Attempted suicide by a 7-year-old child at the family home. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather. Learning includes: it is important to continue to communicate with children about their world; professionals need to be reflective in the context of what may be a change in the child's priorities rather than adhere exclusively to an adult assumption of what the child requires; consider a more judicious use of care planning forums when there is lack of clarity about what the options are in reducing risk within families; there should be more effective planning, assessment and recording at all stages of the achieve best evidence (ABE) process. Recommendations include: for agencies to consider the importance of not making assumptions about the source of a child's distress in the absence of speaking to the child directly, and the clarity about a plan to work together concerning how the child's needs are met while awaiting specialist assessment; ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies; ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance, and there should always be consideration as to whether a further strategy meeting is required following the ABE interview.
      
    Serious Case Review No: 2022/C9323  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   Child G LCSPR overview report – FINAL 02.11.21  1 Overview  1. The Safeguarding Children Partnership (SCP) decided to undertake a Child Safeguarding Practice Review in the matter of Child G who, age seven, attempted to take their own life at the family home.   2. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather. The allegations were investigated by the police and a risk assessment was undertaken by the specialist sexual risk assessment service in the area. Although the stepfather was prohibited from being in the family home while the police investigation was proceeding, and during the time that the sexual risk assessment was in progress, he returned to live there six months later. There was insufficient evidence to take further action on either criminal grounds or welfare concerns. Stepfather was living at home when the attempted suicide took place. Because of the Covid-19 pandemic lockdown, Child G had not been to school for five months in the period immediately preceding this event.  3. Although, thankfully, Child G did not die or suffer serious physical injury as a result of their actions, the view of the police and the ambulance service was that this was ‘a near miss’.  One hypothesis is that this behaviour may have been the act of a very distressed child, who had been living in the same household as their possible abuser for over a year, with a mother who was not protective and no one outside the family to turn to.   4. From the time of the disclosure to the attempted suicide there was extensive involvement from Children’s Social Care (CSC), specialist sexual risk services, the police, Child G’s school and specialist educational support services. The purpose of this partnership review is to consider if there are any systemic or underlying reasons why actions were taken or not taken by agencies and to provide a summary of any improvements recommended to the area safeguarding partners and/or other agencies to safeguard and promote the welfare of children.   The Process  5. The national Child Safeguarding Practice Review Panel (CSPRP) was notified by the SCP about Child G’s actions as a serious incident. The circumstances surrounding Child G’s attempted suicide qualifies as a ‘serious incident’ because it had implications for the ‘serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development’ of Child G. Working Together recognises that, ‘even if a child Child G LCSPR overview report – FINAL 02.11.21  2 recovers, including from a one-off incident serious harm may still have occurred.’ (pg. 85 para 11)1   6. In keeping with Working Together guidance, ‘rapid review’ reports were requested from all the agencies that knew Child G and their family, or who responded on the day the serious incident occurred.   7. Upon receiving those reports the SCP considered that the criteria were met for a Local Child Safeguarding Practice Review (LCSPR). In a letter dated 26/10/20, the National Child Safeguarding Panel agreed that ‘there is learning to be drawn from this case’ and endorsed the decision to carry out a LCSPR as set out in Working Together (2018).  Independent Management Reviews (IMRs) were requested from eight of the agencies who submitted rapid review reports. In addition, the police submitted a second report from the Specialist Crime Operations Crime Review Team (SCOCRT) of an internal review undertaken after the attempted suicide because of concerns about the initial investigation into Child G’s allegations.  8. The author is an independent social worker, trainer, and safeguarding consultant. She has no other affiliation with the Safeguarding Children Partnership. The author has considerable clinical experience of working in the area of intra-familial child sexual abuse and has been involved as both a chair and an overview report writer for serious case reviews in various parts of the country.   9. The author held interviews at least once with 21 of the practitioners who had the most direct involvement. The majority of the interviews were conducted online but Child G’s mother, their social worker and the social worker’s manager were seen face-to-face at the area office.   10. It was decided that the time frame under scrutiny would be from when Child G disclosed the abuse to when the attempted suicide took place. The SCP Case Review Group met regularly during this period to monitor the progress of the review process.  11. A half-day online learning event for practitioners who contributed to the review was held in June 2021. The participants had sight of Draft 2 of this report prior to the event and their comments and the feedback from the discussion groups held on the day are incorporated into this version of the partnership review.   Family Engagement   1 Working Together to Safeguard Children (2018) https://www.workingtogetheronline.co.uk  Child G LCSPR overview report – FINAL 02.11.21  3 12. The author met with the mother face-to-face on her own for an hour at the area office. Details of the mother’s views can be found in paragraphs 70 - 72 of this report.   13. It was decided not to interview Child G directly in the course of this review. Given her age, and the length of time that had passed since the allegation of abuse and suicide attempt, it was agreed to rely on the impressions of the allocated social worker, who knows Child G and the family well, rather than for Child G to speak to someone they do not know about events that may be retraumatising or confusing for them.   The Case  14. Child G lives at home with their mother, elder half-brother, younger half-sister, and younger half-brother, who was born after they made their disclosure. Child G’s stepfather lives with the family. Their birth father lives in another town with his partner, their child and her two children.  15. The family became known to services when Child G was still a baby. At the time of the first referral there was domestic abuse between Child G’s mother and her then partner (not Child G’s father). There were also concerns about mother’s ability to manage the already difficult behaviour of Child G’s older brother, who has since been diagnosed with autism, and about neglect.   16. Early Help became involved with the family because of the problems experienced by mother in managing the behaviour of the older half-brother and his aggression towards Child G. The family also had problems with debt and their overcrowded housing conditions. Mother’s recent difficult pregnancy had just ended in miscarriage, and she was affected by anxiety. The support worker concluded that, although there were difficulties, mother’s ability to manage the three children, her own mental health, and the overcrowded house, with minimal support from her partner, was just about ‘good enough’. The support worker was about to close the case when Child G made their allegations against stepfather.   17. Child G’s mother contacted their school to say that the previous day Child G had clearly described to her an episode of serious sexual assault against Child G by their stepfather. On the same day the stepfather presented himself at the local police station to ask for advice regarding Child G’s allegations.   18. The school submitted a referral to the Single Point of Access (SPOA) the same day. Child G was not in school on the day that mother shared information about Child G’s disclosure. On the following morning, the day they returned to school, Child G wrote a note to their class teacher saying ‘I am telling the truth’. Attached to the note was the teacher’s comment about what Child G had said to them: Child G LCSPR overview report – FINAL 02.11.21  4  (Child G) came up to me and said that they were scared that they would get into trouble when they told the truth. They were worried that Mum would be angry and wouldn’t come to the topic this afternoon. Child G feels sad because Mummy doesn’t believe them, and they are telling the truth.  19. Two days later Child G was spoken to at school by a police officer and duty social worker. They again named their stepfather, Daddy A, as the person who sexually assaulted them. The interviewing police officer contacted their sergeant who went to the family home and arrested the stepfather. He denied the allegations and was subsequently bailed on condition that he did not return to the family home. The arresting officer recorded that the mother was immediately reluctant to believe her child’s allegations.  20. The Achieving Best Evidence (ABE) interview took place four weeks after the initial disclosure. A Registered Intermediary (RI) was appointed three weeks prior to assess Child G’s communication needs and ensure that these were taken account of in the interview.   21. In the period between Child G disclosing the abuse and the ABE interview, the mother contacted the police to inform them that Child G had now told her that it was their birth-father and not their stepfather who had abused them. Child G repeated this change in the identity of the perpetrator in the ABE interview ‘basically I thought it was Daddy A (step-father) who did it, but when I woke up it was Daddy B (birth father)’.  22. An Initial Child Protection Conference (ICPC) regarding the children in the family was held on the same day as Child G’s ABE interview. As part of the protection plan specialist family services were commissioned to undertake a risk assessment concerning the stepfather and the birth-father and a Protective Parenting Intervention (PPI) with the mother. Only after that work was completed could the separate offer of therapeutic work by specialist sexual risk services be considered.    23. Because Child G was now naming their birth-father as the perpetrator rather than their step-father, the birth-father was also interviewed by the police. This interview did not take place until three months after the ABE interview and was on a Voluntary at Station (VAS) basis rather than as a result of an arrest as had been the case with step-father.   24. The step-father’s bail conditions were lifted a month following the ABE interview and no further action was taken although the investigation was not officially concluded for another four months. He returned to live in the family home prior to the completion of the investigation. On the advice of specialist sexual risk services, he was asked to leave again because their risk assessment work with him had not yet begun. He agreed to do this.  Child G LCSPR overview report – FINAL 02.11.21  5 25. The specialist sexual risk-assessment concluded that step-father presented an increased risk of sexual abuse towards children at that time and recommended that he did not have unsupervised contact with any of the children in the family and that mother was not sufficiently protective to act as supervisor. Until mother was able to participate in protective parenting work, which she delayed because she was heavily pregnant and feeling overwhelmed with appointments, it was the specialist sexual risk service’s conclusion that it was too dangerous for step-father to return to the family home. Both he and mother disagreed with this conclusion, and he returned to live at the family home regardless but with a safety plan in place that required him never to be alone with the children. This safety plan was developed with the family by the allocated social worker but not agreed by the specialist sexual risk service.  Aftermath of the allegations  26. Although step-father ostensibly complied with the requirement to live outside of the family from the time of his arrest until the conclusion of the specialist service risk assessment seven months later, mother still became pregnant with his child during that period. The pregnancy was difficult and fraught with anxiety because of her miscarriage the previous year.   27. The school reported that Child G’s behaviour was becoming increasingly disruptive and aggressive, and this downward spiral was also evident at home. Although the allocated social worker saw Child G regularly as part of the child protection plan, there was no structured emotional support pending the therapeutic work that the specialist sexual risk service was expected to undertake. Eventually, in the absence of work commencing with this specialist service, the school arranged for Child G to have help from Emotional Literacy Support Assistance (ELSA), an initiative that was aimed at supporting children who have emotional barriers to making progress at school. They had regular sessions with a member of staff who was trained in this approach. The school also contacted the Education Support Behaviour and Attendance Service for advice on managing Child G’s behaviour in the classroom.  28. As mother’s due date drew near and there continued to be concern about complications in her pregnancy, the family decided that Child G should go and stay with their aunt in another part of the county until after the baby was born. It was anticipated that they would be there for three months and was enrolled in the local school. In the event Child G only stayed six weeks, with visits home at weekends, because they wanted to return to their mother. During the time that they were living with their aunt, the specialist sexual risk service undertook one session with Child G. It was planned for the sessions to continue once things had settled down at home after the birth of the baby, but mother put these on hold because of the COVID-19 lockdown. It was also felt by the specialist sexual risk service that any subsequent work with Child G would have to be done online from home, where their step-father was still residing, and that this would have been inadvisable in terms of Child G’s safety. Child G LCSPR overview report – FINAL 02.11.21  6  29. There was a Review Child Protection Conference (RCPC) nine months after the Initial Child Protection Conference (ICPC) where, by unanimous decision, the statutory status of the family’s involvement with services was stepped down to child in need. The rationale for this was ‘mother’s openness and honesty throughout the child protection process’, the commencement of the therapeutic work, elder brother’s placement at a more appropriate school and Child G’s settled behaviour both at their new school and in their aunt’s household.   30. The family quickly self-isolated as the pandemic took hold in March 2020, wanting to take no risks with a newborn baby in the household. The family social worker’s last recorded ‘doorstep’ visit was mid-April. The social worker visited again in early summer to deliver a laptop to the family.  31. The school continued to check on the welfare of Child G and their family throughout the first lockdown via weekly phone calls to the parent and they were provided with vouchers for free school meals. The school notified CSC that Child G was not attending school and their name was included in the Vulnerable Children Risk Assessment Group. This was a system established by the local authority during the first lockdown to monitor the welfare of children in the county considered to be vulnerable and was reviewed weekly. Although Child G was no longer on a CP plan and, as a vulnerable child, they could have come to school, their mother decided to keep them at home. The school had no direct contact with Child G from the start of the COVID-19 lockdown until early July, apart from four days in April and again for three days in July. Child G did not engage with Google classrooms during this period, attend lessons or participate in ‘Show and Tell’ sessions at any time.   32. The worker from the specialist sexual risk service who had seen Child G for the initial session contacted mother in April 2020 to ask how Child G was and enquire about resuming their sessions. Mother advised that she was not concerned about Child G now as they were not showing any signs of distress or trauma. Whilst she was happy for the work to continue, she was not sure that it was currently required. The decision was made to pause the work and review the situation when Child G returned to school.  33. In May 2020 the case was closed to the locality with the understanding that the specialist sexual risk service could still offer therapeutic work if requested by the family.  34. In July 2020 the police and an ambulance were summoned when Child G was discovered in their bedroom having attempted to take their own life. There was concern that this was linked to the allegations they had originally made against their step-father concerning sexual abuse.   Child G LCSPR overview report – FINAL 02.11.21  7 Analysis and Learning  35. There are five key themes arising from the events leading up to the apparent attempt by Child G to take their own life. Analysis of these themes has implications for reflections on practice and learning  These themes include  • Meaning of Child G’s behaviour to themself • Practice interface between specialist services and Children’s Social Care • The ABE interview process • The use of power and authority in relationship-based practice • The impact of Covid-19 on practice and outcomes  The meaning of Child G’s behaviour  36. Much emphasis in recent years has rightly been placed on the importance of professionals listening to the ‘voice of the child’ in matters concerned with safeguarding.   37. Although the attempt by a seven-year-old to end their own life is extreme and rare it is important that unilateral assumptions are not made about what the behaviour meant to the child.   38. Much of the tenor of the rapid reviews and the IMRs appears to imply a linear relationship between the allegations of sexual abuse made by Child G and their actions some 16 months later in apparently attempting to kill themself. The impression seems to be that they deliberately tried to end their life out of despair that they were not listened to, not protected, and had spent much of the time following the disclosure at risk because they were living in the same house as the originally-named perpetrator, with a mother who was not able to safeguard them.    39. Sixteen months is a very long time in the life of a seven-year-old and there were many events subsequent to the abuse allegations that affected them. In the opinion of the staff at Child G’s school their main concerns during the time that their behaviour was so problematic, in the autumn of 2019, was not worry about having been sexually abused by and resuming contact with their step-father whom they had originally named as the perpetrator. Their view was that Child G was very much pre-occupied with their mother’s health and survival as the date for the birth of the baby drew closer. The head teacher at the school showed the author drawings made by Child G at the time, of their mother bleeding to death.   40. In the autumn of 2019, the specialist sexual risk service was coming under some pressure by the family social worker regarding commencing the therapeutic intervention with Child G. Child G LCSPR overview report – FINAL 02.11.21  8 The practitioner from the specialist service who was to undertake the work with Child G took advice from the manager of the Child Assessment and Treatment Team (CATT) and a child psychiatrist about starting the work with Child G whilst they were living with their mother and step-father. The advice was that it was not possible to offer this safely under these circumstances. What the specialist service practitioner was intending to do with Child G was a specific programme developed for young children who had been traumatised by experiences of sexual abuse. To open up those areas in therapy when they were still living with the perpetrator was thought to be potentially confusing and re-traumatising for Child G. Whilst these reservations are understandable, it assumes that the source of Child G’s distress was the events of March 2019. It was the view of Child G’s school, who knew them well, that this was not currently their main concern.  41 During the autumn of 2019, there appeared to be a feeling of paralysis by other agencies regarding giving Child G an opportunity to talk to someone in depth about what was troubling them because that work was due to be undertaken by the specialist sexual risk service.  The specialist service seemed organised around the belief that the problem was still trauma induced by the sexual abuse and the assumed pressure put on Child G by the family to change the identity of the perpetrator and the fact that, despite their disclosure, nothing had changed for Child G and their step-father was still in the family home. By not having any exploratory discussion with Child G about what they were currently worried about, professionals may have imposed on Child G an interpretation of the most important issues in their world that was not consistent with Child G’s own reality. It may be that changing from a position of focus on the sexual abuse to a more holistic presentation of the family, the risk factors and the children’s presentation may have moved the situation on’.  Learning Point- It is important to continue to communicate with children about their world. Professionals need to be reflective in the context of what may be a change in the child’s priorities rather than adhere exclusively to an adult assumption of what the child requires.  42 The mother said that on that day of the attempted suicide there had been a disagreement between herself and Child G concerning being told to fold their own clothes, when their younger sister had her clothes folded for her by mother. It was when the mother was momentarily out of the room after that conversation with Child G that the suicide attempt was made. There had been no previous indications that Child G was unusually depressed, upset, or unhappy. The threat to ‘kill myself’ was one that Child G would have heard frequently from their elder brother, but which he appeared not actually to have attempted. The police officer who attended the scene shortly after the event said that Child G told them that the reason for their actions was because ‘nobody loves me, I was feeling left out, and everyone had a dad but me’. Child G told the police officer that no one suggested the idea of harming themselves, ‘the idea was in my head’. They apologised to their mother and to the ambulance personnel and police officers who attended the scene saying ‘I am so sorry I tried Child G LCSPR overview report – FINAL 02.11.21  9 to kill myself’. But whether, at the age of seven, Child G really understood the finality of death and the concept of their life ending would require further exploration, preferably in a therapeutic setting.  43 The police officer asked them directly whether this was anything to do with what they had said about their step-father. Child G originally couldn’t recall the incident but eventually told the police officer that ‘it wasn’t daddy A it was daddy B’ and that nothing had happened since. They were profusely apologetic to everyone for ‘trying to kill myself’ but within about 20 minutes that mood of contrition appeared to have passed with Child G playing happily.  44 The craving that Child G seems to have for their mother’s attention should not be underestimated and their actions could have had tragic, but possibly unintended, consequences. Nevertheless, it is important that the meaning behind this behaviour is not reliant exclusively on an adult-oriented interpretation of events.   Practice interface between Specialist Services and Children’s Social Care  45 One of the themes that emerged from the IMRs and the interviews with practitioners was tension in the relationship between the specialist sexual risk service and CSC concerning the management of risk once Child G had disclosed that they had experienced sexual abuse on two occasions.   46 There appeared to be general agreement that there are usually good relations between the specialist sexual risk service and the locality teams and that the expertise that the specialist service brings in their knowledge about the difficult dynamics in intra-familial child sexual abuse is highly regarded. It was to the specialist service that the interviewing social worker turned for support in trying to shift the mother’s denial about the truth of Child G’s allegations. The social worker welcomed the offer from one of the specialist service’s advanced practitioners to accompany them to the family home in an attempt to open her mind to the possibility that step-father could be a risk, but to no avail.  47 There is discussion above about the dissatisfaction expressed by some locality practitioners, by the school and also by Child G’s mother that the therapeutic work with Child G never happened in the way they expected it would; and by the time it was offered the moment had passed.   48 The fact that Child G named a different perpetrator at ABE interview was perceived as diluting the focus of the risk assessment and criminal investigation in having to take what Child G said seriously and put birth-father in the frame as well. There was concern that this rendered the assessment reports ‘ambiguous’ and ‘on the fence’, a description that the specialist service denies. The duty social worker who spoke to Child G at school expressed Child G LCSPR overview report – FINAL 02.11.21  10 their disappointment that they were not invited by the specialist service to discuss with them the social worker’s first-hand experience of Child G’s presentation when interviewed at school.   49 The specialist sexual risk service received a short notice invitation to the RCPC and was not able to attend. It was at this meeting that there was unanimous agreement to step down the case from child protection to child in need. The specialist service subsequently expressed reservations about the decision. In their view the risk to the children had not gone away with step-father still in the family and Child G still without a ‘safe person’ in the family to believe and support them.   50 It was clear from discussions with the front-line practitioners in this case that there was a difference in opinion between the specialist service and the social work team about the appropriateness of the specialist service commencing work with Child G while the original alleged perpetrator was in the family.   51 There is a danger that the frustration with the intractable situation concerning risk within the family was being mirrored in what also appeared to be an intractable situation in the perceptions held within the professional system as well, especially between the police, the specialist sexual risk service and CSC. The sense of ‘stuckness’ at not being able to move forward was frustrating and there was a danger that this frustration could be projected as criticism by each agency for the others.   52 Both the CSC and the specialist sexual risk service IMRs suggest that one way to manage this situation would have been to take this matter to the Care Planning Forum (CPF) for consideration and an airing of the issues. This could have been especially helpful at times in the life of the case when risk was high and the power to do something to reduce that risk was low. The specialist service IMR refers to occasions when such a meeting may have helped to bring people together rather than polarise them, thereby creating a forum for discussion and attempting a mutual understanding of each side’s perspective. The author understands from the specialist service Practice Manager for sexual risk that, currently, there is no expertise in the area of sexual risk represented in the CPF and they are not usually invited to their discussions. Allowing the specialist service a presence on the CPF when the case being considered involves intra-familial sexual abuse may be something to consider as a result of this review.  53 In the author’s experience it is very common for professionals to share a sense of anxiety about the safety of children in situations where there is a high level of concern about likely sexual abuse but very little by way of the firm evidence that is required to reach the threshold for intervention, either in civil or criminal proceedings.  Child G LCSPR overview report – FINAL 02.11.21  11 54 The CSC IMR (3.8.9) ‘acknowledges that opportunities were missed to take a structured approach to planning at key points in the progress of the case: following the conclusion of the police investigation; following receipt of the specialist sexual service risk assessment; and when the stepfather was back in the home (in sole care of the children) because mother was in hospital’.  55 The CSC IMR goes on to suggest that ‘whilst professionals felt that the threshold was unlikely to have been met, a formal discussion and consideration of a Meeting Before Action (MBA) might have resulted in a clearer plan’. It was clear from discussion with practitioners across agencies that this would be usual practice and that the case management in Child G was not typical of how cases were usually conducted.   Learning Point- More judicious use of Care Planning Forums should be considered when there is lack of clarity about what the options are in reducing risk within families and to form a plan with a clear way forward that can be owned by all the relevant agencies   The ABE Interview  56 Following Child G’s allegation of abuse, Child G wrote a note to their teacher to say that they had been telling the truth even though they didn’t think their mother believed them. This is referred to as Note 1 in the discussion below regarding its significance to the subsequent investigation.  57 Child G was spoken to at school by a police officer and duty social worker, the day after the mother had shared the allegations with Child G’s school (Child G was not in school on that day). The social worker felt that Child G’s embarrassment and reluctance to tell them out loud what had happened added to their credibility. Child G agreed to write down the words rather than speak to them. The police officer established with Child G what they understood those words meant. Although they were not specific about when this took place, it was the impression of the duty social worker that the events were recent. This document, made by Child G during the conversation at school, is referred to as Note 2.  58 The mother appeared to disbelieve her child from the start; at first saying they were ‘confused’ and ‘couldn’t work it out’ and then accusing Child G of ‘lying and trying to break up the family’. Despite a visit the following week by the duty social worker and the specialist sexual risk service advanced practitioner to encourage her to consider the possibility that there may be some truth in what Child G had said, the mother maintained her point of view.   59 During the four-week period between the disclosure and ABE interview, the mother phoned the police to say that Child G had now changed their account of what happened and that it was their birth-father (Daddy B) and not their step-father (Daddy A) who had abused them. Child G LCSPR overview report – FINAL 02.11.21  12 This information was shared with the ABE interviewing team who saw Child G two weeks later.  60 The ABE interview took place almost a month after the interview at school. The reason for this delay was complications in the timing for the Registered Intermediary (RI) to see Child G in school to assess their communication needs because of the intervening two-week Easter school holidays.   61 It is usual police practice to provide the services of an RI in ABEs involving children as young as Child G, despite it sometimes involving a delay between allegations being made and the interview being conducted. The risk is that, in the interest of assisting the child’s communication needs, the delay may mean that the child’s memory for details is compromised, and the child may be open to other influences during that time.   62 Child G’s school broke up for the Easter holidays the day the RI was appointed. The RI arranged to see Child G in school for the communication assessment the day that school re-opened two weeks later. The ABE interview took place at the end of that week. Although there were other interview venues available for undertaking the communication assessment which may have reduced the delay, these would have involved a distance to travel and would have been strange to Child G. It was deemed important that proximity and familiarity were the priority in this instance.   63 The RI sent the author the notes of their assessment interview with Child G titled ‘Things to consider when asking (Child G) questions at ABE’. It was very detailed and practical and may have been helpful to those who spoke to Child G subsequently in a non-evidential capacity.  64 The police officer and social worker who interviewed Child G at school were not given Note 1 that Child G had written to their teacher about not being believed by their mother. It is not clear whether they were made aware of its existence at any point during their visit to the school that day. The note was still in the school files when the matter was re-investigated by the Complex Abuse Unit. Because of the mother’s reluctance to believe Child G in her subsequent conversations with professionals and the change in Child G’s account of the identity of the alleged perpetrator between what they said at school and what they said in the ABE, not having access to this note becomes especially significant. It is an unfortunate omission that note 1 was not produced, which the school was unable to account for.  During the ABE interview it was only Note 2, which included what Child G wrote down at the time that they were spoken to in school, that was referred to.   65 The ABE interview was also affected by the fact that it was scheduled at the same time as the ICPC which meant that the mother could not attend both. In the event it was the maternal grandfather who accompanied Child G to the interview.   Child G LCSPR overview report – FINAL 02.11.21  13  66 Because of mother’s previous phone call to the police, it should not have been a surprise to the interview team that Child G was now naming their birth-father and not their step-father as the perpetrator, but they had now heard this account directly from the child. However there appears to have been no attempt to convene a strategy discussion after the interview to discuss the criminal and welfare implications as a result of this development.  67 The social work interviewer said that their impression was that the matter would only be of interest to the local authority, not the police.  68 Not having a multi-agency post interview strategy meeting, with input from legal services, was a missed opportunity to formulate a more effective plan as to how services should go forward in view of this change of direction.   69 In the matter of the interview with Child G, it was determined by the police that what was said did not reach threshold for submission to the Crown Prosecution Service (CPS), therefore a detailed Record of Taped Interview (ROTI) was not required. Instead, the police interviewer wrote up brief notes of the interview on the police log so that other officers were aware of the salient points of the interview. It was this record that was shared with CSC but not until five months after the ABE interview took place.    Learning Point- There should be more effective planning, assessment and recording at all stages of the ABE process. This should involve • deciding whether a strategy discussion would assist future planning for how both the criminal investigation and safeguarding concerns proceed, especially if information shared at interview takes those concerns in a different direction  • the summary of the ABE interview report to be made and distributed to all relevant agencies as soon after the interview is conducted as possible  Building more effective relationships with the family  70 The powerful presentation of the mother of Child G and the implications of this for professionals in trying to establish a relationship with her has been mentioned at several points throughout the process of this partnership review. The CSC IMR mentions the wide variation in how the mother was experienced by staff who were trying to engage her. She was variously described as ‘lacking in emotional warmth’ (especially toward Child G) and ‘difficult’, ‘aggressive’ and ‘demanding’ in her dealings with practitioners. Others considered that she did well to manage the many demands on her and that she was a vociferous presence in fighting for her children, especially in securing for her eldest son the appropriate services he needed as a child who had significant additional needs associated with his autism spectrum condition.  Child G LCSPR overview report – FINAL 02.11.21  14  71 The duty social worker who interviewed Child G said that (the mother) ‘presented as cooperative if you agreed with her but would become oppositional if crossed’. The family social worker agreed that mother could be ‘fiery’ but also said that ‘I have never been denied entry to the house even if she is angry with me’. ‘There was never any disguised compliance’.  72 Child G attended a small village school. There was awareness by the school that at times mother fell out with other families and that this discord sometimes found its way into life at school as well. But the headteacher and deputy headteacher described her as a ‘strong mother’ who had a sense of Child G as a person in their own right, even though much of her energy often went to securing services for the eldest son. They did have concerns that mother sometimes ‘over-shared’ with Child G, particularly when it came to her anxieties about her pregnancy. They did not, however, consider her to be a neglectful mother.   73 Mother said she felt ‘very judged’ by agencies about what had happened to her child (the suicide attempt) and their implication that she was neglectful.    74 She told the author that she felt ‘let down by the specialist sexual risk service’ who she was told were ‘amazing, wonderful’. She said ‘if they can offer me so much why didn’t they?’ In addition to not working with Child G at the time when she was ‘spiralling out of control’, mother felt that the assessment and protective work that the specialist sexual risk service offered was one-way; her perception was that she and step-father were cooperative with what was being asked of them but received little in return from the specialist service. She said she was especially disturbed by the specialist service requiring her to ‘tell everyone who comes into the house that there had been allegations of sexual abuse against (step-father)’ as part of the safety plan to manage his return to the family home. She thought that the specialist service practitioner who did the PPI work with her and the risk assessment of step-father ‘got a lot of the information wrong’…’she wrote down what she thought and took no notice of what it was like for me’.  75 Child G’s mother did have more favourable things to say about other professionals in whom she had trust. When Child G first made their allegations against step-father she went straight to the school to tell them and ask for their advice. On the day of the attempted suicide mother phoned the family social worker to tell them what had happened. ‘If it hadn’t been for (the family social worker) where would the support have been for my family?’.  76 It is the author’s understanding that the mother did not share her intentions to send Child G to live with their aunt with the Local Authority although the children were on CP plans at the time. The school were surprised by the decision for Child G to move to the aunt and were not consulted on this decision or the planning around this. Had they been they could have Child G LCSPR overview report – FINAL 02.11.21  15 proactively supported Child G in this process and undertaken some transition work. The liaison with the receiving school was reported by the temporary school to have been undertaken by the social worker. There was an RCPC at the end of January which unanimously agreed that Child G and their siblings no longer needed CP plans. The fact that Child G was residing with their aunt at the time and was expected to remain there for three months, during which time the therapeutic work with Child G would take place, was a significant factor for the agencies in reaching this decision. The author of the CSC IMR acknowledged that, in hindsight, it would have been better practice to seek more information about the plan for Child G to live with their aunt, perhaps through a viability assessment, rather than basing their decision to step away on an apparently casual plan between the mother and her sister.   77 Another occasion when the family took matters into their own hands without adequate reference to the authorities was when Child G’s mother said that she wanted to have the risk assessment on step-father completed in time for him to come home for the birthday of their youngest child. The response to that by several staff members from both specialist services and CSC was to the effect that mother did not control the terms of the child protection arrangements, and it was not for her to say when he came home and perceived this as an example of the family being oppositional. From the family’s perspective they had waited a long time for the assessment to begin, they had cooperated by agreeing that step-father would leave the family again even after his bail conditions were lifted, they had attended sessions and gone along with safety measures they did not always agree with. The child’s birthday party was an important family event and Child G’s mother felt that this was not recognised by those who set the rules for how their family was to live. In the event, step-father was there for the birthday, but the incident appeared to contribute to the impression of professionals that mother was ‘difficult’ and left mother feeling disempowered ‘who am I, I am only the parent’.  78 The reality is that when state child protection services become involved the family inevitably loses some of their autonomy in making decisions about their family life. Those procedures are there to provide a structure for safeguarding children who are deemed to be at risk but adhering to them is sometimes experienced by the family as oppressive rather than ‘working in partnership’.   79 The significance of relationship-based practice has been identified as an essential component of good practice in child protection (Munro 2011)2. Relationships require give and take and compromise. The importance of taking the perspective of the client into account and really listening to what they have to say reduces the likelihood that the client  2 The Munro Review of Child Protection: final report, a child-centred system (2011)  https://assets.publishing.service.gov.uk › uploads › file   Child G LCSPR overview report – FINAL 02.11.21  16 will experience their dealings with professionals as oppressive and resort to ‘disguised compliance’.   80 The Child Safeguarding Practice Panel Review: Annual Report 2020 3 lists ‘Six Key Practice Themes that Make a Difference’. The second theme describes ‘Working with families where their engagement is reluctant and sporadic’ and makes the observation that one of the key learning points from safeguarding reviews in the past year includes recognition of ‘the importance of effective relationships and connections between practitioners and families in creating the motivation and opportunity for change’. Understanding by the practitioner of the client’s experiences is a significant component in creating such a relationship.  81 Although there are indicators that the mother was attempting to do the best she could under the difficult circumstances she found herself in there are also examples of emotional neglect by mother that had a negative impact on Child G. They may well have been in receipt of too much information from their mother regarding the difficulties in her pregnancy, rendering Child G very fearful and preoccupied about their mother’s safety. Their mother’s focus on securing services for their older half-brother because of his autism may have made Child G feel overlooked and unprotected during the many times he was aggressive towards them. If mother did question Child G’s reality regarding the identity of their abuser, it may have left Child G feeling confused and unsupported and alienated from their father and their relationship with the children in his household. Whatever her emotional state in the 16 months prior to the attempted suicide, on the day itself Child G told the police officer that they felt ‘unloved’ and that ‘everyone else had a daddy except me’.  82 It is notoriously difficult for practitioners to know how to work with families in which the children are affected by the emotional abuse/neglect of their carers. The quality of the relationship that can be established by professionals with the family can help to create conditions where such challenging work may have a better chance of being effective.  Learning Point- To be aware of the importance of emotional intelligence and empathy in strengthening trauma informed practice with clients to improve working relationships and promote the safeguarding of children.  The impact of Covid-19 on practice and outcomes  83 The onset of lockdown in mid-March 2020 in response to the developing COVID-19 pandemic occurred at a time for this family when the baby was just weeks old after a difficult pregnancy and complicated birth. The decision of Child G’s mother was to keep all the children home from school for the duration of the lockdown because of the vulnerability  3 https://www.gov.uk/government/publications/child-safeguarding-practice-review-panel-annual-report-2020  Child G LCSPR overview report – FINAL 02.11.21  17 of the baby. This meant there were four children, including a new-born baby, and two adults, one of whom was the originally named perpetrator of sexual abuse against Child G, in a small two-bedroom accommodation.  84 The step-father had completed his risk assessment which concluded that he should not be alone with the children. This requirement had not been complied with during the later stages of the mother’s pregnancy because of her admissions to hospital due to complications in the pregnancy. The mother was assessed as needing to increase her ability to protect the children, especially Child G, through the PPI programme that the specialist sexual risk service was planning to deliver. The terms of this were discussed with her just a few days after delivery and it was decided to put commencement of the work on hold for the moment because of all her commitments to the family.  85 Child G had one session with the specialist service worker who was going to do the therapeutic programme with them. This was while they were staying with their aunt two months earlier because it was thought to be unsafe to commence that work while they were living in the same household as the step-father who they had originally named as the perpetrator.   86 The children came off CP plans at the RCPC because of mother’s ‘open and honest’ relationship with professionals, Child G being more settled at school, elder brother’s placement in a more suitable school and the commencement of therapeutic work for Child G. They were stepped down to child in need status.  87 The combination of these factors meant that Child G and their family entered the social isolation of lockdown with a less than robust safety plan around the children and no possibility of regular, effective contact with anyone outside the family, either friends or family members or professionals.  88 The names of the children in the family were all included in the Vulnerable Children Risk Assessment Group and, as such, were reviewed weekly by CSC. The mother received a weekly phone call from the school to ascertain the welfare of the children who were also in receipt of free school meals. The school kept a notebook with the number and nature of their contacts with the families of all children that weren’t in school, but unfortunately those notebooks were not retained so no record of school’s contact remains. It is unclear how frequently the family social worker undertook doorstep visits.   89 Child G did return to school for a few days after the Easter holidays and for three days in July but did not stay because they said they wanted to wait until they could go to ‘proper school’. Although the family was given a laptop toward the end of the first lockdown, Child G did not take part in any online learning or activities during this time. Child G is a bright child who Child G LCSPR overview report – FINAL 02.11.21  18 usually enjoyed school, apart from the troubled time they had with their behaviour in class during the previous autumn. It is likely that they were quite academically under stimulated during this time and resumed school in September with a lot of learning to catch up on.  90 Although there was a degree of remote contact and monitoring, and some direct doorstep visiting by the family social worker, there was little direct involvement with the family by professionals during the first lockdown.  91 The worker from the specialist sexual risk service contacted mother in April to discuss resumption of therapeutic work with Child G. The mother said that Child G was more settled, and their behaviour had improved. Even though it might be useful at some point for Child G to have sessions, now was not the right time. Additionally, any direct work would have to take place online in cramped accommodation with the step-father being in the household at the time and using equipment and connectivity of indeterminate effectiveness. So, the opportunity for Child G to speak to someone in depth about how they were feeling was postponed again, in part because of the restrictions imposed by lockdown.  Conclusions and Recommendations  Several learning points were identified in the course of the Partnership Review process.  Communicating with the child  92 There was considerable anxiety expressed by those working with Child G that Child G was not offered any focused direct work in the immediate aftermath of the allegations of sexual abuse. This was based on the reluctance by anyone to work with them in depth until the therapeutic work to be undertaken with them was completed. This work never happened as planned, leaving Child G in a distressed state, and displaying increasingly disruptive behaviour.    93 Because Child G received no therapeutic support it is not known whether their disturbed presentation was directly related to their experience of sexual abuse or to other events going on in the family at the time.  Convening multi-agency meetings   94 There was concern among the agencies that it was difficult to create conditions of safety for Child G after they changed their account as to the identity of their abuser. There were a number of missed opportunities for practitioners to meet together to discuss their options in the wake of new developments in the life of the case.   Child G LCSPR overview report – FINAL 02.11.21  19 95 The three points at which a multi-agency professionals meeting with input from legal services would have been helpful in making clearer plans and reducing tension between agencies by giving opportunities for open communication were  • Immediately following the ABE interview when Child G named the perpetrator as their birth-father and not their step-father • Upon the lifting of step-father’s bail conditions, freeing him to return legally to the family and when the police officially decided to close the investigation and take no further action • When the specialist sexual risk assessment was completed, and recommended that step-father remain outside of the family home until the protective parenting work with mother was finished. The couple decided not to adhere to the recommendations but did agree to a safety plan that included step-father not being alone with the children in the house. This soon proved unsustainable when mother had a series of hospital appointments and overnight stays because of complications in her pregnancy  Improving practice and quality when undertaking ABE interviews  96 The ABE interview with Child G was a crucial event in determining the direction of this case. There was a four-week interval between Child G being spoken to at school and the ABE interview. It is felt that living in the situation where mother openly did not believe step-father abused Child G for a number of weeks before the interview may have compelled or influenced them to change their account.  The delay was mainly because of the need to work around the Easter school holiday which meant there was no opportunity for the Registered Intermediary to assess Child G’s communication needs prior to the ABE until school re-convened after the Easter break, nearly three weeks after the RI had been appointed.  97 During those four weeks mother also learned that the children in Child G’s father’s household were on CP plans. Not only should mother have been told this at an earlier stage because Child G occasionally stayed with their birth father for sleepovers with the other children in his household, but the timing was such that it may have been that learning this information when she did played a part in Child G changing the identity of the person they said had abused them.  98 The ABE interview is important in both safeguarding the child and in the criminal investigation and should be conducted with adequate thought and planning both before and after the interview. Not being able to hear from the police officer who spoke to Child G at school and conducted the ABE interview has made it difficult for the author to gain an accurate impression about the nature of the pre-session planning or the thinking behind not having a post-interview strategy meeting. Although the social work interviewer at the ABE was spoken to by the author, their role was specific to the execution of the interview itself Child G LCSPR overview report – FINAL 02.11.21  20 on the day, and their memory of it was understandably affected by the passage of time. As cited above, not having access to Note 1 about Child G telling the teacher they didn’t think their mother believed them became extremely relevant to both how the investigation unfolded and to the conduct of the risk assessment.   99 Neither was there any post-interview strategy meeting, ideally with advice from legal services, about how to take both the child protection process and the criminal investigation forward now that Child G had changed their account of what happened.  Building more effective relationships with the family  100 Child G’s mother reported a very unsatisfactory experience in her contact with some of the agencies she met following her child’s disclosure of sexual abuse. She felt let down that the specialist sexual risk service did not deliver the help for Child G that they had promised. She believed that she had cooperated with them regarding the risk assessment recommendations but they did not appreciate how this affected her.   101 Her motivation to make arrangements in the best interests of Child G and of the family were interpreted by some professionals as a lack of cooperation or disguised compliance. It is the opinion of the author that some of the professionals who worked with mother did not adequately convey to her that they understood the impact on her of this interference in her life by the requirements of the child protection system. There is also evidence of mother feeling understood and supported by some of the professionals she encountered e.g., the allocated social worker and the teachers at school.  Recommendation One  For agencies to highlight the learning from this review regarding;  • the importance of not making assumptions about the source of a child’s distress in the absence of speaking to the child directly. • clarity about a plan to work together concerning how the child’s needs are to be addressed during the time that they are awaiting a specialist assessment  Recommendation Two  Partnership to ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies. All relevant agencies, including specialist services are invited to contribute.   Recommendation Three  Child G LCSPR overview report – FINAL 02.11.21  21 ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance. All documentation arising from ABE interviews should be shared appropriately and in a timely manner.  There should always be consideration as to whether a further Strategy Meeting is required following the ABE interview.    Gretchen Precey Independent Social Worker  2 November 2021     