and management of Archie’s case at that stage was an appropriate intervention plan which addressed the presenting issues.  5.4.8 The Community Youth Team received a referral in January (in response to his minor shoplifting offence). They carried out a home visit with Archie and his mother. After an assessment, he was deemed to require a ‘mini’ intervention although the Prevention worker was proactive in recording that this was a ’borderline’ case which could have warranted a ‘full’ intervention. The home visit went well, and he seemed fully engaged in the process. However, when the Prevention worker returned in February he was not at home. Nevertheless, the worker completed forms for referrals to specialist services and left details of positive activities available. The worker also proactively contacted the ‘missing’ team to enquire on his whereabouts. This is good practice.  5.4.9 The Prevention worker returned to Archie’s home later that month but by this time, he had been arrested for a burglary so local protocols meant that the Community Youth Team would no longer work with him. The Prevention worker explained to Archie and his mother that his case would be taken up by the Youth Justice Service. This process requires further review.  If behaviour is escalating and there is a need for positive or diversionary activities it is difficult to rationalise why a professional would be withdrawn when they have already started to make a connection with a young person. Ending the involvement of the Community Youth Team was a negative step when trying to divert him away from offending.   5.4.10 In March 2017, Archie met with his Youth Justice case manager. He disclosed his associates (most of who were known to the Youth Justice Service). He discussed how he carried a knife, had held a gun and had witnessed a violent incident. It is positive that the case manager was able to gain a rapport with him so that he revealed these aspects of his life. Indeed, it is a very good way of ‘seeing life through his eyes’.  The issue is what was done with this information.  We can see now that the violence, knives, weapons and involvement with criminal associates was starting to become an ever- 18 present part of his life. This was an opportunity to make a referral to Children’s Social Care for an assessment if the case manager believed he was at risk of significant harm.  5.4.11 Due to police concerns about his mother’s ability to exercise control over him, the police arranged a meeting with Children’s Social Care in June together with representatives from the Youth Justice Service, MAST, Archie and his mother. The Social Worker did not attend and so the meeting did not progress. This was not the right message to send to him or his mother and no doubt added to his sense of operating ‘on the street’ out of mainstream norms and also to his mother’s frustration.  5.4.12 Over the next six months, he was repeatedly involved in offending with the offences becoming more frequent and more serious. We should also consider these are ‘reported’ incidents. Given police statistics and the national crime survey we know that much crime goes unreported and of course there may well be more offending that he was involved in but was not named or identified. Clearly, offending behaviour was now a major part of his life.  5.4.13 All agencies should work together to prevent offending by children and young people. Within the scope of this review, we consider the actions of four key agencies in tackling or addressing youth offending:  Police, the Youth Justice Service, Community Youth Teams and Sheffield Youth Court. 5.5 Specific Agency Issues  The Police  5.5.1 The police deal with protecting the vulnerable, preventing crime, gathering intelligence, conducting investigations and gathering evidence to put before the courts. Archie’s activities fell into all of these categories.  In some instances, this is purely ‘intelligence’, in others there is evidence against him. The police have a duty of care to the public, the victim of a crime, the witnesses and also to the perpetrator. This is especially so with a young offender. In many of the reported crimes involving Archie, the police take swift and positive action. He is arrested, interviewed and in cases where the evidential threshold is met, he is charged with an offence and put before the Youth Court. In a minority of cases the police could have taken more robust action.  5.5.2 For example, when he was seen by a Police Community Support Officer with a knife, although the PCSO does not have a power of arrest a swifter response by officers may have detained him with the evidence. Or in March 2015 when the police were called by his mother as he had ‘smashed the house up’ and although his mother did not wish to make a formal complaint and therefore a charge was unlikely, he could have been arrested to investigate further.    5.5.3 On other occasions positive action was taken by the police; in February he was arrested after threatening patrolling officers he would “Smash their face in.” In March when he  19 was involved in damaging a car he was arrested and interviewed about the incident. No charges were likely, but the investigation followed a logical course. This was essential at this stage as he was repeatedly coming to the notice of many agencies. Positive police action was a way of setting boundaries and introducing consequences for his behaviour.  5.5.4 The police did refer to Children’s Social Care but the approach was not always consistent. There are instances where police had been involved with him but this interaction was not always shared with Children’s Social Care or the Youth Justice Service.  5.5.5 Breaches of his bail were dealt with well by the police and he was repeatedly arrested for the breaches and put back before the Youth Court.  5.5.6 One problem was that so many different police officers dealt with Archie. It is pleasing to see South Yorkshire Police has now reintroduced Neighbourhood Policing Teams who can get to know their local communities and this includes young people involved in crime and at risk of exploitation. The Youth Justice Service  5.5.7 The Youth Justice Service is a multi-disciplinary team; comprising professionals who both manage cases involving young offenders and also deliver activity and interventions that divert young people away from the criminal justice system. 5.5.8 Following a referral by police in January 2017, the Youth Justice Service completed an assessment and developed a comprehensive plan including , engagement in offending behaviour sessions, a substance misuse referral, a speech and language assessment, victim awareness work and work to reengage him in education. All work was recorded as completed with the exception of his education placement which was shown as ‘pending.’ This may have been a premature closure, given that he had missed so much of his education. There is no doubt that the Youth Justice Service case manager was proactive in trying to obtain a placement for him, but this appeared to cause confusion to which agency was trying to pursue this. 5.5.9 There was also some confusion on the role of the Youth Justice Service as they were also completing ‘return’ interviews with him following his episodes of ‘missing’ together with their role addressing his offending. It does appear that his mother found this confusing and sometimes did not know who to contact.  5.5.10 Comment has already been made regarding the good rapport established between Archie and his case manager.  5.5.11 In later incidents, when he was repeatedly offending, a decision was taken by the case manager to put all matters before the court in one appearance. Due to his continual  20 offending, this meant a significant delay in obtaining any form of sanction. However, the decision was made in the best interests of Archie and the case manager did not have the benefit of hindsight.  5.5.12 There were delays in completing bail assessments and this is identified by the Youth Justice Service as a systemic issue that requires addressing. 5.5.13 When he did appear at Youth Court, he received either bail support packages or Referral Orders. His repeated reluctance to engage with services meant these were difficult to progress but there is ample evidence that the case manager pursued this despite the challenging circumstances.  5.5.14 The case manager was tenacious in ensuring contact was initiated and maintained with Children’s Social Care, especially as their assessment showed he was at risk of exploitation. They also referred him to a gang panel, but it appears he was not heard at the panel nor mapped as a gang member.  5.5.15 Archie’s case was taken to a ‘Multi Agency Risk Panel’ in April 2018. In itself, this was good practice, but it is difficult to see how this operated in conjunction with the existing Child Protection Plan. All efforts should have been directed through a single pathway.  Sheffield Futures (Community Youth Teams) 5.5.16 Sheffield Futures is a large charity which delivers the Youth Crime Prevention Service in the city. These services include the Community Youth Team who employ professionals that support young offenders and deliver activity and interventions which divert young people away from the criminal justice system.  5.5.17 Their initial involvement is already documented. An assessment and engagement with Archie in early 2017 was abruptly cut short due to his repeated and escalating offending.  It was a mistake to withdraw the service at that time. The Community Youth Team is commissioned to deliver a pre court service. After that stage, responsibility passes to the Youth Justice Service. These agreed thresholds for intervention between the two services form part of the recommendations within this overview report. 5.5.18 Even though the decision was made to withdraw Sheffield Futures’ services they were re- contacted nine months later in an attempt to introduce some positive activities for Archie. They sent a letter to his mother in November 2017. This was a positive step. However, only nine days later, Sheffield Futures withdrew their involvement as he had again reoffended. This process as earlier stated requires review, if the aim is to divert away from offending, why is the assignment of a professional youth service withdrawn?     21 Sheffield Youth Court 5.5.19 HM Courts and Tribunal Service are not part of this review. However, the Youth Court is referred to on several occasions by agencies.  5.5.20 Following his involvement in crime (together with evidence he was also being exploited) he was arrested and charged many times. As with all young people he appeared at the Youth Court.  5.5.21 Data has already been provided of the significant reduction in young people now receiving either a formal caution or conviction (c 80% reduction in less than a decade). The Youth Justice Board notes in its 2017-2018 annual report that due to the huge reduction in numbers in the system, those cases remaining are particularly challenging:   ‘Many of the children remaining within this smaller cohort have complex needs. Reoffending rates and serious violence within the secure estate are high.’   5.5.22 No one wants to see children and young people held in secure custody unless for the most grievous crimes.  But with criminal exploitation of young people this can be a difficult arena. 5.5.23 We know of Archie’s home circumstances; his disengagement from his own family, his mother’s inability to control him, his finding a new ‘FAM’ on the streets and his association with older boys and young men. The challenge is how this exploitation and risk of significant harm is articulated to the courts. 5.5.24 The Youth Justice Board has both a ‘vision’ and a ‘mission.’ The vision is: ‘Every child lives a safe and crime free life and makes a positive contribution to society.’ 5.5.25 The ‘mission’ puts ‘Preventing offending by children’ at its core and then also illustrates how it will achieve this – by monitoring the youth justice system, advising ministers, identifying good practice and commissioning research. The mission does not mention ‘safeguarding’ and this omission should be revisited. 5.5.26 Archie appeared before Sheffield Youth Court many times. On each occasion he was released on bail. Initially there were no conditions attached. At later hearings there was imposition of a curfew (without electronic tagging) and then further curfews (with electronic tagging). On several occasions he was arrested for breaching his bail conditions only to appear back at court to be released again with the same conditions. Each time, he was released he went ‘missing’, breached his bail conditions or became involved in further crime. There is a suggestion from the Crown Prosecutor that during his last court appearance, the prosecutor was considering seeking a remand in custody. However, he declined to do so when he reviewed the content of the Youth Justice Service report. We do not know if the lack of detail on the report contributed to this as  22 the prosecutor is speaking hypothetically and the ultimate decision would be one for the Court.   5.5.27 The main reasons a court can refuse to grant bail to a defendant are:  They will abscond  They will commit further offences on bail  They will interfere with witnesses (Bail Act 1976) 5.5.28 Archie repeatedly absconded and committed further offences. As a young person, any remand in custody must be an absolute last resort. But the Bail Act also lists an additional important reason that bail can be denied: ‘For the defendant’s own protection’. The court is reliant on the quality of evidence and the quality of reports for it to make an informed decision. The exploitation of a young person and their risk of being at significant harm when their ‘FAM’ is ‘on the streets’ should be taken into consideration. 5.5.29 There does not appear to have been consideration by the Youth Court to remand Archie to secure custody or to Local Authority care for his own protection. All indications were that his mother could not control his behaviour and that he was ‘missing’ in breach of his curfew. The ‘breaches’ placed him at further risk of significant harm. His mother had expressed her frustrations about his offending and asked for him to be taken into custody instead of being released back to their home address. 5.6 Responses to episodes of ‘missing’ 5.6.1 Being ‘missing from home’ was a regular feature of Archie’s life and linked to other concerns of him being at risk of harm, exploited, exposed to ‘gang’ culture and involved in crime. Best practice for dealing effectively with episodes of ‘missing’ is contained in the document ‘Statutory guidance on children who run away or go missing from home (2014)’. Section 13 of the Children Act 2004 requires: ‘Local Authorities and other named statutory partners to make arrangements to ensure that their functions are discharged with a view to safeguarding and promoting the welfare of children. This includes planning to prevent children from going missing and to protect them when they do so.’ 5.6.2 The statutory guidance also recognises that children who go missing are at risk of sexual exploitation, gang exploitation, violent crime and drug abuse.  As part of this framework, Local Authorities and the police should have an RMFHC protocol (Running and Missing from Home and Care).  23 5.6.3 The first episode of Archie being reported missing was in January 2017. He was found by police sleeping in a fast food restaurant in the city centre. The Social Care Emergency Duty Team was notified.  5.6.4 Regular episodes of ‘missing’ followed. This included in June 2017 when he was missing for 13 days. When police officers visited his mother, they realised she had very little control of her son and submitted a referral to Children’s Social Care which triggered a strategy meeting. 5.6.5 Records from the Police indicate that he was reported missing a total of 12 times between January 2017 and January 2018. The duration of him being missing varied from a few hours through to 13 days. Each time he returned (sometimes of his own volition, sometimes when found by the police) he refused to say where he had been and only that he had been with ‘friends’. 5.6.6 It is important to note that several agencies realised that his mother did not always report him as ‘missing’ and so we can reasonably assume he was actually ‘missing’ on many more occasions. Indeed, during the last few months of his life it appears he was missing from home almost on a daily basis with his mother having little idea of where he was.  5.6.7 All children who go missing are at risk. This risk is increased when other vulnerabilities exist such as an unstable home life or associating in a gang culture. The police tactics will be determined by their risk assessment. This in turn is influenced by their ‘APP’ (Authorised Professional Practice). Guidance is that all children (as opposed to adults) should be a ‘medium’ or ‘high’ risk.    5.6.8 All of the incidents of missing relating to Archie were assessed by the police as ‘medium’ risk. He was never assessed as high risk. 5.6.9 High risk is defined in their APP and other guidance as:  The risk posed is immediate and there are substantial grounds for believing that the child is in danger through their own vulnerability,  or   The child may have been the victim of a serious crime,  or   The risk posed is immediate and there are substantial grounds for believing that the public is in danger.  5.6.10 By declaring a missing episode as ‘high risk’, the police will commit substantial resources and equipment, together with putting command structures in place in order to find the missing child quickly and safely. Most police ‘high risk’ missing episodes relating to children are when they are either very young and are in immediate danger from the  24 elements, motor vehicles etc. or when there are concerns they have been abducted or trafficked.  5.6.11 Archie was identified as part of gang culture; often on the periphery though being drawn further into that culture as time progressed. Some episodes of missing extended into significant periods – in some cases a week, in one instance for 13 days – then police should actively re-assess these cases. The assessed risk at the outset of the episode may not be correct as time passes and especially if intelligence is received that he is involved in crime or is being exploited.  5.6.12 Often when he was reported ‘missing’ he was engaged in criminal activity. This can be seen in January 2017 when he was reported missing and was detained for committing a burglary. Another example was in September 2017 he was reported missing when he carried out an assault.    5.6.13 The statutory guidance on RMFHC protocols includes advice around return interviews when a child is found or returns home. The guidance states ‘When a child is found they must be offered an independent return interview. This is to provide an opportunity to uncover information that can help protect children from the risk of going missing again. Interviews should be carried out within 72 hours of the child returning home and carried out by an independent person who has been trained to carry out such interviews.’  5.6.14 In Sheffield, at that time the return interviews were carried out by the Youth Justice Service or the police. Initial ‘safe and well’ checks were carried out by the police.   The Youth Justice Service carried out three return interviews with Archie; in June 2017, in September 2017 and in October 2017. (He declined to participate in an interview following his lengthy absence in January 2018). The police often found him when he was missing or attended his home to speak with him when he had returned. Whichever organisation is conducting the interview, it should link in to wider planning around safeguarding. As already noted, the police initiated a meeting after one missing episode and the Youth Justice Service notes the June 2017 episode triggered a strategy meeting and on others they notified the Social Worker.  5.6.15 There is an example of some confusion over where responsibilities lay regarding missing episodes. In October 2017 his mother reported to the Youth Justice Service case manager that she had been advised by the Social Worker to contact the Youth Justice Service after she had reported to the Social Worker that she was worried he was being drawn into gangs and that she could not keep him safe. At that particular point, the case manager had to in turn advise his mother that the Youth Justice Service were only involved with him for his return from missing interviews. This must have been a source of frustration and confusion for his mother.   25 5.6.16 The ‘missing’ episodes themselves were dealt with effectively. The interviews were conducted and this was fed into wider strategy meetings for consideration. The weakness is that once ‘missing’ was identified as a factor, it did not then inform the risk assessment, especially when the Child Protection Plan was in operation. 5.7 Support Archie received in relation to the bereavement of his sister 5.7.1 Archie’s older sister died in a house fire in September 2015, when Archie was aged 12. She had been his carer for the first period of his time in the UK. The sudden and unexpected death of a close family relative would have a significant impact on any young person.  5.7.2 The first record of an agency acknowledging the impact of the death on the family was with Sheffield Housing and Neighbourhood Services when a Housing Officer contacted Children’s Social Care. This was not treated as a referral by Children’s Social Care and no further action was taken. Although they were not formally involved with the family at that time, they could have signposted the family for additional support. 5.7.3 Later the same day an education support officer recorded that Archie had disclosed his sister had died and that he felt guilty as she used to be his main carer and he hadn’t seen her for six months. Three days later the safeguarding lead at the school contacted his mother, who said that she was happy for her son to be supported in school, but she did express a wish for her son to move school to be with his siblings.   5.7.4 A subsequent referral was received at MAST (early intervention service) in October and MAST record the referral was from Archie’s school to support the family after the loss of his sister. Unfortunately, due to his mother not responding to phone calls, messages or letters plus some staff absence within the MAST service there was a delay in MAST carrying out their first home visit, which didn’t take place until two months after the death.       5.7.5 The MAST worker assessed that the whole family were struggling with the loss. As well as bereavement, there were other practical issues. To their credit, the support worker from MAST became involved in advising Archie’s mother on issues such as finance, housing, benefits and in particular mother’s concern about Archie’s education.  The support worker also noted that he did not have a bed and so slept on the sofa. These were very real issues for the family. However, this meant the MAST role became blurred and the original reason for the referral became lost.  It is unclear if the referral for bereavement was made directly to the MAST service by the school or via a third party.  5.7.6 As well as the issues around finance and housing, the MAST support worker became increasingly involved in trying to access education for Archie (this was his mother’s primary concern). There were over 70 contacts from MAST in their period of involvement; the vast majority of these in trying to establish a school place.   26 5.7.7 The family were served notice by the private landlord to leave their accommodation. His mother registered with Sheffield City Council and began bidding for properties and in June they started a new tenancy. This led to a move to a different part of the city and would have meant a change in the MAST team allocation.  The worker asked Archie’s mother if she still wanted support, this was declined and MAST closed the case in August as the family moved home.     5.7.8 Meanwhile, Archie had started at a new school, but it was not a successful placement and he was repeatedly absent for a variety of reasons already documented. There are no records of any handover between the schools indicating that he may be suffering from bereavement.   5.7.9 In December, Archie accompanied his mother to an appointment with his GP. After discussing concerns, the doctor made a referral to the Child Adolescent Mental Health Service (CAMHS), indicating that the GP believed Archie required further support. However, the referral states the concerns are for his ‘anger management.’ It does not specifically mention bereavement. It is worth pausing at this point to give some context to this period in his life: 5.7.10 After repeated issues in school, his mother had again started to home educate him, but he was not accessing any form of formal education provision. 5.7.11 He had been removed from the school roll.   5.7.12 Four days before the GP appointment he had committed his first criminal offence 5.7.13 During the following fortnight (Christmas and New Year holidays), access to any non-emergency services was difficult 5.7.14 In January he was reported ‘missing’ by his mother and found sleeping in a fast food restaurant 5.7.15 By February, he had become involved in more serious offending when; in the company of a group of older boys they had threatened and robbed another teenager.  5.7.16 The next reference to support is in January 2017 when the CAMHS team met with MAST to discuss the GP’s referral. The decision at the meeting was for MAST support and there was no further involvement by CAMHS. The GP referral did not specifically mention bereavement and the meeting used their existing protocols to assign what they believed to be the most appropriate service; in this case MAST. 5.7.17 Later that month a Community Youth Team Prevention worker carried out a home visit.  The service was to try to engage him in positive activities. As part of the assessment the Prevention Worker documented a referral for ‘counselling support’.  Clearly the  27 professional had identified an issue, but their referral also did not specifically mention bereavement. Any subsequent checks on progress were lost when the service was withdrawn two weeks later as Archie had reoffended. 5.7.18 Following the GP referral, in March, MAST reopened their case file. This is a delay from the referral nearly three months earlier. The role of MAST was to explore parenting strategies with his mother, conduct ‘wishes and feelings’ work, seek counselling for Archie and achieve stability around his education. There were no timescales to the work and once again the lack of focus in their role meant the MAST worker was drawn into assisting his mother and repeatedly trying to get him education provision. There are no documents showing referrals to bereavement counselling.  5.7.19 Due to his repeated offending he was now also supported by the Youth Justice Service. During a meeting in June 2017, he agreed to a referral to an ‘Interchange’ counsellor. The meeting with ‘Interchange’ was facilitated by Youth Justice and took place in October. There had been delays with both a waiting list and Archie’s lack of cooperation.  5.7.20 His life was now chaotic with little voluntary engagement with services. This made his situation very difficult for professionals to make progress. In April 2018 at a ‘Multi Agency Risk Panel’ (convened by the Youth Justice Service) one action was for CAMHS to liaise with the Interchange counsellor. A subsequent informal meeting took place when Archie happened to be in the building and was introduced to the counsellor, but further meetings were difficult due to Archie’s refusal to engage.   5.7.21 Archie received no formal psychological support for his bereavement issues. 5.8 An analysis of the Child Protection Plan and its effectiveness 5.8.1 At the time of his death Archie was the subject of a Child Protection Plan.  To consider the effectiveness of the plan we need to explore several aspects:  the assessment leading to the decision to convene an Initial Child Protection Conference  the decisions made and actions agreed at the Initial Child Protection Conference   the engagement of Archie and his mother  the engagement of agencies in making progress to protect him within the plan  the attendances and information shared at Child Protection Conferences and Core Groups. 5.8.2 Regulatory guidelines are for a Review Child Protection Conference to be held within 90 working days of the Initial Child Protection Conference and for there to be Core Groups held every 20 working days following the first core group that takes place within 10 days of the Initial Child Protection Conference.   28 5.8.3 Working Together to Safeguard Children 2018 provides specific advice relating to Initial Child Protection Conferences and Child Protection Plans: ‘The purpose of an ICPC is to bring together and analyse, in an inter-agency setting, all relevant information and plan how to best safeguard and promote the welfare of the child. It is the responsibility of the conference to make recommendations on how organisations and agencies work together to safeguard the child in future.’ 5.8.4 Due to a number of presenting and escalating concerns within Archie’s life, an assessment (under section 47 Children Act 1989) was undertaken which concluded in August 2017. It identified he was not in education, employment or training, had repeated episodes of ‘missing’, was involved in gang offending areas and there were concerns around maternal mental ill health. However, the assessment initially concluded that he was not at risk of significant harm. The assessment was reviewed by the Children’s Social Care manager who re-assessed this conclusion and as a result the case proceeded to an Initial Child Protection Conference. This demonstrates that the poor assessment was an individual performance issue; not a systemic one. The intervention by the manager in Children’s Social Care was the right outcome.  5.8.5 The Initial Child Protection Conference took place in November 2017 (10 days outside the agreed statutory timescales). It was chaired by a safeguarding officer employed within Children’s Social Care but independent of any line management of the social workers assigned to this case. Information was shared by all attending agencies. An advocate represented the views of Archie which was identified as good practice. Due to the information shared, the scaling score (a strengths-based approach was being used in child protection conferences at this point) was 1. This is a low score (with 0 being the most ‘unsafe’ to 10 being ‘safe.’) The unanimous decision of the conference was to make Archie the subject of a Child Protection Plan under the category of ‘physical abuse’.  Archie himself did not attend and had been reported missing earlier that day. His mother was not in the meeting but later informed the social worker that she had attended as requested but was left in the main reception area and not brought into the conference suite. This was unfortunate and a missed opportunity for her to inform the child protection plan.    5.8.6 The majority of agencies were represented at the Initial Child Protection Conference but the allocated social worker was absent due to sick leave and their line manager was not present. A duty social worker attended in their place. The safeguarding officer recorded in their notes ‘My concern is that the level of risk is such that a Child Protection Plan is likely to have very little impact’.  It is not clear from Children’s Social Care records how the decision and the recommendations of the conference were accessed by the allocated Social Worker on their return.   5.8.7 The day after the conference the safeguarding officer raised a challenge stating that the report by Children’s Social Care had been inadequate and missing key information, for example the death of the older sibling.  The social worker in attendance was a duty (agency) worker and was not the same social worker who had written the report for conference.   29 5.8.8 Recommendations made by the conference were for Archie to engage in education, other positive activity placements to be sought, ‘Interchange counselling’ to be offered and to include bereavement issues and for him to be seen fortnightly by the social worker. Even though the social worker’s assessment did not refer to bereavement, it is positive that the conference deliberated this issue anyway.  5.8.9 There is no evidence of a core group meeting taking place within 10 days and therefore the outline child protection plan drawn up in the Initial Child Protection Conference did not become a more detailed plan. The core group is the vehicle to drive the progress of the plan and if it does not convene then progress cannot be measured.   5.8.10 Whilst subject to a Child Protection Plan matters continued to escalate significantly as previously outlined and Archie became involved in several concerning incidents.  5.8.11 Matters were escalating so rapidly that decisive action was necessary.  In January Children’s Social Care arranged a strategy meeting involving several professionals. It was agreed that the police would gather more information and the meeting would reconvene later that month.  However, there was no consideration of the need to escalate the concerns to the Senior Leadership Team using the ‘High Risk Tracker’, a tracker which had been recently introduced for those children or young people identified as at the most serious imminent risk to provide high level scrutiny.    5.8.12 In February the Review Child Protection Conference was held within statutory timescales.  The safeguarding officer was the same professional who had chaired the Initial Child Protection Conference in November. The allocated social worker remained absent from work and an agency social worker attended the conference.  The conference record notes;  ‘No progress since initial conference, an escalation in concern because of a serious incident in January.’ The record also notes;  ‘There have been times when Archie has not been at home.’  This comment does not reflect the escalation, the frequency and length of the missing episodes suggesting he was rarely at home during that time.  When linking these episodes of ‘missing’ with the serious criminality he was now engaged in, then, clearly, he remained at risk of significant harm. There were concerns raised that the sharing of the police intelligence was not always timely. The police information sent to the Review Conference contained only one incident, though it was apparent from the multi-agency strategy meeting held in January that more information was already known to agencies by other routes. The police must ensure that all information is shared through the agreed channels so that nothing is missed.  5.8.13 The Child Protection Conference Grid lists concerns: ‘same as before, disobeys his mother, missing from home for longer periods, serious violence incident - Archie involved’.  Under the section on the grid ‘what is going well’, the comment is ‘Mum had  30 reported him missing’.  Although his mother had done so on several occasions it was evident this was no longer the case and she had stopped reporting him missing from mid-January onwards even though he was now frequently missing. The Review Conference scaled at ‘0’ indicating that attendees believed Archie to be unsafe and the conference attendees stated that Archie was at risk of ‘killing or being killed’. As a result of the scaling and the comments made in the conference there should have been a rapid and significant intervention to try to remove him from harm and the concerns escalated.  The child protection plan focussed around the home where he had tensions with his siblings who felt he was bringing trouble to the home and his mother could not control him when the actual risks were ‘on the streets’ with what Archie described as his new ‘FAM’.  5.8.14 Care proceedings or secure accommodation on ‘welfare grounds’ (section 53 Children Act 1989) could have been considered as options. It is very rare to place a young person in secure accommodation without a criminal conviction but in this case, it may have been the only option that would keep him safe. A way to highlight to the Executive Director and other members of the Senior Leadership Team would have been through the ‘High Risk Tracker’.  5.8.15 From the comments recorded, it is clear that attendees considered Archie to be at risk, there is acknowledgement that since the Initial Child Protection Plan no progress had been made, that he remained at risk of significant harm and that the High Risk Tracker should to be used to escalate matters to the highest levels of management within Children’s Social Care, with the secure welfare placement to be considered.  The actions that were required immediately were identified in the Review Conference but then not actioned.   5.8.16 In March a Core Group was convened to consider the progress of the Child Protection Plan. It was a poorly attended meeting. Given the serious nature of the case it was vital that all invitees attended. No actions were set during the meeting but without high level intervention the plan was clearly not going to work. Again, the High Risk Tracker is not mentioned. Core group meetings did not take place with the required frequency and were not a driver for progression of the child protection plan.  5.8.17 Throughout March, Archie continued to be arrested either for new criminal offences or for repeatedly failing to attend court to answer existing charges. He did not engage in any education or other provision. His mother had stopped reporting him missing even though it was clear he was rarely at home.   5.8.18 In April, the Children’s Social Care Team Manager made an entry in the case recording for the social worker to take the case to ‘RAPP’.  RAPP is the ‘Resource Allocation or Placement Panel’, chaired by an Assistant Director. The case record also asks for a risk matrix assessment to be undertaken to get on to the High Risk Tracker. Neither of these tasks was actioned.    31 5.8.19 As Archie’s offending increased in severity and frequency, the Core Groups did not have sufficient rigour and did not contribute to the child protection plan. Although the Review Child Protection Conference was held within timescales it offered nothing new. This was when intervention was necessary. The ‘High Risk Tracker’ was mentioned and documented several times but was never actioned.  5.8.20 The Child Protection Plan and its management through the Initial Child Protection Conference, Review Conference and Core Group was ineffective. The plan should have been based on the notion of ‘contextual safeguarding’ and not around the home environment. It was clearly right to identify that Archie was at risk of significant harm but the main risk was not located in the home but on the streets.   5.8.21 The plan needed to match those assessed risks and consider the context of the identified risks (The definition of contextual safeguarding is provided at the beginning of this analysis). Sheffield shares the same problems as many other Local Authorities when trying to manage a Child Protection Plan with a teenager who is at risk on the streets rather than in the home.  5.8.22 As individuals move from their early childhoods and into their teenage years, most will spend an increasing amount of time away from the home. In Archie’s case this became the norm as he no longer readily identified with his own family. His ‘FAM’ was his new associates, most of whom were involved in offending and several of whom were much older than he was.  5.8.23 Sheffield has recognised that traditional child protection methods, where change within the family is used to safeguard the child, are not always appropriate and are unlikely to be effective for young people where the risk of harm is not located within the family setting. Such risks might be present in the young person’s community; whether this is a physical, social or an online community and as such these risks have to be identified and addressed. Sheffield (along with other Local Authorities) need to work differently with young people where contextual safeguarding is the issue, by assessing and intervening where that young person is deemed to be at risk. It is important for all partner agencies to fully embrace this new approach as Children’s Social Care cannot tackle this alone.   5.9 Support offered to his mother (for example housing, police, health, education, courts, social care) 5.9.1 All agencies involved in this review had contact with Archie’s mother. Some professionals described her as ‘struggling’, others as ‘cooperative’ and others as ‘inconsistent.’ The MAST worker who worked very closely with her described her as ‘a very proud woman. She would not ask for help until she reached rock bottom.’  5.9.2 There is no doubt that as a mother with five children having fled domestic abuse, she needed support. The sudden and tragic loss of her adult daughter caused further distress within the family and affected family members in different ways.  32 5.9.3 After the bereavement and following the referral from school for support to the family, there was a delay of six weeks before the first home visit by MAST. It is accepted that Archie’s mother was often difficult to contact and did not return telephone calls or reply to letters, however, agencies needed to be more creative in attempting to contact her.    5.9.4 The first interaction with Sheffield Housing and Neighbourhood services appears positive and after making several bids she took up a tenancy with them in June 2016. 5.9.5 The practitioners with the most regular contact with her were the support workers within MAST. They carried out extensive supporting roles in areas where she required help and advice.  The service ended its involvement in August 2016 after the family had moved to another area of the city. Although it was her choice to end the support as she believed it was no longer required, the withdrawal may have been premature as the family issues were not fully resolved. The more important issue was that their role was often ill-defined.  5.9.6 Archie’s mother had poor experiences with the education system. She was concerned to receive notifications about his poor attendance or behaviour and this resulted in her electing to home educate him on at least two occasions. The schools could have done more to communicate with her. The bureaucracy within the Education Department during her earlier exchanges meant that Archie missed significant amounts of his education. However, subsequently the efforts of the education professionals were commendable in trying to secure alternative provision for him.  5.9.7 An assessment was carried out by a social worker in Children’s Social Care over a two month period in the summer of 2017. The assessment included a reference to ‘the mother’s mental health problems’ but does not give details of what these are nor any strategies for intervention.   5.9.8 The assessment concluded that Archie was ‘not at risk of significant harm’ despite clear evidence that he was. The assessment was reviewed by a manager in Social Care who recognised the concerns and the matter was escalated to the Child Protection arena shortly afterwards. But this delayed services being introduced which could have supported him and his mother.  5.9.9 The police had regular contact with the family due to Archie’s repeated offending and almost constant episodes of going ‘missing’.  They attended the home on a couple of occasions when he was allegedly ‘smashing the house up’. Each time his mother stated she did not want him to be prosecuted. Although there could be a view that his detention may have set some boundaries for him; from his mother’s perspective the police respected her wishes. There is one instance when she rang the police because he would not get up and go to school. The police declined to attend which is expected, as it is not their role.  However, by that stage, they had significant information at their disposal about his offending, his exposure to gang culture and his vulnerability to exploitation. By assisting his mother in getting him to an education provision it may  33 have helped her (and meant fewer calls to the police about his being ‘missing’ or committing crime). With the exception of that incident, the police maintained a reasonable relationship with his mother which would not have been easy when considering they were frequently detaining her son for criminal offences.  5.9.10 In November 2017, Archie’s mum attended the GP for an appointment. Following the consultation, the doctor described her as ‘vulnerable’ and gave her safety advice and spoke to her about Archie’s behavioural problems. This resulted in a second visit a couple of weeks later accompanied by her son. Archie did not want to engage but the doctor persisted and told him he could see a professional alone if he wished to do so. This is good practice with Archie more likely to reveal his concerns without his mother present and the GP did the right thing by making the attempt. His mother was diagnosed with ‘low mood’ and was signposted for IAPT services. Given her chaotic lifestyle, it would have been more effective to refer to IAPT rather than ‘signpost’.  5.9.11 When his mother applied to be rehoused this was progressed by Housing and Neighbourhood Services.   At this first instance, the Housing Officer tried to progress, but matters moved forward slowly as Archie’s mother frequently did not respond to telephone calls or messages. The Housing Officer, recognising her chaotic lifestyle, arranged a joint home visit with the MAST worker which meant the housing application could move forward. They had tailored their approach to match her needs.   5.9.12 In March 2018, Archie was appearing in court. Initially his mother refused to take him back home as she said she could not keep him safe. She was only persuaded to take him after the Youth Justice Service manager rang Children’s Social Care who agreed a social worker would attend that afternoon to establish what support could be provided. At a subsequent court appearance nine days later, the case manager enquired but was told that nothing had yet been put in place. This type of reassurance which was not followed with action will have added greater pressure to Archie’s mother’s circumstances and a mistrust of agencies.   5.9.13 The biggest single concern with agencies’ contacts with Archie’s mother is her constant and repeated message that she could not control her son; he was exposed to gangs and violence and she could not protect him. She was right: it was clear he was no longer living with his family and any attempts to plan care for him around the ‘family’ was most likely to fail. 6 Findings and Recommendations. 6.1 His experience of mainstream education was poor. From the time he arrived in the UK, there was no assessment of his needs carried out. Professionals knew little about his background, early life experiences, his exposure to domestic abuse or his academic ability or prior learning.  34 6.2 Early contact with the Education Department was bureaucratic. He was left with no provision and spent an increasing amount of time ‘on the streets’ associating with older boys and young men.  6.3 Every child has a right to education.   Recommendation 1: Every child arriving from outside the UK and taking a place in the education system should receive an assessment in the school by a trained professional to assess their academic ability, level of attainment and other vulnerabilities that may impact on their learning. This assessment should be recorded and should be available to influence future interventions by all agencies. Recommendation 2: It is the responsibility of all agencies to ensure every child in Sheffield is in an appropriate educational setting every day and that their policies and procedures work to support this. Where agencies do not have a role in education but failing to attend school or an appropriate educational setting is identified, they should have procedures in place to ensure this is referred to the relevant agency. Sheffield Safeguarding Children Board to seek assurance from agencies that their work meets this responsibility. Recommendation 3: When a parent elects to home educate their child, the Local Authority should seek reassurances that the child is receiving a balanced education which means they are not disadvantaged from children in other education settings. This should include a home visit for an assessment by a trained professional to ensure suitable learning is taking place.                               It is acknowledged that no specific powers exist, and parents may not wish to comply, but the Local Authority has a duty (section 436 Education Act 1996) to make arrangements to establish (so far as is possible to do so) the identities of children in their area who are not registered pupils and are not receiving suitable education otherwise than at a school. If a parent did not comply then established routes for escalation could be considered. Recommendation 4: The Local Authority must develop and communicate a clear escalation process for children not on school roll. Recommendation 5: All schools within the City of Sheffield should be reminded of their legal obligations to place a child on their school roll on the day they are notified.  35 6.4 Archie was involved in gang related activity. He was initially on the periphery but became more involved and was later identified as making threats of violence and carrying weapons. He was controlled by older associates and thus exploited. The vulnerabilities of his young age, an unstable home life and lack of education provision all contributed to his exploitation through gang culture. 6.5 Despite several records noting a referral to a gang matrix or gang panel, no such panel ever convened to discuss his case and therefore no plans were made to intervene and remove him from this culture. Recommendation 6: Sheffield Safeguarding Children Board must be assured that there is an ongoing commitment to maintain and build on the multi-agency response to addressing child criminal exploitation and reducing youth violence in Sheffield. Recommendation 7: Sheffield Safeguarding Children Board and the Community Safety Partnership should ensure there are structures in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and Organised Crime Groups operating in the city. The referral pathway should be promoted to all agencies. The launch of the Child Criminal Exploitation team (Sheffield’s partnership approach to dealing with serious violence and organised criminality) should be assessed to confirm it identifies and intervenes with young people at risk of exploitation. 6.6 From Archie’s involvement in a minor offence in December 2016, there was a rapid escalation in his offending behaviour and agencies struggled to keep pace with these developments. By the time plans were made to intervene, he had already escalated to more serious offences.  6.7 Early positive steps with youth engagement were abruptly ended when he reoffended. This manifested itself in yet further offending which was both frequent and serious. 6.8 There were blurred lines for areas of responsibility between agencies. This was particularly evident between the Youth Justice Service, Children’s Social Care and the Community Youth Team.  Recommendation 8: There must be a clear referral route for vulnerable young people who engage in offending. Services should be commissioned to ensure that once a service is engaged with a young person; a lead professional is identified providing a key point of contact for the young person and their family. Irrespective of further offending, the intervention should continue as appropriate. This will require a review of current commissioning arrangements.  36 6.9 Episodes of being reported ‘missing’ were frequent. There was confusion both with the family and professionals regarding who was responsible for conducting ‘return’ interviews. These are a vital component in keeping a young person safe. Recommendation 9:   A review of the arrangements for ‘missing’ should be undertaken and assurance provided to Sheffield Safeguarding Children Board of the appropriateness of these arrangements in keeping children safe.  All practitioners should be aware of the policy and process. 6.10 Police recorded Archie as a ‘medium’ risk when he was reported missing. However, this is the minimum risk level for all missing children and young people. He was never escalated to ‘high risk’ even when in one episode he was missing for 13 days and during several instances when he was clearly involved in violent criminality. His bereavement following the sudden and tragic death of his sister was never fully addressed. He never accessed a professional counselling service. Recommendation 10:  The current Missing Young People protocol should be revised to ensure that all risks are identified at the point of reporting and all levels of risk, responses and actions are reviewed regularly throughout the missing episode.  Senior managers and officers should approve and oversee the development of a multi-agency safety plan for all high risk missing young people. 6.11 The role of the MAST (early intervention) team was ill defined. Individual workers developed a good rapport and understanding with the family, but they became absorbed within the daily problems and therefore were not able to focus on the bereavement. Recommendation 11: A clear pathway should be developed for children and families to access support following the bereavement of a close family member. This should include a mapping of services for children’s emotional and mental well-being. Recommendation 12:  The deployment of resources from MAST is a vital early intervention service. To ensure maximum benefit to the family, their role should be clearly defined with a written plan agreed with the referring agency to include key targets and regular reviews. 6.12 Archie’s mother exhibited a number of vulnerabilities. These included mental health issues, low income, fleeing domestic violence and being a single parent in an unfamiliar country. There were several individual errors in contacts with her which will have added to her frustrations. However, she did receive support from many committed and dedicated professionals across many agencies.  37 6.13 The Child Protection Plan was not effective and the Core Groups were either poorly attended or did not take place at the required frequency. The Review Conference noted the increase in his exposure to violent offending and being reported missing on an almost continual basis. It recorded actions to progress to a ‘high risk tracker’ to alert senior management as it had reached the highest possible level of risk and required immediate intervention. Yet it failed to implement the actions to deal effectively with the assessed risk. 6.14 The Child Protection Plan was not working and the family home was not the right environment in which to base the plan. The danger was on the streets rather than in the home environment.  Recommendation 13:  Sheffield Safeguarding Children Board must put mechanisms in place to ensure agencies involved in the safeguarding of children and young people commit to both the sharing of information in a timely manner and their agency’s attendance at Child Protection Conferences. Recommendation 14:  Sheffield Safeguarding Children Board must put mechanisms in place to check agencies identified as having a role in the Child Protection Plan must ensure they send representatives to the Core Groups to ensure the plan is implemented and developed. Recommendation 15: Sheffield Safeguarding Children Board must ensure that there are clear lines of responsibility on who delivers actions against the Child Protection Plan. This is especially important when escalation to senior management is required.  Recommendation 16:  When a young person is subject to a Child Protection Plan, this must be the forum that takes primacy over all other forums. The Youth Justice Service Multi Agency Risk Panel or the ‘gang matrix’ have important roles to fulfil but they must be incorporated into the Child Protection Plan to prevent duplication and ensure a focus of effort to keep the young person safe. Recommendation 17: Sheffield Safeguarding Children Board to research, develop and assist with the implementation of Child Protection Conferences that assess risk and develop plans in line with our increasing understanding of contextual safeguarding. Recommendation 18:  Sheffield Safeguarding Children Board should commission workforce development for delivery to all front line professionals on the issues of contextual safeguarding. This training should include recognising the risks of criminal exploitation and sexual exploitation.   38 Recommendation 19: Contextual Safeguarding should be embedded in all agencies’ considerations, planning and processes linked to safeguarding of children and young people.     39 6. Glossary APP                             Authorised Professional Practice CAMHS                      Child and Adolescent Mental Health Services CME                           Children Missing from Education County Lines            Cross cutting issue involving drugs, gangs and exploitation Core Group              Forum responsible for developing and implementing the Child Protection Plan CPP                            Child Protection Plan CSC                            Children’s Social Care CYT                            Community Youth Team EDT                            Emergency Duty Team EGVE                         Ending Gang Violence and Exploitation                    FAM                           Street slang for ‘family.’ GP                              General Practitioner HMICFRS                  Her Majesty’s Inspectorate of Constabulary, Fire and Rescue Services IAPT                           Improving Access to Psychological Therapies ICPC                           Initial Child Protection Conference Interchange             Counselling service IMR                            Individual Management Review HM government     Her Majesty’s Government MARP                        Multi Agency Risk Panel (Youth Justice Service) MAST                         Multi Agency Support Team NASSEA                     Northern Association of Support Services for Equality and Achievement OFSTED                     Office for Standards in Education, Children’s Services and skills PCSO                          Police Community Support Officer RAPP                          Resource Allocation or Placement Panel RMFHC                      Running and Missing from Home and Care S. 47 enquiries         Assessment of whether a child is likely to be at risk of significant harm SOS                            Signs of Safety (Grid used by Children’s Social Care) YJS                              Youth Justice Service  