Alleged sexual assault of a 13-year-old girl by a former foster parent. Learning includes: keeping children safe from harm in foster care; supporting looked after children and young people who have reported sexual harm; and taking account of a looked after childs lived experience. Recommendations include: the safeguarding children partnership should ask the local authority to provide evidence of an audit of annual reviews of foster carers; the partnership should undertake a multi-agency audit of the management of serious complaints and allegations against foster carers; the safeguarding partnership considers how it can help professionals support looked after children who are the victims of sexual crimes and/or who make allegations against carers; and access to a single source of information could be considered for young people which clearly explains the likely steps in the days, weeks and months following a sexual assault.
      
 Title:  Child safeguarding practice review: Scarlet. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2021  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.                                  Child Safeguarding Practice Review ______________________________________________  SCARLET                           This report will be published in line with statutory guidance.  In order to preserve the anonymity of the child in this case, Wirral Safeguarding Partnership has taken steps to disguise their identity.  It has: • represented the child and family members by different names; • not necessarily reflected the child’s true gender or gender identity (or that of siblings); • avoided the use of exact dates, where possible; and, • removed details about services which could lead to the recognition of the children and family. 1  Wirral Safeguarding Children Partnership July 2021 1. Background to review  1.1 When Scarlet was 13 years old, she alleged that a former foster carer had sexually assaulted her.   Action was taken to safeguard the children still living in the household and a criminal investigation was opened.  Scarlet had been living with a new foster carer for about approximately 3 months when she made this allegation.   Other young people subsequently made allegations against this individual of assault, grooming and inappropriate behaviour.  1.2 As Scarlet was in the care of the local authority at the time of the alleged incident, Wirral Safeguarding Children Partnership undertook a rapid review of all information readily available to the local authority and partner agencies.    The Partnership concluded that the criteria were met to undertake a Child Safeguarding Practice Review (CSPR) as the allegation against a person in a position of trust was of such gravity that its impact was likely to be severe and enduring.  This decision was consistent with requirements of Working Together 2018.  The decision to undertake a CSPR was subsequently endorsed by the national Child Safeguarding Practice Review Panel.  1.3 An independent reviewer was commissioned in November 2019.  It was agreed that the review would be conducted using a hybrid systems approach, to promote learning at the levels of individual practitioners and first line managers; of single agencies and organisations; and, in respect of multi-agency practice.  The progress of the review would be overseen by a CSPR Panel (the Panel) which would contribute to the overall analysis and to the formulation of recommendations which, if endorsed, the Partnership would have responsibility to implement.      1.4 A timetable was set for the completion of the review.  Unfortunately, that timetable has had to be revised on a number of occasions for a variety of reasons, both unavoidable and avoidable.    Covid 19 arrangements have also had an impact on the conduct of the review.  It was not possible, as had been planned to hold a learning event with practitioners.  In March 2021, a virtual meeting between the Chair of the CSPR Panel, the independent reviewer and  Scarlet’s then social worker (SW3).  On the basis of learning from this review,  WSCP has made improvements to its case review structures to improve its case review function.    1.5 The final draft report on which this review is based was presented to the Safeguarding Children Partnership Executive on 14 June 2021.  The Executive has endorsed the recommendations contained in this report and approved the CSPR for publication.                                                                                                                                                                                                          2  Wirral Safeguarding Children Partnership July 2021 2. Key lines of enquiry  a) Inasmuch as can be reasonably ascertained, how effective was multi-agency childcare and safeguarding practice during the pre-review period?  2.1. Scarlet is one of a very large family of brothers and sisters.  The family first became known to CSC in 2004 when Scarlet’s mother (MS) was pregnant with Scarlet.  When Scarlet was 2 years old, a serious incident led to care proceedings being initiated in respect of all the children.  Scarlet and her brother, Alex, were placed together, while their siblings went to live in different households.    2.2. The children were made subjects of care orders and placed at home with parents.  This placement decision by the court appears to have represented an unjustified degree of optimism about MS and FS’s capacity to change.  And indeed, this proved to the case.    2.3. After three turbulent years, a crisis led to all the children’s being removed from parents’ care.   Scarlet, aged 6, and Alex, aged 5, were placed with local authority foster carers, Mary and John.    As the children had lived with Mary and John before, this placement had the advantage of offering established relationships and the familiarity of place and routines.  There is no evidence, however, that placement choice was influenced by an assessment of the children’s long-term needs or of sibling relationships.   2.4. Scarlet and Alex settled quickly in Mary and John’s busy household.   After five years,  documents supporting Special Guardianship Orders were submitted to the local authority’s legal services.  By this stage, the children called their foster carers ‘Mum and Dad’.   They were said to be ‘happy’.      2.5. Safeguarding practice in the pre-review period has not been analysed in detail.  Nevertheless,  the known history raises questions about practice in relation to responding to neglect; care planning for children who the subject of family court proceedings are; and, keeping children safe when they are placed at home with parents.    2.6. Significantly, it is not clear that early placement and care planning recognised the enduring impact that Scarlet’s experience of neglect might have had.  Progress to achieve the proposed Special Guardianship Orders was also slow.      2.7. Nevertheless, the accepted professional view, during the pre-review period, was that John and Mary were providing Scarlet with the care that she needed and that she should remain with them.      b) What were the circumstances that led to Scarlet’s placement with Mary and John coming to an end, and how effectively were they managed?  3  Wirral Safeguarding Children Partnership July 2021 2.8 In 2016,  Scarlet alleged that John had committed a sexual offence against her while Mary was out of the house.  A strategy discussion was held on the same day.  John was arrested but he denied the offence.    2.9 Scarlet and Alex were moved to a temporary placement with Jean and Bill on the same day.    This placement was made four months after an incident involving Bill was investigated by the police.   Although the investigation was not of direct harm to a child and no offence had been committed; the incident raised concerns about whether Bill might pose a risk of harm to children.   Allegations of risk of harm posed to children by professionals are managed by the Local Authority Designated Officer (LADO)1.  The LADO concluded that, in Bill’s case, those concerns were ‘unsubstantiated’.   Nevertheless, as the circumstances suggested a breach of fostering standards; the local authority fostering service should have asked the Fostering Panel to review the appropriateness of couple’s registration as foster carers.  That did not happen.  Scarlet’s social worker was unaware of the concerns that had been raised about Bill.    2.10 Nine months after Scarlet had alleged that John had sexually assaulted her, the Crown Prosecution Service (CPS) advised that John should not be charged in connection with the allegations.   When Scarlet was told, she was comforted by the social worker and by foster carer, Jean, who reassured her ‘that she had done the right thing and that she was very much believed in what she had said’.    The following month, the LADO recorded that the potential risk that John posed to children was  ‘unsubstantiated’.    There is some evidence that not all practitioners clear as to what a finding of ‘unsubstantiated’ meant for both John and for Scarlet.  2.11 A review of Mary and John’s continuing suitability to foster was undertaken by the fostering panel.  John and Mary continued to be registered carers for one young person, aged 17, who had lived with them as a long-term placement.      2.12 The effectiveness of the management of allegations against foster carers and the nature of support offered to young people who are alleged victims of serious crimes are considered in more depth below.    c) Scarlet and Alex lived with Bill and Jean for more than two years.  How effective were childcare and safeguarding practices during this time?  2.13 When Scarlet and Alex went to live with Bill and Jean, it was anticipated that this would be a temporary placement.  Efforts ensued to identify a permanent placement for both children.   Scarlet and Alex were reported to be pleased that they had moved, although the situation was undoubtedly more complex for them.     1 This officer is now formally the Designated Officer (DO) but the former title is still widely used.  4  Wirral Safeguarding Children Partnership July 2021 2.14 When the children had been living with Bill and Jean for about a year, new concerns about Bill’s behaviours were identified following an incident in school.  After discussion with the children’s social worker; the fostering team manager and the supervising social worker spoke separately to Bill about the inappropriateness of what had occurred.   On this occasion, there was no discussion with the LADO, although it would have been warranted and, as before, there was no consideration of whether fostering standards had been breached.    2.15 This incident took place around the same time that the CPS concluded that no charges would be brought against John.   Soon afterwards, Jean began to tell professionals that she wanted both children to be moved due to Scarlet’s behaviours and the impact that they were having on other children in the house.   Jean’s concerns, and what they meant for Scarlet, were not explored.   Scarlet’s behaviour was also said to be deteriorating in school: she was seeing a school counsellor.   A plan to seek an independent fostering placement was agreed, as it had not been possible to find an in-house permanent placement for the children.  2.16 Six months later, in October 2017; although Jean and Bill were not willing to care for the children long-term, the children were described in their looked after child reviews as seeing themselves ‘very much as part of the family’.  No significant progress had been made in identifying an alternative placement.    2.17 Towards the end of the year, Jean and Bill were allocated a new supervising social worker (SSW).   This social worker was in her assessed and supported year in employment (ASYE) as a newly qualified social worker.   There is no evidence that a case transfer discussion took place or that any of the issues which had previously been raised about Bill were discussed with the new worker.    2.18 Jean told her new SSW that she was concerned about some of Scarlet’s ‘sexualised’ behaviours.  She said that she was also worried about leaving Scarlet alone in the house with Bill, as she was ‘nervous about possible allegations against her husband’.  The SSW shared this information with Scarlet’s social worker but, at this point, Jean’s comments about Scarlet’s ‘sexualised behaviours’ were not explored further by either service.     2.19 The local authority fostering service acknowledges that Jean’s assertions should not have been accepted without challenge.   The SSW should have also been supported through this process by supervision and additional ASYE support.  2.20 In the spring of 2018, casework responsibility for Scarlet and Alex transferred to a new social worker (SW2).   Around this same time, Scarlet began to talk very unhappily about ‘just wanting to settle somewhere’.   Scarlet wondered whether she and Alex could move to live with their brother, who had recently moved to an independent placement some distance away.   Jean was in favour of this suggestion.    5  Wirral Safeguarding Children Partnership July 2021 2.21 Billy’s foster carers welcomed the plan for Scarlet and Alex to move to their care and the proposal was agreed in principle by the couple’s fostering agency.  The local authority’s ‘Planning for Children Panel’, however, required further assessment of the potential risks before the placement could be agreed.   2.22 In the meantime, Scarlet’s placement with Jean and Bill began more obviously to break down.   Scarlet was distressed and agitated in school and, on one occasion, after an argument with Jean, she ran off from home and could not be persuaded to return.  2.23 The following morning, a number of telephone conversations took place in the hope that, with support to both Jean and Scarlet, Scarlet could remain in placement until a planned move could be made the following week.   During one of those conversations, Jean repeated her concern for Bill, saying that Scarlet was ‘flirtatious’ with him.  SW2 challenged this comment, asking Jean to reflect on Scarlet’s experience.     2.24 As no agreement could be reached for Scarlet’s return,  arrangements were made for her to stay in a respite placement with Cathy for the weekend.   SW2 described Scarlet as ‘feeling low’, ‘rejected’ and ‘unwanted’, and facing the possibility of a lot of change.  2.25 Although Scarlet did not return to live with Jean and Bill, Alex had made it clear that he did not want to leave.   It was now suggested that Scarlet could move alone to live with Billy, but she was reluctant to go without Alex.    2.26 Overall, therefore, while Scarlet appeared to professionals to be, for the most part, happy and settled with Jean and Bill;  this was at odds with Jean’s view of the placement.   This contradiction was not explored, however, and so the reality of Scarlet’s experience could not be known.     2.27 An opportunity was also lost to assess the legitimacy of Jean’s description of Scarlet’s ‘sexualised behaviours’ and to understand whether Scarlet might need support to recover from earlier trauma or sexual abuse.  In addition, there had  twice been an inadequate response to incidents that raised questions about Bill’s continuing suitability to foster.      2.28 In the event, Scarlet’s placement with Jean and Bill ended in an unplanned and unsatisfactory way.  There is no evidence of what might be called a disruption meeting taking place to help understand what had happened, even if only to reduce the risk of a similar placement breakdown in future.  At the end of this period, Scarlet was living apart from Alex for the first time.  d) How effective was professional practice during the time that Scarlet lived with Cathy?  2.29 Shortly after Scarlet moved placement,  the Planning for Children Panel approved a plan for Alex to remain with Bill and Jean and for Scarlet to move to live with Billy.  Scarlet, 6  Wirral Safeguarding Children Partnership July 2021 however, was adamant that she did not wish to go alone.  For the moment, she would remain with Cathy.  2.30 Very late one evening, having been living with Cathy for six weeks,  Scarlet was found in a state of collapse in a local park and was taken by ambulance to the ED.  She was thought to have been given a form of ecstasy by a group of young people she had met in the park.  Following a period of assessment and observation in hospital, Scarlet returned to Cathy’s.  2.31 A duty social worker arranged to visit Scarlet and a referral was made to a local young people’s specialist advice and support service.   Although it was agreed that community policing would be notified of the incident in the park, there is no record on police systems that this happened.   At this point, SW2 had left the local authority and there was ‘no active social worker allocation’ for Scarlet.  It was anticipated that a new social worker would be allocated the following week   2.32 Two days later, Cathy was visited by her supervising social worker.   Scarlet was said to be feeling very down and now wanting to speak to anyone.  Cathy told the SSW that Scarlet  had said that Bill was no longer living at home, as another child (Child A) had made an allegation against him.  At the same time, Bill had been texting Scarlet, meeting up with her for tea and giving her money.   Scarlet had told Cathy that she had spent some of that money on vodka.   Cathy said that she had given SW2 this same information a week earlier and had been assured that the situation would be investigated.   When Cathy had not heard back from SW2, however, she had also tried to speak to the team manager but without success.  Cathy had later established that SW2 was no longer employed in the authority.   2.33 The SSW spoke to the team managers (TMs) in both fostering and in the permanence team.  The allegation said to have been made by Child A was not recorded on the electronic information system and was not known the LADO.    2.34 The duty SSW and Jean spoke by telephone.  Jean said that Child A had made an allegation of sexual abuse against her husband when she and others were on holiday almost two weeks earlier.  Bill had not been with the group as he had stayed at home.   Jean explained the circumstances in which the allegation had been made.  Jean said that she had spoken to Child A and to Bill, by telephone.  She and Bill had agreed that he should move out until the matter was ‘sorted out’.   Jean said that she had been trying, without success, to make contact with her supervising social worker and Child A’s social worker since then.   2.35 A strategy meeting took place.   It was agreed that Bill would remain out of the household.  Jean made it clear, however, that she did not believe the allegations against him and that she wanted her husband to return.  Alternative placements were, therefore, to be sought for the looked after children in the household.  Referrals were made to the LADO in respect Bill, due to the nature of the allegation, and in relation to Jean, ‘due to her delay in reporting the allegation and subsequent response’.   7  Wirral Safeguarding Children Partnership July 2021  2.36 At this point, SW3 joined the local authority and was allocated casework responsibility for Scarlet, Alex and Billy.   SW3 has described being allocated ‘a whole caseload’ with no handover.   As a result, SW3 had little background information about Scarlet and her circumstances when she first visited Scarlet two days later2.  2.37 Scarlet said that she did not think Bill meant any harm in meeting with her and giving her money: ‘he just wanted to help her’ and ‘to continue his role as a fatherly figure in her life’.   Scarlet said that she was happy living with Cathy and told SW3 she would like to stay.  Cathy, however, was not in a position to provide Scarlet with a permanent placement.    2.38 About two weeks later, a second child (Child B) made an allegation of sexual abuse by Bill.  At this point, Scarlet’s behaviour was deteriorating both in school and at home.  Strategy meetings were taking place to coordinate the different strands of investigations, enquiries, assessments and safety plans.  SW3 had the opportunity to read more of the children’s files and had a supervision session with her manager.   2.39 Alex was moved to a placement with Marian and Steve.  He was upset about this as he did not want to leave the placement he had regarded as home.    As it was anticipated that this could be a long-term placement for both children, Scarlet joined Alex a few days later.    Neither child was happy with the move, however, and Alex blamed Scarlet for the disruption to his life.  Scarlet was almost 14 years old at this point.  2.40 A few days later,  Scarlet told a member of school pastoral staff that Bill had seriously sexually assaulted her earlier that year.  Scarlet said that the reason Bill had been giving her money was ‘to keep her quiet’.   Scarlet later told SW3 that she would be willing to make a statement to the police and an arrangement was made for her to be interviewed the following day.   There is no evidence that a strategy meeting was held, or planned, to consider what the next steps should be.   No consideration appears to have been given as to whether Scarlet should have a child protection medical.    2.41 Scarlet showed SW3 some of the text messages that Bill had sent her.  SW3 gained the impression that Scarlet was telling the truth about Bill. SW3 referred Scarlet to the sexual assault support centre.     Bill was arrested.     2.42 Some days later, Scarlet telephoned ChildLine and said that she was going to kill herself.  ChildLine alerted the police who telephoned Marian and Steve.  Marian went to Scarlet’s room: she was sitting up in bed and was visibly distressed.   There was a police patrol car outside.  Marian went by ambulance with Scarlet to hospital.    Scarlet said that she could  2 2.27 It is also notable that SW3 had not work previously within the context of the legal childcare framework in England.  She had, for example, no knowledge of the role of the LADO in managing allegations against foster carers.  SW3 appears not to have been informed either about the strategy meeting, which took place on the day that she started work, in respect of Child A’s allegations against Bill. 8  Wirral Safeguarding Children Partnership July 2021 not stop thinking about what Bill had done and about what she could have done differently to stop him and get help.  Scarlet was admitted for CAMHS assessment.  2.43 Scarlet remained in hospital overnight and a possible move to CAMHS in-patient care was considered.   The following day, however, Scarlet presented as quiet but bright and engaging.  She was fit for discharge although a safety plan needed to be in place before she could be discharged.   Marian said that she felt unable to manage the risk.   Scarlet was, therefore, discharged to Cathy’s care until more permanent arrangements could be agreed.   The Children’s Social Care chronology suggests that Scarlet’s allegations of assault may not have been appropriately explored within the CAMHS assessment, but this may have been due to the ongoing investigation.    2.44 On returning to school, Scarlet continued to show high levels of distress.    2.45 Just beyond the end of the CSPR review period,  Cathy took Scarlet again to hospital.  She  was assessed by CAMHS and discharged, with a review appointment 10 days later.  By this point, SW3  had developed a positive relationship with Scarlet and was attending regular appointments with her.     2.46 Scarlet remained in placement with Cathy a number of months until Cathy reported that ‘she did not feel able to meet Scarlet’s needs or to manage her behaviours any longer’.    2.47 Two years after Scarlet had told the police that Bill had sexually assaulted her, the CPS decided that no charges were to be brought against him.   Jean and Bill are no longer registered foster carers.     Scarlet continues to struggle with her mental health.  e) How effectively did professionals communicate and work together during the review period?  2.48 The principal agencies, organisations and services involved with Scarlet during the review period were GP; School Nursing Services; hospital and CAMHS; police; education; CSC child and family services; CSC fostering services; allegations management service (LADO); and Independent Reviewing Officers.   All services provided a management review report for the CSPR.     2.49 The school nursing service had good knowledge of Scarlet’s family history.  Throughout the review period, there was a single, consistent allocated health practitioner.   There is evidence of good communication between the school nurse and the school safeguarding lead about Scarlet.   Looked after child health reviews were completed quarterly as required.   These were, however, completed within the school environment.  This had the advantage of giving Scarlet the opportunity to talk about what was important to her without her carer being present.  At the same time, there was no opportunity to see Scarlet in her home or to talk to her foster carers.   9  Wirral Safeguarding Children Partnership July 2021 2.50 The school nurse received safeguarding and looked after child specialist supervision in accordance with Health Trust and Children Partnership policies, procedures and guidelines.  2.51 Although Scarlet had limited contact with hospital services, records demonstrate concerns about Scarlet’s welfare in her early life and show how Scarlet’s legal status and living arrangements changed over time.     2.52 The hospital services management review, however, acknowledges that, when Scarlet was found in the park having taken illegal drugs, there ‘was a lack of professional curiosity throughout this attendance’ and ‘a missed opportunity (for Scarlet) to disclose alleged sexual assault to professionals sooner’.    In addition, no child sexual exploitation screening was completed and no referral was made for specialist support for Scarlet.  At that time, the sexual exploitation screening tool was not available within the hospital IT system which made it difficult for staff to access.  This has now been rectified and staff are able to access all safeguarding and safeguarding screening tools with the system.  When they are completed, they can be shared immediately as appropriate.  2.53 When Scarlet was admitted with suicidal thoughts,  Cathy and SW3 spoke with the ward staff about recent events.  The discussion was documented.  Expected safeguarding processes were followed.  Staff were aware that there was an active police investigation and that there was no immediate risk of harm from Bill to Scarlet.    The hospital provided and managed mental health support and requested that CAMHS review Scarlet when she was medically fit.    2.54 Cathy and SW3 attended Scarlet’s CAMHS review.   Advice was given to Cathy about managing risk.  Scarlet and Cathy agreed to attend a learning about mental health workshop, with the possibility that Scarlet might later engage with an ‘emotional regulation group’.    2.55 An appointment was made for Scarlet for the following week with the sexual assault referral centre.  In the event, the centre was not in a position to offer counselling while CAMHS was involved and a criminal investigation was pending.  They did, however, allocate an advocate/key worker whom Scarlet could see on a regular basis.   It is not clear from information provided to the review if this was an Independent Sexual Violence Advisor [ISVA].    2.56 Sexual health screening of Scarlet was completed in the community.   All agencies were informed of Scarlet’s admission to hospital: SW3 spoke directly to the school.    2.57 The police have had significant involvement with Scarlet and family members over the years.  In particular, police undertook six investigations on behalf of Scarlet, mainly in respect of allegations she had made against John and Bill.   Investigations of Bill were also undertaken in relation to the allegations made by Scarlet and two other children.     10  Wirral Safeguarding Children Partnership July 2021 2.58 At the time the police management review was written, police were still awaiting a decision from the Crown Prosecution Service.   The report acknowledges that the process of reaching a charging decision was protracted in this case, as in many other cases, despite the investigation record demonstrating that ‘both supervisors were working tirelessly to achieve a conclusion’.    It is not clear, however, what consideration was given to the potential impact on Scarlet of this lengthy process and how that might affect police practice.   2.59 The police management review concluded that communication both internally and with partner agencies was effective.   The single exception identified was that the police were not informed in August 2018, when the circumstances of Scarlet being taken to hospital suggested that there was a wider immediate risk to vulnerable young people in the area of the park where she was found.    The reviewer advises that such incidents should be reported to the police immediately ‘in order to maximise opportunities to locate other potential victims, secure evidence and apprehend offenders’.   2.60 The children’s social care (CSC) management review, however, is less confident about the general quality of professional communication between CSC and the police.  That report highlights a perception that ‘police tend to lead an investigation when an allegation has been made without including social care’.    2.61 Both school and Virtual School (VS) provided management reports for the review.  The school report was completed by its Designated Safeguarding Lead and the VS, by the Virtual Head Teacher.   2.62 Scarlet started at the school at the beginning of her secondary education.  She had an enhanced induction as would be expected for a looked after child.  Scarlet’s name was placed on the Special Educational Needs register, following assessment and testing.     2.63 The school has described ‘significant conflict’ between Scarlet and other children who lived in John and Mary’s household for some time after she had reported that John assaulted her.  2.64 Throughout her time at school, Scarlet required extensive pastoral support.  She was referred to the designated youth service for schools.  In addition, school staff consulted with CAMHS and agreed what is described as ‘a full supervision risk management plan’.  The school reports being in regular communication with Scarlet’s social worker and having a good working relationship with her.   2.65 The VS relies mainly on the contents of Personal Education Plans (PEPs) to track looked after children’s progress in school, although there is an expectation that staff will keep themselves informed about children’s lives through access to electronic case records.    The VS management review has found Scarlet’s PEPs, completed during and just after the review period, demonstrated a decline in Scarlet’s attitude to learning and in her social, emotional and mental health wellbeing. It notes that ‘this was not picked up at the time’.   11  Wirral Safeguarding Children Partnership July 2021 As a result, there was no communication with the school or enquiry about what could be done to support Scarlet.     2.66 The VS report acknowledges that staff cannot properly know the child and act on their behalf, without increased involvement in professional exchanges of information.   At the moment, VS staff attend all relevant meetings for children identified as high priority but there is limited capacity to develop this further.  2.67 The VS is one of a number of council services which describes having become ‘more joined up and knowledgeable about each other’s practice and the support they can offer’ since all children’s teams have been co-located.    It is not clear what impact COVID-19 working arrangements and subsequent decisions about office/home working will have on this more integrated experience for practitioners and managers.   2.68 A summary of CSC involvement has been given in earlier key lines of enquiry.   In addition, various types of multi-agency meetings took place which involved CSC.  These included strategy meetings, care planning meetings, allegations management meetings and looked after children review meetings.  The latter two are considered in separate lines of enquiry.    2.69 Information provided to review indicates that one strategy discussion and seven relevant strategy meetings were held during the review period.   The LADO did not always attend strategy meetings despite their relating to allegations against foster carers.    In September 2018, the LADO and CSC professionals met to discuss the allegations which had been made.  The LADO services management review states, however, that there do not appear to be any minutes of the meeting and that, although there are some notes on the child record, they are not comprehensive.    2.70 In October 2018, a complex multi-agency meeting was held.  This was chaired by an IRO.  The LADO was also present. The subjects of the meeting included Scarlet, Child A, Alex and other children who had been cared for by Bill and Jean, as well as child family members.   The meeting considered police actions undertaken; welfare issues relating to the children; and, managing restrictions on information-sharing while criminal investigations were current.   Further actions were set.    2.71 Overall, it appears that strategy meetings provided an adequate forum for reviewing and planning actions to keep the child subjects safe, although the absence of a dedicated strategy meeting in respect of Scarlet’s allegation against Bill is a significant gap.  In addition, it is not evident that all relevant professionals were in attendance on every occasion.   It is not clear, either, whether minutes of meetings were appropriately circulated.   2.72 The CSC management report states that there have been significant improvements procedures and practice in respect of strategy meetings since the review period.  For 12  Wirral Safeguarding Children Partnership July 2021 example, strategy meetings are now coordinated by business administration officers and a minute taker is available.    2.73 There is little evidence in the pre-review or review period of care planning meetings meeting being held.  It is reported by CSC that regular care planning meetings for looked after children now take place and that they have ‘a clear agenda which includes an analysis and impact upon the child with oversight from the team manager’.  2.74 The CSC management report acknowledges that, although information was shared regularly by phone and through requesting reports from other agencies; multi-agency communication and working were not as effective as they could have been.    2.75 Fostering service involvement with Scarlet has also been summarised in key lines of enquiry above.  It has been noted that, in three of the four placements discussed in this review, Scarlet was not matched with foster carers prior to being placed with them in urgent circumstances.  During the review  period, Scarlet remained with Bill and Jean and with Cathy much longer than had been anticipated.  Although it had been hoped that Marian and Steve would be able to offer a permanent home to both Scarlet and Alex, this quickly broke down when Scarlet’s distress led to her thinking about suicide.  Scarlet made evident her sense of dislocation and need to belong.   2.76 While the children were living with Bill and Jean, the fostering service is reported to have made sustained, if unsuccessful, efforts to  identify a suitable permanent family placement for Scarlet and Alex, whether through in-house provision or through an independent provider.   This focus on family placement for the children was consistent with Wirral’s practice3.   For this to continue to be a successful strategy, however, the local authority acknowledges that it needs ‘to work with partners to wrap support and services around these placements’.      2.77 It is notable that, during the review period, supervising social workers did not routinely attend looked after child reviews and, according to the fostering management review, ‘they were not always consulted’.   This is significant because, if vulnerable and traumatised children are to be provided with the care, they need in family settings; supervising social workers should be aware of the particular child’s needs and  3 Wirral Sufficiency and Commissioning Strategy for Children Looked After in Wirral 2016-2020   In 2015, Wirral placed approximately 75% of its looked after children with foster carers, demonstrating a considerably higher fostering to residential ratio when compared to other authorities in the Northwest.  The vast majority of foster placements in Wirral were with local authority carers.  A substantial minority (42%) of children placed with all foster carers were between the ages of 10 and 15.  Wirral’s Sufficiency Strategy describes this group of children as ‘often the most challenging children and young people to place with foster carers’.    This group contained Child L and Alex.    13  Wirral Safeguarding Children Partnership July 2021 experiences if they are to adequately support the continuing development of the carers for whom they are responsible.     2.78 Since April 2019, it has been expected that the supervising social worker will both attend children’s looked after reviews and provide a report to it ‘looking at the routine and daily lived experience of the children’.  That report should be based on direct contact with, and observations of, the child in placement.  2.79 In addition to the role of the supervising social worker, foster carer annual reviews are designed to offer ‘an opportunity to reflect…to consult others…to consider any challenges as well as exploring (a carer’s) support needs’4.   In Wirral, the completion of foster carer annual reviews is a commissioned service.  They are undertaken by an Independent Reviewing Officer.      2.80 The fostering management review describes significant gaps in Jean and Bill’s annual reviews.  Despite allegations and complaints that have been made in the previous 12 months being a specific section of the report; the relevant annual review made no reference to the LADO enquires which took place prior to Scarlet and Alex being placed with them.     In addition, the incident which took place at school was not formally recognised as a complaint or allegation against Bill.   This meant that it would not have been considered in the foster carer annual review unless raised as an issue by the SSW, SW or other professional with whom the reviewer consulted.     This emphasises the importance of correctly identifying and recording those incidents which might call into question a carer’s suitability to foster.  Otherwise, the capacity of the annual reviewer to conduct a comprehensive review is significantly diminished.    2.81 The fostering service has provided additional information to the review which indicates that changes have been made to the annual review authorisation process.  The fostering service team manager now quality assures the review report and can ensure that any allegations or complaints in the last twelve months have been addressed.  All foster carer annual reviews are subsequently approved by the Agency Decision Maker.   2.82 Services provided to parents during the review period  2.83 Limited information is available to review about services provided to parents during the review period.  It has been noted that Scarlet’s contact with MS was terminated by court order when Scarlet was living with Mary and John.  Details of Scarlet’s contact with FS are unclear.     2.84 Substance misuse services were asked to provide management report to the review about their involvement with MS.  MS had two separate periods of treatment.   On both occasion, staff had difficulty engaging with MS which made it challenging to develop a  4 The Fostering Network, Annual Reviews 14  Wirral Safeguarding Children Partnership July 2021 therapeutic relationship with her.   The substance misuse service’s involvement was non-statutory.     2.85 At no time during the service’s work with MS was it aware that MS had children.  The information was not given by the prison service when, on her discharge, an assessment of MS’s care and treatment was undertaken.  Neither did MS disclose it, although having a large number of children with whom she had lived and who had been subsequently removed from her care was probably the most significant feature of MS’s life history.   It is difficult to know how MS could have consistently provided any information about her past experiences without reference to them.  Although MS’s consent would have been required to seek further information from external services, there is no indication that this was sought and declined.   f) How effective were looked after children reviews in Scrutinising the local authority’s plan and in evaluating the quality of multi-agency working?    2.86 All looked after children are required to have a care plan which, the law prescribes, has to be reviewed on a regular basis.  Reviews are undertaken by Independent Reviewing Officers (IROs) who are required to oversee and scrutinise the child’s care plan and to ensure that everyone who is involved fulfils their responsibilities.  As it may not be appropriate to bring together everyone who is involved with a child; the review can be a process rather than a single event.   Parents’ views should be sought if they are unable to attend.   2.87 Before each review takes place and between reviews; the IRO is required to speak with the child in private.  The IRO should also ensure that the child or young person is able to participate as fully as they can in the reviews of their care plan.   Outside the formal review, the child’s social worker has a duty to inform the IRO of any significant events in the child’s life.    2.88 The first key line of enquiry has referred to the slow progress made by the local authority towards achieving legal permanence for the children with John and Mary.  The IRO service management review acknowledges that successive looked after child reviews did not address this.  Recommendations were not specific enough to progress the children’s plans: ‘it would have been appropriate (for the IRO) to raise more than one (escalation) given the drift and delay in the application for the SGO …’.  2.89 The management report found that looked after child reviews were ‘held regularly and mostly within timescales’.  Such gaps as have been identified are associated with the children’s plan changing and/or a move between placements.  For example;  in the early months when the children were living with Jean and Bill, when Scarlet left her placement with Bill and Jean, and then, when both children moved to live with Marian and Steve.  2.90 There is evidence that the IRO spoke to Scarlet alone prior to review meetings and recorded elements of her views and feelings.  On most occasions, Scarlet said that she 15  Wirral Safeguarding Children Partnership July 2021 had no worries and felt settled in placement.  During the review period, there is no evidence that the IRO made contact with parents, although it is acknowledged that MS’s whereabouts were not always known.     2.91 It is not clear how effectively the IRO service was informed of significant events in Scarlet’s life between planned reviews.   As noted earlier, supervising social workers were not routinely invited to looked after child reviews, at this time.  While it is now expected practice that IROs make contact or visit children between reviews, the IRO management report states that this was not locally a standard practice during the period of the review.    2.92 Information provided in the CSC management review indicates that Scarlet’s looked after child reviews were always attended by Scarlet; her social worker; either Mary or Jean; and a representative from education services/school.  A member of the 0-19 service attended two reviews, as did Scarlet’s grandmother.   It is not known what written submissions were provided, other than the social worker’s review report.   CSC states ‘no Scrutiny or challenge’ was offered in respect of the local authority’s plan.  Although agencies contributed and there were clear recommendations made for each professional; in general, information presented appears to have been accepted and agreed.  2.93 The IRO service management review notes that terms such as ‘challenging behaviours’ and ‘deterioration of behaviour’ were used several times in reviews and linked to recommendations for the social worker to undertake ‘direct work’, without any these terms being ‘unpicked’.    2.94 More particularly, the review author was concerned that greater attention should have been given to Jean’s reference to Scarlet’s ‘sexualised behaviour’, seeking ‘understanding the nature of the behaviour and if in fact it was an accurate description of what was happening at the time’ rather focusing on ‘how carers could avoid allegations being made against them’.   In response to a follow-up question, the review author indicated that she would have expected the IRO to identify how ‘more opportunities (could be given) for Scarlet to express her wishes and feelings’ and to comment on what ‘further training (could be done) with the carers to assist them to understand the behaviour linked with trauma’.  The presence of supervising social workers at looked after child reviews may make this more easily achievable.   2.95 The management of allegations against foster carers is a key issue in this review.  During the review period, there appears to have been no reliable mechanism for the IRO to be informed about allegations made either by children for whom they were IROs or by children living in the same household.   The IRO management review author has acknowledged this as a gap.   She indicates, however, that since the appointment of a new LADO, IROs are being invited to managing allegations meetings.  They are also now receiving electronic alerts of ‘significant events’.    16  Wirral Safeguarding Children Partnership July 2021 2.96 It is not known whether IROs have access to foster carer annual review reports which might allow them to gain a fuller independent view of everyday life for looked after children as part of that family.   g) How effectively were allegations against foster carers managed?  2.97 Foster care aims to provide looked after children with a secure place to live where they are cared for by reliable, trustworthy adults who will promote their development and keep them safe from harm.    Managing serious complaints and allegations against foster carer is a small but significant part of the complex system of interacting elements designed to reduce the likelihood of harm to children in care.   Other elements include foster carer preparation and training; the quality of assessment of foster carer capabilities and skills; and an understanding of the principles of safe care and how they can be applied in practice.   Good quality analysis of a child’s needs and informed ‘matching’ are also important.   As in Scarlet’s case, these latter elements are less likely when children are placed ‘in an emergency’.  2.98 This review has demonstrated a number of gaps in different processes for managing allegations against foster carers which, cumulatively, meant that the system provided less protection for children than it should have.  As has been highlighted in key lines of enquiry above:  i. There was no recognition that Bill’s behaviours, on two occasions, raised concerns about his suitability to foster; ii. When allegations were made against carers, there is evidence that the LADO was not as involved in all stages of the allegations management process as would have been expected.  This is acknowledged in the LADO service management review which states that ‘the LADO role and responsibility was not clear and subsequently timely referrals, attendance at strategy meetings and decision-making have been compromised’.  Recording, including of rationale for outcomes, was also poor. iii. Foster carer annual reviews were found not to have provided an accurate record of concerns and allegations, so reducing their effectiveness in evaluating whether carers continued to be suitable to foster;  and, iv. Although they are charged with providing scrutiny to the local authority’s plan and arrangements for placements, IROs did not have access to information about serious complaints and allegations against foster carers  2.99 The inadequate exploration of Jean’s comments about Scarlet and her alleged behaviours has been considered above.  The fostering service has acknowledged that social workers and supervising social workers do not always challenge foster carers ‘when things do not seem right’.  This is attributed to ‘accepting explanations on face value rather than reflecting on what this may mean and challenging this further’ and on ‘(not having) confidence to challenge foster carers who they may have developed a positive relationship 17  Wirral Safeguarding Children Partnership July 2021 with over several years’.    Ensuring that challenge is embedded within the fostering service is described as a current area of development by the fostering management team.   2.100 The CSC child and family service report also emphasises the relative absence of information relating to either John or Bill in the child record:  ‘they were rarely mentioned during visits and in conversations with Scarlet’.   CSC suggests, therefore, that children’s social workers should have regular conversations with carers and children and that these should inform assessments and care planning.   2.101 It is notable that, since this review was commissioned, the Safeguarding Children Partnership has published revised multi-agency procedures for managing allegations against staff  and Wirral Fostering Service has published guidance in respect of managing allegations against foster carers.    h) How well was Scarlet’s lived experience understood?  2.102 The management reports suggest that Scarlet’s lived experience was not well represented in the children’s records.  It is acknowledged that expectations of record-keeping have changed since Scarlet became known to services.  The lack of contemporary analysis from professionals who knew Scarlet and her family well, however, means that what follows is necessarily tentative in terms of understanding Scarlet’s lived experience.   2.103 Prior to Scarlet’s birth, MS was known to be drinking excessively and there were reports that her three older siblings were being neglected.  Then, during her earliest years, Scarlet lived with domestic violence between parents who were misusing drugs and alcohol.  The children witnessed other adults having parties, drinking and taking drugs.  Information from that time suggests that the children were not adequately fed or clothed and that they were living in dirty, chaotic conditions.   When she was 2years old, Scarlet was removed from her family for the first time, away from her parents and three older siblings.      2.104 Although the impact of neglect will vary between individual children, evidence suggests that ‘neglect is a particularly damaging form of maltreatment’5. Experiencing neglect at this young age is likely to have affected Scarlet’s developmental progress and her capacity to make secure attachments.  It is also likely to have increased her vulnerability in adolescence to ‘other types of maltreatment and/or victimisation’6.    2.105 Over the course of the next three years; Scarlet continued to experience uncertainty about where she would be living permanently.  She twice moved between periods of being foster care to periods of living at home, until she was finally removed from her mother’s care, in a crisis caused by MS’s drinking.    5 The impacts of abuse and neglect on children; and comparison of different placement options - Evidence review - HM Government 2017 6 Ibid p 29 18  Wirral Safeguarding Children Partnership July 2021  2.106 While at home, Scarlet continued to experience parents’ violent behaviour and to suffer further material, physical and emotional neglect.   Two younger children joined the family while her oldest sibling and her father went to live elsewhere.  The plan for reunification did not provide Scarlet with a permanent and stable home.  Difficulties that she had already experienced were repeated.   The impact of the neglect which led to her being taken into care, in the first instance, is likely to have been compounded in the years which followed.  2.107 Although Scarlet and Alex had lived with John and Mary previously, the children’s return to them did not take place in the context of planning and preparation.   At the same time, Scarlet and Alex were seen to settle very quickly and this was considered to be a positive indicator for a successful permanent placement.   Given their previous experience of separations and loss,  however, the apparent ease with which they fitted into a new family could have been indicative of their having a reduced capacity to develop close and trusting relationships with adults.   There is no evidence that this was explored.   2.108 Nevertheless, over the course of the next 5 years, the children’s behaviours, views and expressed feelings satisfied the local authority and partners that the children genuinely felt they were in what might be described as a ‘forever family’.     2.109 Scarlet was 11 years old when she alleged that John had sexually abused her.  Scarlet had thought of John as ‘Dad’ for most of her remembered childhood, by this point.   In those circumstances, if Scarlet’s allegations against John are true, his behaviour would constitute a gross betrayal of Scarlet’s trust which cannot be overemphasised.  The allegations management outcome, however, leaves open the possibility that Scarlet’s allegation was motivated by another, as yet unknown, impulse.  There is no evidence that professionals considered the potential ramifications for Scarlet’s well-being of either circumstance.    2.110 There appears to have been limited acknowledgement of Scarlet’s emotional wellbeing as Scarlet moved from living with Mary and John to living with Bill and Jean.   This move, from the home where they had expected to remain, took place the day after Scarlet talked about John sexually abusing her.  The inherent difficulties in this situation were not, however, represented in reports of Scarlet’s positive adjustment to her new placement.  There appears to have been little reflection on how Scarlet might have experienced the bitterness of the end of her relationship with Mary or the bullying she was experiencing from children she had previously considered to be family members.   2.111 Again, the children’s apparently low-key reactions appear not to have raised questions about their underlying emotional wellbeing or the quality of their attachments.  There was no exploration of what having, and losing, a ‘Mum and Dad’ meant to Scarlet and Alex.  It is possible that instead of being an indicator of Scarlet and Alex’s sense of safety and security;  the concepts of ‘Mum’ and ‘Dad’ were, for them overlaid with expectations 19  Wirral Safeguarding Children Partnership July 2021 of being let down.   Their experience, at this point, would have reinforced any such feelings.   2.112 The two years that Scarlet and Alex spent with Bill and Jean coincided with Scarlet’s early adolescence.  This is a time when a child’s focus is on ‘becoming comfortable with body changes, psychological separations, gaining self-control and beginning to sort out identity issue… The adolescent is trying to answer four questions … Who am I? Where do I belong? What can I do, or be? What do I believe in?’’7.   Scarlet’s circumstances made these questions very difficult to answer.  2.113 During the first year of her placement, significant opportunities were lost to understand Scarlet’s lived experience.  For example, when Scarlet was told that there would be no action taken against John, there appears to have been little exploration of this with her, beyond the moment when she learned of the outcome.  In addition, as already noted, there was no exploration either of the contradiction between Scarlet’s reported experience of her every-day life and Jean’s description of the impact that Scarlet’s presence was having on the household.    There is a sense that Scarlet’s positive responses to questions about her life in placement were taken at face-value, rather than being assessed in the context of what was known about her experience to date.  2.114 During the second year of placement with , Scarlet’s unhappiness became more obvious.  Living in a temporary home was taking its toll on Scarlet’s well-being.  She had also lost touch with her mother and was distant from her life as a child with many brothers and sisters.  It is clear that professionals were not insensitive to children’s circumstances and they recognised that the children needed certainty about where they would be living.   It is acknowledged that professional energies and resources were being expended on trying to find a suitable long-term placement where the children could be together.   2.115 It is also recognised that, given the uncertainties they were living with, non-specific ‘direct work’ with the children would not have been risk-free for them.  There is little evidence, however, of professionals reflecting on the complexity of  Scarlet’s emotional life or of planning how to get alongside her, to understand things from her point of view and to help her manage her feelings.   CSC acknowledges that there may have been assumptions that Scarlet’s unhappiness could have been overly ascribed to ‘typical teenager’, ‘clash in personality’ and ‘insufficient skills to manage behaviour’.  2.116 Given the circumstances at the time, it is not surprising that the option of placing Scarlet and Alex with Billy appeared to be attractive.  It is not clear from the records, however, that sufficient discussion took place with Scarlet and Alex to determine that this was what they really wanted or, indeed, with Billy whose life would also have been affected by his brother and sister coming to live with him.      7 Fahlberg, V., A child’s journey through placement; BAAF publications 1994 20  Wirral Safeguarding Children Partnership July 2021 2.117 Scarlet’s placement with Bill and Jean ended in the context of rejection by her female carer.  At that point, Scarlet had not given voice to her allegation against Bill.  Scarlet moved to another temporary placement, this time without her brother.  Again, Scarlet appeared to make a rapid attachment to her new carer.     2.118 It was during this period of transition that Bill began to meet Scarlet secretly while, at the same time, Scarlet did not have reliable access to an allocated social worker.   From a professional perspective, Bill’s actions are characteristic ‘grooming’ behaviours.   Survivors UK, for example, describes ‘grooming’ as a process through which an adult abuser seeks to gain the trust of a child ‘to make it less likely that (the child) would risk losing ‘the special relationship’ by talking to others…’.   There is a suggestion in Scarlet’s discussions with SW3 that Bill’s grooming of Scarlet could have pre-dated the breakdown of her placement with Jean and him8.   2.119 Survivors UK identifies also that a key consequence of grooming can be that ‘the survivor is left carrying the shame of the events, often represented in a sense of complicity…’  It can also reduce perceptions of a child’s ‘believability’ in any criminal proceedings.  It is not clear whether this was a factor which impacted on the CPS decision.  2.120 Child A’s allegation against Bill led to Alex being moved to new placement with Marian and Steve.   Alex ‘blamed’ Scarlet for his having to move and was angry with her.  It is not clear how Alex came to this understanding of what had happened, although there is reference to Alex having continuing contact with current and previous members of the household9.  In any event, when Scarlet joined Alex with Marian and Steve, Alex’s anger and blaming is likely to have been a feature of the children’s relationship with one another.   Again, the need to end the placements in which the children had been living, meant that there was little consultation with the children before what was intended to be a permanent move took place.    2.121 It was shortly after moving to live with Steve and Marian that Scarlet made an allegation of serious sexual assault against Bill.  Scarlet was in a state of emotional crisis, to the extent that she was considered to be at serious risk of suicide.   Her life, since the end of the review period, has been characterised by instability and continuing mental health problems.     8 CSC management report, p 15.  Child L reflected on what had happened and said that (Bill) used to say that he loved her and she meant the world to him’. 9 Strategy meeting minutes 19/10/18 21  Wirral Safeguarding Children Partnership July 2021 3. Lessons learned and recommendations  3.1 There are a number of features of this review which present a challenge to ensuring that the correct lessons are learned and that recommendations remain pertinent to current practice.    These include the time that has passed between the end of the review period and the time of writing as well as the impossibility of holding a learning event with practitioners and managers, as would be the usual practice.  Scarlet’s current circumstances are such that she is not in a position either to contribute to the review.    3.2 The children’s experiences during the pre-review period serve as a reminder of the need to identify and address neglect by parents whose capacity to provide care is compromised both by their own difficulties and by the individual and cumulative needs of the children in their family.   The role of the court and the criticality of securing the correct care option are also emphasised.  Specific issues in respect of ‘placement with parents’ have been identified in previous serious case reviews locally.    CSC reports, however, that there have been significant improvements in both process and focus where children are placed with their parents.   3.3 Scarlet’s experience also demonstrates that simply removing a child from abuse or neglect is not enough.  Care planning also needs to specifically address how looked after children are to be helped to overcome, as best they are able, the effects of abuse and neglect in early life.   3.4 During the review period, a number of gaps have been identified that are pertinent to multi-agency safeguarding and child protection of looked after children.  The Safeguarding Children Partnership has chosen to focus primarily on the following areas of learning:    a. Keeping children safe from harm in foster care; b. Supporting looked after children and young people who have reported sexual harm; and,  c. Taking account of a looked after child’s lived experience.   3.5 Keeping children safe from harm in foster care  3.6 The review has found that there were gaps in the different interacting processes for keeping children safe in foster care.  As a result, the capacity of the system to keep children safe was weakened.   These gaps have been acknowledged by the local authority and details of improvements which have been made, or proposed, been provided.   3.7 Based on the analysis in the relevant key line of enquiry, the Safeguarding Children Partnership intends, however, to seek assurance that those changes have had a demonstrable impact on the improving the effectiveness of the system.   The first 5 recommendations relate to keeping children safe from harm in foster care.  22  Wirral Safeguarding Children Partnership July 2021  3.8 Recommendation 1:   The Safeguarding Children Partnership should ask the local authority to provide an action plan demonstrating how the fostering service will provide the training and learning opportunities for staff it has proposed; specifically:  i. Managing the allegation process for foster carers; ii. Challenging foster carers during the allegation process and how to do this effectively; iii. Mentoring by experienced supervising social workers of less experienced staff on how to make appropriate challenge; iv. Developing critical reflection in practice; and, v. Ensuring staff have an overview of recent learning reviews and their recommendations.  3.9 Recommendation 2:   The Safeguarding Children Partnership should ask the local authority to provide evidence of an audit of annual reviews of foster carers.  The report to the Safeguarding Children Partnership should particularly highlight findings in relation to the recording of serious complaints or allegations that have been made against foster carers and the actions that have been taken as a result.    3.10 Recommendation 3:    The Safeguarding Children Partnership should ask the local authority to detail the expectations it has set out/ intends to set in respect of ensuring that IROs are notified of serious complaints and allegations against foster carers looking after children whose care plans, they are reviewing.   The local authority should also provide details of how it will measure the effectiveness of that process.   3.11 Recommendation 4:   The Safeguarding Children Partnership should undertake a multi-agency audit of the management of serious complaints and allegations against foster carers.  This should include examples of enquiries to the LADO/ Designated Officer which resulted in advice that only management action was required.10  3.12 Recommendation 5:   The Safeguarding Children Partnership should ask the local authority to consider the viability of undertaking a retrospective review of LADO enquiries to ensure that the correct outcomes have been reached and the correct actions taken.    If the local authority considers that this would not be feasible,  it should identify how it will ensure that there is a strategic awareness of any potential outstanding risk.   10 NOTE: As the outcome of the LADO allegations in respect of Bill and Jean were not known to the SCR, it may be appropriate to consider the management of those allegations within the audit cohort of cases.  23  Wirral Safeguarding Children Partnership July 2021  3.13 Supporting looked after children and young people who have reported sexual harm The Survivors’ Trust describes the devastating effects that the experience of sexual violence can have on every aspect of a person’s being and life.   Although it is not inevitable that all victims will suffer from all effects, each individual is likely to experience a unique mix of symptoms of varying severity and degree of complexity.      3.14 For Scarlet, the process of determining whether John would be charged took 9 months.   The outcome was that there would be none.   In relation to her allegation against Bill, the final decision took approximately 2 years to make and was again that no charges would be laid.    LADO enquiries followed on both occasions and concluded that the allegations were unsubstantiated.  The evidence suggests that Scarlet did not receive effective support during periods of waiting or following the decisions.  3.15 There are a number of different processes which begin when a child makes an allegation of sexual abuse against a foster carer.  They are the regional pathway for children who may have been sexually abused; police investigation/criminal justice process; the allegations management process in respect of people who work with children; and, arrangements to review the suitability of a carer to foster.   For all children who report sexual crimes against them, an Independent Sexual Violence Adviser (ISVA) can provide the practical and emotional support that the child or young person might need ‘to understand timelines, processes and procedures that include a police investigation, CPS decision-making and subsequent court processes’.   CAMHS may also have a role in helping a child who has experienced trauma.    3.16 When children are looked after, the responsibilities of agencies working with the child are those of a corporate parent.  It is important, therefore, that professionals working with the child are able to understand, at least at a basic level, how the various processes interact.  They must also, collectively, be in a position to keep track of the progress of the child’s complaint and to be able to identify the right support for the child at the right time.  Helping the child manage their expectations while the police investigation is current is likely to be an important feature of support at that time.  Professionals should determine, in advance, how CPS decisions/ LADO outcomes will be communicated to the child and by whom.   3.17 Recommendation 6: The Safeguarding Partnership should consider how it can best help professionals support looked after children who are the victims of sexual crimes and/or who make serious complaints or allegations against carers, by: i. Exploring the viability of producing a single easy-to-follow guide which explains and links the various processes which are likely to be initiated when  a child makes an allegation in respect of a carer; 24  Wirral Safeguarding Children Partnership July 2021 ii. Adapting current allegations management/LADO training to focus on understanding potential outcomes and their consequences, as well as providing details of process; iii. Asking the police and CSC to set out how, in practical terms, the agencies can work together to ensure that the children and young people are provided with regular updates in respect of the investigation of crimes they have reported, according to the child’s age and understanding; iv. Adapting current training/ development opportunities for IROs to include how they can ensure that professionals work collaboratively to: a. monitor progress in respect of the various processes above as they affect any individual child; and, b. stay alert to, and respond to, the enduring impact on the child.  3.18 Although not a formal recommendation, the review recognises the potential benefit to young people of having access to a single source of information which explains in easy language what is likely to happen over the course of the days, weeks and months following a sexual assault.     3.19 Taking account of a looked after child’s lived experience   3.20 Scarlet suffered significant neglect and instability during her early years.  Then, at the age of 11, her permanent placement broke down when she alleged that she had been sexually abused by her carer.  Throughout the next three years, Scarlet lived in a number of temporary placements or,  on one occasion, in a permanent placement where she remained only briefly.  Scarlet reported that she had been seriously sexually assaulted by a second carer.   In those circumstances, it is likely to have seemed to  Scarlet that events in her life were frighteningly unpredictable; that she had no control over them; and, that she was on her own.  By that stage, however, it was likely to have been increasingly difficult for professionals to mitigate the effect of harmful experiences and to prevent the deterioration of Scarlet’s mental health.   This reinforces the importance, therefore, of understanding a child’s lived experience as a fundamental element, from the earliest days, in the care planning process.  3.21 This is an area of practice improvement which has been identified in management reviews.  The CSPR Panel has confirmed that there already a number of action plans which address this across the partnership.  There has also been reference to a ‘new way of thinking’ inherent in the practice model currently being implemented across CSC.     3.22 In those circumstances, no specific recommendation is made.  Learning from this review, however, should be disseminated in such a way as to support actions and programmes already in place.   Particular attention should be given to the role and responsibilities of first line managers, safeguarding supervisors, and IROs who are often better placed to take a wider view of what might be going on for a child than are frontline practitioners who are frequently caught up in task-management.  25  Wirral Safeguarding Children Partnership July 2021 3.23 Following up recommendations/ actions agreed by other agencies not specifically covered above  3.24 Recommendation 7:  The Safeguarding Children Partnership should require, by July 2022, that agencies and organisations participating in this review provide evidence that proposed changes have been implemented and, where pertinent, an evaluation has been made of their impact on children.   IC: 27/06/21   