Sexual abuse and neglect of three siblings by their father over many years. Father was convicted of sexual offences and received a substantial term of imprisonment. Mother was a repeat victim of domestic abuse by Father. Anonymous report made to Children's Social Care in 1998 that Ash, one of the siblings, had been sexually abused by Father. In 2007, Ash disclosed to police, but later retracted, that they had been raped by Father. Father was arrested, but no further action taken due to insufficient evidence. In 2016, local authority received information that Casey, Ash's sibling, had been sexually abused by Father; abuse disclosed to Mother in 2015. Ethnicity or nationality of family not stated. Uses the Appreciative Inquiry (AI) methodology. Learning includes: professionals need to act with caution when a victim makes a 'retraction' statement; sexual abuse is a possible cause of vaginal discharge; professionals need to recognise when they come into possession of information concerning historical sexual abuse which should be shared with other agencies; providing the victims of domestic abuse with access to an Independent Domestic Abuse Advisor (IDVA) will help professionals recognise and respond to the impact of coercive and controlling behaviour. Recommendations include: partner agencies should ensure their records capture the detail and rationale for actions and decisions and have processes for timely sharing of information about these incidents; when the word 'retraction' is used in connection with an investigation, the reasoning behind that decision is documented in police records and when shared with other agencies.
      
    Serious Case Review No:  2020/C8234  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.   Page 1 of 33                Serious Case Review    Page 2 of 33     Contents  1. Circumstances which led to a Serious Case Review  2. The approach used (including details of review team and practitioners)  3. Scope and Key Lines of Enquiry [KLOE]  4. Overview of what was known to agencies  5. Appraisal and analysis of practice against the Key Lines of Enquiry [KLOE]  6. Concluding comments  7. Summary of learning points and recommendations                Page 3 of 33    1. Circumstances which led to a Serious Case Review  1.1 This family were known to a number of statutory services in an unnamed local authority area.  In 1998 anonymous information was received by Children’s Social Care [henceforth referred to as CSC] that Ash a child in the family, had been sexually abused by their father.  Ash did not repeat the allegation when seen by a social worker and the matter was not reported to the police.    1.2 In November 2007 the police were called to a disturbance at the family home.  Ash disclosed they had been raped by Father.  He was arrested.  No further action was taken following the advice of the Crown Prosecution Service [CPS] that there was insufficient evidence.     1.3 In March 2016 information was received by the local authority that Casey [another child in the family] had been sexually abused by their father.  The information was shared with the police and a joint investigation involving CSC was undertaken. Father was prosecuted and convicted of sexual offences and received a substantial term of imprisonment.     1.4 The Chair of the Safeguarding Children Board in the unnamed local authority area [henceforth known as the SCB] determined there were causes for concern in relation to the way in which agencies had worked to safeguard Casey and other siblings within the family.  Accordingly the Chair made the decision that the criteria for a serious case review had been met and that a review would be carried out in line with statutory guidance and SCB policies.       2. The approach used  2.1 The SCB appointed an independent lead reviewer with experience of undertaking child, adult and domestic homicide reviews.  Although he has undertaken reviews in the SCB area before, he has never worked for any of the agencies involved in this case.  He was supported by another independent reviewer with a similar background who also has never worked for any of the agencies involved in this case.          Page 4 of 33    2.2 A review team, representing the following agencies in the SCB area, was established and chaired by the independent lead reviewer.      Panel Membership  The Independent Reviewer-Assisting Chair and Report Author  A Detective Chief Inspector  The Designated Nurse Safeguarding Children for the Clinical Commissioning  Group (CCG]  An Educational Officer   An Independent Chair  The named GP for Safeguarding for the Clinical Commissioning Group  The Service Manager Quality Assurance & Safeguarding for the local authority  The Head of Youth Service   The SCB Coordinator    2.3 There are a number of recognised methods for undertaking serious case reviews.  'Working Together to Safeguard Children' does not prescribe any particular method to use, except that whatever model is used it must be consistent with the following 5 principles:   • Recognises the complex circumstances in which professionals work together to safeguard children;  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;   • Transparency about the way data is collected and analysed; and  • Makes use of relevant research and case evidence to inform the findings.   The SCB has procedures that provide a number of examples of methods that may be used.  Many of these models involve engagement with front line professionals and managers, often in the setting of a learning event.   2.4 The review panel recognised that in respect of this family a considerable number of years had elapsed since some of the events had occurred. Policy and practice have developed and improved since then and many of the key professionals involved in these historic events were no longer employed within the partnership.  Consequently the panel concluded it was unlikely they would gain any insight or value from following a model that relied significantly on engagement with frontline practitioners.  2.5 Consequently this SCR adopted the Appreciative Inquiry (AI) approach. This is;  Page 5 of 33    ‘rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change.  SCRs conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong.  They get to look at where, how and why events took place and use their collective serious case reviews hindsight wisdom to design practice improvements1’.  2.6 Agencies were asked to provide chronologies of their contact with the family.  When these were available, the first of five panel meetings were held. At the first meeting the panel established the significant events and key lines of enquiry [KLOE] against which they would be reviewed.  Agencies were then asked to provide more detailed reports and information on elements of their agencies practice in respect of the key events.    2.7 This information was brought together and analysed.  The responses provided by agencies were scrutinised and challenged by the panel at a further meeting. Here the panel identified some indicative areas for learning.   2.8 The learning, analysis and challenge from the review panel was drawn together and refined in a first draft of the SCR report.  The review panel then met on a further occasion to consider and further refine the draft before a final report was completed and made available to the SCB Board.   2.9 The chair of the panel wrote to the mother of the children and invited her to contribute to the SCR. At the date the SCR report was completed a response had not been received from her. The chair and the panel remain committed to meeting with her and discussing the case at any time in the future should she wish to do so.        3. Scope and Key Lines of Enquiry  3.1 The review panel agreed that the period under review would be from the date of the first allegation until the date Father was convicted and imprisoned.  This allowed the review panel to identify the response of agencies to the serious harm the children suffered, as well as to determine why there was such a long period of time between the events that led to the conviction coming to light and matters being referred to the SCB Sub Group.    3.2 The panel agreed the following would form their Key Lines of Enquiry [KLOE];  1. What opportunities were presented to professionals to safeguard the children?  What was the response of professionals to those opportunities and were those responses reasonable?  Were there any missed opportunities to                                            1 Extracted from the SCB safeguarding policy.  Page 6 of 33    assess the potential risk of ongoing sexual abuse to the children?  If there were, what were the reasons for those missed opportunities?  2. To understand whether agencies identified, assessed and responded appropriately to any safeguarding risks present, and consider if plans and arrangements were child focused and compliant with statutory requirements. Did professionals listen to the voices of the children, or did professionals focus too much upon building relationships with mother?  3. What confidence did professionals have in the children’s mother to safeguard and protect them?  What challenges did professionals make to the mother when they felt she may not have been complying with measures to safeguard and protect her children?  Was there any evidence of disguised compliance by mother and how did professionals respond if there was such evidence?  4. What evidence is there that professionals recognised sexually harmful behaviour in the children?  If they did, what evidence is there that they knew what do with that information?  Are there now robust multi-agency processes in place for recognising, receiving and responding to such information?  5. To consider if there were organisational or contextual obstacles or difficulties in this case which prevented agencies from fulfilling their duties.  For example, was there a loss of focus in this case because the emphasis was upon training professionals to recognise and respond to child sexual exploitation?  Did the multiple handovers between staff in this case have an impact?    6. To review and consider: the procedures in place for referral of potential serious case reviews to the Critical Sub Group; the professional’s understanding of these procedures; why it took over two years for the case  to be referred to the Critical Sub Group.  7. Is there any evidence that professionals and/or agencies worked in isolation? What evidence is there that professionals recognised the value of isolated pieces of information and the impact such information may have had on assessing the risk children faced?  Did professionals know how to share information that impacted upon risk with other agencies?   8. Were the conditions for children to disclose information about abuse supportive towards them?  Were there any barriers in place that might have prevented the children disclosing abuse?      The responses to the above terms should be based on the procedures and policies in place at the time of the events under examination.        Page 7 of 33    4. Overview of what was known to agencies  4.1 Appendix A sets out a chronology of the key events.  The following paragraphs summarise the significant features in this case.   4.2 Mother was known to services in the unnamed local authority area as a child.  She had been in care until she was 17 years of age and had made allegations of sexual abuse against her father.  She had a history of overdoses and had received services from mental health services.  In the mid 1990s she gave birth to Ash.  Father was reported to be her partner.   Sexual abuse and child neglect   4.3 The significant feature of this case was the sexual abuse and neglect of the children by Father.  The first incident reported to agencies was in January 1998.  CSC received an anonymous allegation that Father had sexually abused Ash.  A joint visit to Mother at home was undertaken by a social worker from CSC and a Health Visitor.  Mother denied all the allegations and no further action was taken.   4.4 In November 2007 the police received a call to a disturbance at the home of Mother and her children.  Ash said Father had tried to sexually assault them.  They later told police he had anally raped them earlier that year.  The police investigated the allegation.  Father was not prosecuted following advice from the Crown Prosecution Service [CPS].  Shortly after the advice was received Ash gave a statement to the police retracting their allegation.     4.5 In May 2008 a report was made to CSC from someone who knew Mother and said she had disclosed to a neighbour that Father had sexually abused Ash.  CSC investigated the report and spoke to Mother.  She denied the allegation saying she had not spoken to a neighbour.    4.6 In September 2011 Blaire, another child of Mother and Father, was locked in the house and left alone by Father who had been given care of the child by Mother, contrary to an agreement that Father should not have contact with the children.  After Blaire rang the police, they forced entry and took them to safety.  Father was arrested and cautioned for the offence of child neglect2.   4.7 In June 2015 Casey attended the GP practice with Mother.  They had a temperature, leg pains, and vaginal discharge.  During discussions with the doctor Mother did not disclose any suspicions of sexual abuse in respect of either Casey or any of her other children.  Casey made a further presentation to their GP surgery in August complaining of being sore                                            2 The offence is committed if a parent or the legal guardian, or other person legally liable to maintain a child or young person has wilfully neglected the child in a manner likely to cause injury to health by failing to provide adequate food, clothing, medical aid or lodging or, if having been unable to provide such items, they fail to take steps to procure them.  S1 (2) (a) Children and Young Persons Act 1933.  Page 8 of 33    ‘underneath’ and in February 2016 with a urinary tract infection. Sexual abuse was not considered a cause at that time.    4.8 In March 2016 an anonymous referral was made to CSC.  The referrer said that Casey had disclosed that Father had sexually abused them since they were five years of age.  The referrer said it had also happened to Ash for years and that Mother was still in a relationship with Father.  The children had been told to keep this secret.  As a result of this information a strategy meeting was held and a joint visit made by the police and CSC.  A detailed and extensive investigation was then conducted as a result of which Father was charged and later convicted of the offences described in section one of this report.  4.9 During that investigation Mother said that Casey had disclosed to her in early 2015 that they had been sexually abused by Father.  Mother had decided to deal with the matter ‘within the family’.  It was because Casey disclosed this information that Mother had taken them to see the doctor [see paragraph 4.13].     Domestic Abuse  4.10 Mother was a repeat victim of domestic abuse at the hands of Father over a number of years.  The police were called on four separate occasions to reports of disturbances either at the family home or in the street involving verbal and physical abuse by Father upon Mother.   4.11 The police shared details of all the incidents they attended during this period with CSC.  As well as the police, Mother also told other professionals that she had been physically and verbally abused by Father.  There may well have been many incidents of domestic abuse that were never reported to the police.  However, her experiences were well known and documented in agency records.  The children in the family were present on many occasions when domestic abuse took place and there is evidence from comments the children made to professionals that they were troubled by the behaviour of their Father and concerned about their Mother.     4.12 During the period of the review the abuse Mother suffered escalated.  For example, in June 2008 Father was arrested and charged with assaulting Mother after reports that she was being dragged down the street.  The children were with her and suffered minor injuries.  Father appeared before court and was convicted of assault and received a suspended sentence.    4.13 The conviction did not stop Father from continuing to perpetrate abuse.  For example in June 2009 he turned up at the family home and the police were called to remove him.  The children were present and about to go to school.  Father was described as being drunk.    Page 9 of 33    4.14 In July 2009 Mother disclosed to a social worker and health visitor that Father had tried to strangle her3.  The children were present when it happened.  Despite Mother moving to a refuge in 2010, and then a new home, this did not appear to prevent Father from resuming contact with her and incidents of domestic abuse continued to happen periodically over the following years.   4.15 Misuse of alcohol by Father was another feature of this case and he was described as being drunk or intoxicated during a number of contacts involving Mother and the children.  He was also suspected of misusing drugs.  Mother also had vulnerabilities as a result of the misuse of alcohol, for example she told a social worker in 2013 that ‘alcohol did not help’ and that she had sought help from her GP.         Safeguarding responses  4.16 A Child Protection Conference4 was held and the children were first placed on the Child Protection Plan in December 2007 following the allegations made by Ash.  After a review conference in March of the next year, the category of abuse was changed from sexual to ‘physical’ and they remained on the plan.  Following the conviction of Father for assault upon Mother, and reported improvements in her lifestyle, the children were removed from the child protection plan in February 2009 and instead were supported by child in need5 plans.  Following further review in July 2009 this was modified to EHAT6.  4.17 As well as CSC contact with the family in respect of the allegations of sexual abuse, CSC also had significant contact with Mother in respect of her domestic abuse at the hands of Father.  Part of the CSC response was the appointment of a family support worker who paid regular visits to Mother and her children.  Another significant feature of this case was the large number of written agreements made between Mother and CSC.  The principle feature of these agreements was that Mother would not allow Father to have contact with the children.                                             3 It is believed the visit of the social worker and health visitor on this occasion was in response to a police referral from the incident of domestic abuse in June [paragraph 4.13]. It is not clear whether the information that Mother provided during the visit in July related to the incident of domestic abuse in June or whether it was another incident that had occurred since then and that she had not reported to the police. The gap here is that the information about strangulation was not made known to the police by the social worker and health visitor.  4 A child protection conference brings together family members (and the child where appropriate), with the supporters, advocates and practitioners most involved with the child and family to make decisions about the child's future safety, health and development.  5 A child in need [CIN] is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Children in need may be assessed under section 17 of the Children Act 1989 by a social worker. 6 All services and agencies in the area of the review work with an information gathering tool called an early help assessment tool (EHAT).  Page 10 of 33    4.18 Over the following years a number of reports were received by CSC of events involving either domestic abuse of Mother and/or reported contact between Father and the children in breach of the agreement.  The response to these reports, on most occasions, was for a new written agreement to be made.  While some of the terms changed, the consistent one was that Father should not have contact with the children.    4.19 A number of child in need [CIN] meetings were also held.  These coincided with Father’s admission to hospital in 2013 and concerns that he was being visited by Mother and Ash.  An issue of concern to the CIN in 2013 was that Casey was now of a similar age to Ash when they had made allegations of sexual abuse against Father.  Mother agreed to the continuation of the written agreement that Father would not have contact until the children were aged 18.  The case was then closed.   4.20 In November 2014 a police investigation was undertaken around concerns Jordan, another child of Mother and Father, had been involved in an incident involving risky sexual behaviour and possible Child Sexual Exploitation [CSE].  This did not involve Father, rather a group of unconnected males who had reportedly had sexual contact with a friend of Jordan while they were present.  A number of multi-agency meetings concerning CSE were held and, although there was no prosecution, a CIN plan was agreed for Jordan.   4.21 In December 2014 it became known that Mother was pregnant with another child, although there was an agreement she would not have contact with Father. Despite Mother’s denial that she had any involvement with social care, a member of staff in the hospital recognised Mother when she visited the hospital with Father.  The staff member knew something of her history in respect of child protection concerns and made a referral to CSC.  A pre-birth assessment was then undertaken by a social worker.    4.22 The case was kept open as there were concerns Mother had not followed any previous plan that had been put in place and had failed to protect her children by resuming her relationship and becoming pregnant by Father. This led to CIN meetings being held in respect of the child both before and after birth.  A further agreement was made that Mother, her new-born child [Denny] and her other children would not have contact with Father.  After it was reported that Mother had engaged well, that Father had moved away, and that there were no further concerns, the case was closed with an EHAT led by the primary school.  This was the final safeguarding contact before the allegations of the sexual abuse of Casey were reported and investigated in 2016.      5. Analysis of Practice  5.1 In this section of the report, the key events are analysed through the framework of each individual KLOE.  This helps ensure that each of the Page 11 of 33    KLOE is adequately addressed.  Some key events may fit in one or more of the KLOE and when this happens a ‘best fit’ approach has been adopted.  5.2 When analysing practice, the review panel were mindful of some important issues. Many of the events occurred a long time ago; in some cases over twenty years.  This means it has not always been possible within this review to understand precisely what happened and the underlying reasons that led professionals to act as they did.    5.3 Another important issue for the panel was the need to avoid hindsight bias.  This refers to the common tendency for people to look back over cases and believe that the outcome was more predictable than it actually was.  Consequently, people often believe they would have predicted the outcome, or perhaps even would have known with a high degree of certainty, what the outcome would have been.  The panel attempted to keep an open mind at all times about why professionals took certain actions and decisions in respect of this family.  In particular, where there were gaps in information because of the passage of time, the panel avoided making assumptions to bridge those gaps.   5.1  KLOE 1: What opportunities were presented to professionals to safeguard the children?  What was the response of professionals to those opportunities and were those responses reasonable?  Were there any missed opportunities to assess the potential risk of ongoing sexual abuse to the children?  If there were, what were the reasons for those missed opportunities?  5.3.1 The children in the family faced a number of risks. Although there were others, the primary one they faced was exposure to sexual abuse at the hands of Father.  The first opportunity agencies had to identify that risk was the anonymous information received by CSC early in 1998.     5.3.2 The panel felt there were some gaps in practice in the way in which agencies responded to this event.  One of these was when Mother told the social worker and health visitor that Ash had thrush.  The health visitor felt that it may have been due to Ash not being potty trained.  The panel heard from a health professional member that the child still wearing nappies might be a contributory factor to the child suffering thrush. There could have been others.  Crucially, that thrush might have been the result of sexual abuse. The records from 1998 contain no written rational as to why professionals did not take other steps to investigate the cause and exclude or confirm the reasons why Ash had thrush. The panel heard that there is now guidance in place around vaginal discharge, and standards regarding the management of prepubertal vulvovaginitis6.                                                 6 Child maltreatment: when to suspect maltreatment in under 18s: Published 22 July 1990 www.nice.org.uk/guidance/cg89  Page 12 of 33    5.3.3 The lack of detailed rationale for actions/omissions in practice was a theme that the panel identified in this and some subsequent events.  While it was good practice to undertake a joint visit in response to this anonymous allegation, only CSC appears to have made a note within their agency records about the visit.  There was nothing written within health visiting records. While the decision to close the referral was signed by a manager in CSC, there was no written rationale for the manager’s decision.     Learning point 1: It is important to ensure that records contain sufficient detail and a rationale as to the actions and decisions professionals take when undertaking visits and investigations.   5.3.4 Notwithstanding these omissions, the panel felt the overall response from CSC was appropriate and in line with what would have been expected in 1998. It appeared to the panel that the enquiries that had been made with other agencies, and the home visit, was a reasonable approach to assessing the needs of Ash and Mother’s ability to meet them.   5.3.5 The anonymous information, and the results of the joint visit and actions were not shared with the police.  The panel recognised that, as the event pre-dated ‘Working Together’, processes in 1998 differed from contemporary practice.  While there were still grounds for suspicion, the actions CSC took in 1998 did not lead to the discovery of any information beyond that contained in the original referral. This meant that, even if it had been shared with the police, there was nothing beyond the anonymous allegation that was capable of investigation.    5.3.6 The panel were told by the CSC and police representatives that in 2019 different processes are in place.  An allegation such as this will now result in a strategy discussion involving CSC, police and health.  From this an action plan will be agreed and a joint or single agency investigation undertaken.  Although the process now differs, the panel did not think this would necessarily mean the outcome of an anonymous allegation such as this would have been any different as that would always depend upon the strength of the evidence available.   5.3.7 When the next opportunity to address the risk of sexual abuse emerged in November 2007, legislation, policy and practice had shifted significantly towards greater multiagency working.  The panel felt the multi-agency response of the police and other agencies to this allegation was satisfactory.  Ash consented to a medical examination and Father was arrested and interviewed.  5.3.8 The panel were provided with a copy of the report the police sent to the CPS and their advice.  The panel recognised that then, as now, Page 13 of 33    allegations of rape [and indeed all crimes] require an evidential test7 to be met.  The behaviour of perpetrators of sexual abuse on children is such that they commit their offences in a way that it is rarely witnessed by a third party.  Consequently, it can be difficult for investigators to discover evidence that corroborates the disclosure by the victim to the point at which the evidential test is met.    5.3.9 The review panel recognised that conviction rates for rape and sexual offences have been, and continue to be, a cause for concern nationally.  A detailed explanation of the subject is beyond the scope of this review.  However, it is noteworthy that in 2017/18 only 1.7% of reported rapes resulted in a prosecution when sexual crimes recorded by the police had risen by 9% in the previous five years9.   5.3.10 While it did not alter the outcome of the CPS decision, the panel felt it was important to consider the decision that Ash took to ‘retract’ the allegation.  ‘Retraction’ is a word that is used within legal guidance on sexual offences and can describe occasions when a victim takes action that indicates they do not wish to continue with a case.  ‘Retract’ can have many meanings. For example it can mean the victim does not want to give evidence in court, they do not wish any further action to be taken or that they are indicating the events did not take place.   5.3.11 It is important to understand that victims may not always be exercising free choice when ‘retracting’ an allegation; ‘true allegations can be retracted for a broad range of reasons. Very often such allegations are made by a person who is vulnerable or in the context of a relationship, often with a protracted and complicated history, all of which is bound to have a bearing on the issues in the case…Prosecutors must not resort to using myths and stereotypes once associated with victims of rape and / or domestic abuse. These include:   • Victims always physically resist and fight off their attacker;  • Victims always receive injuries;                                             7 All criminal prosecutions are subject to a continual review pursuant to the Code for Crown Prosecutors (the Code), which sets out how the CPS makes the decision to prosecute. The Code sets out a two-stage test which has to be applied by Crown Prosecutors to ensure that our decisions are both fair and consistent. Primarily a Crown Prosecutor has to be satisfied that there is sufficient evidence for a realistic prospect of conviction. If this evidential stage is not met then the case cannot proceed however sensitive or serious it might be. If the evidential stage is satisfied the Crown Prosecutor must consider whether a prosecution is in the public interest.  9 Source: Guardian on line 19 May 2019  10 https://www.cps.gov.uk/legal-guidance/false-allegations-rape-andor-domestic-abuse-see-guidancecharging-perverting-course   Page 14 of 33    • Victims provoke / invite offences because of the way they act and dress or because they have consumed alcohol or drugs;  • Victims report the crime as soon as possible;  • Victims always recall events consistently; and  • Victims always get away from their attacker as soon as possible’10  5.1.12 The panel do not know which meaning was being ascribed to the word ‘retracted’ when Ash provided their statement.  There can be many reasons why victims do so.  While the panel cannot say why Ash gave a ‘retraction’ statement, based on what is now known about Father and his behaviour, it is beyond doubt that Ash was at risk from him and as such was a vulnerable child.  Ash told a social worker at the time of the investigation that they were worried about Mother knowing what had been disclosed and of violence between their parents.  A possibility the panel considered is that Ash feared the allegation of rape may have put Mother at risk from Father hence they retracted it.     Learning point 2: All professionals need to act with caution when a victim makes a ‘retraction’ statement.  They may have made this statement because they felt under duress or for other reasons.  Just because a victim makes a retraction statement does not mean that they are no longer at risk.  Professionals need to assess risk based upon all the information and evidence available.  5.1.13 The panel heard that since this allegation, there have been many changes to the way the police and CPS handle such cases.  Significant effort has been put into improving outcomes for victims.  This has included the CPS adopting a “merits-based approach” to decision-making in rape cases: building a prosecution case around all the “merits” of a case, assuming the jury will be objective and not prejudiced8.  The police representative on the panel explained there is now a process in place for police supervisors to escalate a CPS decision to the lawyer’s line manager to review. Escalation of CPS decisions is common practice; however this is on a case by case basis and is dependent on officers highlighting any CPS issues to supervisors.  An escalation may not have altered the decision in this case, however the rationale from the CPS for their decision is limited.   5.1.14 The panel concluded that police actions in relation to the investigation, and the initial steps taken by CSC to protect Ash and the siblings, seemed appropriate.  This included placing the children on the child protection plan under the category of sexual abuse, the appointment of a support worker and a number of referrals to other services.  These steps were underpinned by the written agreement with Mother. The robustness of these actions as well as the way in which Mother complied with measures to protect her children are considered in more detail within section  5.3.                                               8 Ibid 10 June 2019: Guardian  Page 15 of 33    5.1.15 An issue of concern to the panel was the decision taken in March 2008 to record the category of harm in the Child Protection Plan as ‘physical abuse’.  It is clear to the panel, from all the evidence available, that the category should have been ‘sexual abuse’.  While there was evidence the children were exposed to domestic abuse perpetrated by Father upon Mother, the risk of sexual abuse they faced from Father was significant. The panel has not been able to establish whether the change of category was intentional or a mistake as there is no rationale within the notes.  The panel agreed that, if such a decision was being considered now, then the primary risk would be recorded as ‘sexual abuse’.  Because the CPS did not find the evidential test was met, and because Ash had ‘retracted’ should not have automatically led to a change in the category of risk.   5.1.16 In May 2008 information was received that Mother had found Father abusing Ash.  The panel felt this was another opportunity for professionals to protect Ash and the other children from sexual abuse.  It appeared to the panel that the action taken by CSC, making an unannounced visit and following this up with a core group meeting, was the correct course.  Mother denied the allegation was true.  The panel questioned whether this was a reasonable response by CSC to anonymous information.  They felt the information provided was vague.  It is not clear why CSC did not pass this latest information to the police; it may have been that their enquiries established it was a repetition of the information that had been investigated following the disclosure in November 2007. The police representative on the panel said that every new allegation reported to the police should be recorded in line with Home Office Counting rules and fully investigated. If the information was already known at the time of the earlier allegation, then this would have already been considered, however if this was new information then this should have been reinvestigated taking all the evidence into account.  5.1.17 In June and August 2015 Ash attended the GP surgery complaining of soreness in an intimate area.  The panel considered whether the response of the doctors to Casey’s presentation on these occasions was reasonable.  5.1.18 The GP surgery told the panel that Casey did not register with the practice until September 2013.  The practice had no record of current social care involvement.  It does not seem therefore that the doctors who saw Casey in 2015 would have been aware, from the records available to them, of the history of suspected sexual abuse by Father upon Casey’s sibling Ash.   5.1.19 On the first occasion Casey was seen the doctor arranged for swabs to be taken and for an intimate examination to be undertaken. Vulvovaginitis is the most significant cause of discharge [82%], with only 5% of cases being related to sexual abuse. As the doctor had no evidence, it therefore seems the actions of the first doctor in not referring Casey were reasonable. However, there is also no evidence that the doctor asked any questions of either Casey or Mother about the family history and therefore neither elicited nor excluded evidence of sexual abuse.  As there is no record of what action was taken when Casey presented for the second time in 2015 it is not possible to reach a conclusion as to whether the second doctor acted appropriately on this occasion.  Page 16 of 33      Learning point 3: Sexual abuse is a possible cause of vaginal discharge. Health professionals should have regard to NICE guidance [Child maltreatment: when to suspect maltreatment in under 18s], consider the possibility of sexual abuse in such cases and ask questions about the family history so as to elicit or exclude any relevant information that may lead to the making of a referral.      5.1.20 During the police investigation in 2016, it emerged that Casey had in fact made disclosures of sexual abuse at the hands of Father to Mother in 2015. Casey told Mother of a number of occasions when Father had raped them. It was as a result of this information that Mother had taken Casey to see the doctor with discharge and soreness.  Mother told the investigators that she had dealt with this information ‘within the family’.  Had either doctor been made aware of that information at the time of the presentations, then it would have undoubtedly led to an immediate referral to CSC for sexual abuse being made.    5.1.21 When the anonymous information was received by CSC some twelve months later it appears to the panel they, the police and other agencies responded swiftly and appropriately to the allegations.  Their actions were in accordance with contemporary policy and practice.  There was a robust investigation and it seems to the panel that all reasonable steps were then taken to safeguard the children from any further sexual abuse.      5.2  KLOE 2: To understand whether agencies identified, assessed and responded appropriately to any safeguarding risks present, and consider if plans and arrangements were child focused and compliant with statutory requirements.  Did professionals listen to the voices of the children, or did professionals focus too much upon building relationships with mother.  5.2.1   As well as the opportunities to respond to the risk of sexual harm [discussed in KLOE 1 above] the panel reviewed a number of other key events to establish if agencies responded appropriately to other safeguarding risks.   5.2.2   Although sexual abuse was the most significant risk to the children there were also other risks both to them and to Mother, principally domestic abuse at the hands of Father. The first time these risks were apparent within agency records was in July 1998 when Mother requested CSC that she should be rehoused because of ‘issues with her boyfriend’.  Because a significant period of time has elapsed it is not clear what the response to that request was. However it does show the likely longevity of her victimisation.  5.2.3   The panel considered the response of agencies to the events in June 2008 when Mother was dragged into a house.  This incident pre-dated the introduction of the ‘bronze, silver, gold’ graded response to domestic incidents.  None the less, the response of the police in arresting and charging Father and making domestic abuse and child protection referrals to CSC appeared to be appropriate and in accordance with the policies then in place.  These referrals ensured that information was made available to the subsequent review child protection conference.  5.2.4   Domestic abuse permeated the lives of this family during the period covered by this review and it is clear the children continued to witness the verbal and physical abuse Page 17 of 33    of their mother at the hands of Father.  Alcohol misuse seems to have been a common denominator in many of these events.  For example the event in June 2009 when there was a domestic violence incident involving Father who was drunk in the presence of the children.  While the panel considered the police response to this was appropriate, the timing of the event [as the children were about to leave for school] reinforced the dysfunctional nature of family life and the failure of Father to comply with any agreements not to visit the family home.  5.2.5   Although information about the incident was shared by the police with CSC, it is unclear why there was then a gap of nearly one month between the event being reported to the police and information appearing in CSC records.  Whatever the reasons, earlier notification/receipt would have provided agencies such as CSC with a more immediate opportunity to visit the family and assess the risks and impact of the children’s continued exposure to domestic abuse.     Learning point 4: Timely sharing and/or recording of information about relevant incidents ensures that professionals can respond promptly to assess risk and protect vulnerable persons.    5.2.6   However, within a week of the receipt of the information a social worker and health visitor saw Mother and her children during which Mother provided significant new information: that Father had attempted to strangle her.  The panel felt this information would now alert professionals that the risk to Mother from Father had significantly increased, as it had for the children.  Placing hands around a victim’s throat is now recognised as a significant factor within risk assessment processes for domestic abuse12.  It seems the information about the incident was not shared with the police.  It is not clear from the records why that did not happen.  Neither do the records indicate whether any consideration was given to listening to the voices of the children to determine how witnessing such events impacted upon their welfare and the risks they faced.   Learning point 5: Placing hands around a victim's throat and/or attempted strangulation significantly increases the risk of harm to a victim and children in the home.  Professionals need to recognise all facets of domestic abuse and know how to respond to such information and when such information should be shared with other agencies.  5.2.7   The immediate response to this event was that Mother and the children moved to a hostel.  Then, and now, that might be an appropriate protective measure for Mother and children. However, separation can also significantly increase risk.  In a case such as this, contemporary multi-agency policy in SCB would now lead to additional steps such as the completion of a risk assessment, recording the incident as a crime on police systems and referral to a MARAC13.  There was a considerable history of domestic abuse within the family that was well documented in agency records.   1215 high risk factors of serious harm or homicide in domestic abuse cases: https://www.reducingtherisk.org.uk/cms/content/identifying-risk-indicators  13 Multi-Agency Risk Assessment Conference (MARAC) https://www.reducingtherisk.org.uk/cms/content/marac  Page 18 of 33    5.2.8   The panel felt this was a case in which, had all that information been triangulated, it would have presented an opportunity to arrest and prosecute Father for a serious offence.  Dealing with the abuse Father perpetrated through criminal justice sanctions would have presented many other options to reduce risk and protect Mother and the children.  It is important to recognise that much has changed in the way in which professionals are trained to recognise and respond to domestic abuse in the ten years since this event. That may well be the reason why professionals acted in the way they did.    Learning point 6: Undertaking a recognised risk assessment process allows behaviour such as this to be recognised and then a referral made to MARAC.  Consideration at MARAC allows all relevant information to be triangulated and protective measures to be put in place which may include criminal justice sanctions.   5.2.9 In addition to the move into a hostel, the other response to this incident was to update the written agreement that was in place between CSC and Mother relating to not allowing Father contact with the children.     5.2.10 While the version of events given by Father and Mother for the event in January 2010 vary, it seems that Mother’s move to a hostel, and then into a private tenancy did not preclude further contact between them.  What is clear from the police visit is that the children were with Father in a clear breach of the agreement with CSC.    5.2.11 The panel considered the police and CSC response to this incident.  The police response was felt to be appropriate and in line with policies then in place.  It is not possible to reconcile the different version of events given by Father and Mother.  However, CSC records show that when Father was spoken to a few days later he told them he had made the incident up to get back at Mother.  The panel noted that is a tactic often used by perpetrators of domestic abuse to try and turn the tables on their victim.         Learning point 7: Perpetrators of domestic abuse will sometimes make false              reports to agencies claiming that they are the victim of abuse in an attempt to            mitigate their previous actions or make agencies doubt the word of the victim.    5.2.12 The panel considered the response by CSC to this incident which was to speak with Mother and renew the written agreement in respect of no contact with Father.  The panel questioned why a more robust response, such as seeking legal advice about removing the children, was not taken.  The records do not provide a rationale.  One possibility is that, because the incident occurred in the street and not the family home, it was felt the grounds for legal action may not have been sufficient.  Nonetheless, the panel felt this was still a clear breach of the agreement in place as the evidence from the police visit was that the children were in bed and therefore under the control of Father.   5.2.13 The panel felt the next incident in September 2011, when Blaire was left in the house by Father, was very different and should have been recognised as being a serious Page 19 of 33    escalation.  Not only was Blaire in contact with Father [in clear breach of all agreements] he had also been left alone.  The panel felt strongly that the response to this incident by CSC was not appropriate.  There is no record this event led to a CIN, child protection conference or strategy meeting.  There is also no indication that the voice of Blaire was considered.  The event should have been an opportunity to seriously question Mother’s ability to protect her children and for reasons the panel cannot establish why that opportunity was missed.    Learning point 8: Professionals need to be able to recognise the indicators of abuse and be able to accurately assess and document the risks that children face.  They need to understand when risk escalates and what are the appropriate responses to put in place so that risk is reduced or can be managed at an acceptable level.     5.2.14 As well as the risks that arose in relation to domestic abuse and the contact between the children and Father, the panel felt there would now be a very different response to the allegations Mother made about her father in July 2008.  While it seems the social worker recognised that Ash may be at risk and gave some advice, there is no record within CSC that the information was shared with the police. The police representative carried out a check and confirmed to the panel that police systems also contained no record of this event.   5.2.15 If Mother’s father was still alive at that time [there is no information to say whether he was or not] then he may have presented a risk to other people and in particular children he had access to [such as Mothers] as well as presenting a continuing risk to Mother herself. The social worker who received this information from Mother no doubt acted with integrity and in what they thought were the best interests of Mother. However, without sharing that information further with agencies such as the police, they were not in a position to assess and respond to this risks.   Learning point 9: Professionals need to recognise when they come into possession of information concerning historical sexual abuse which should be shared with other agencies.  Professionals need to understand the processes for responding to such information.  5.2.16 The panel were given assurances that much more would now be done to recognise, assess and respond to the potential risks such information contained. This would now include; a strategy discussion involving CSC, police and health; the recording of the information within agencies including the police crime recording systems; consideration of a joint investigation and discussion of the information at the core group and next child protection conferences.         5.3  KLOE 3: What confidence did professionals have in the children’s mother to safeguard and protect them?  What challenges did professionals make to the mother when they felt she may not have been complying with measures to safeguard and protect her children?  Was there any evidence of disguised compliance by mother and how did professionals respond if there was such evidence?  Page 20 of 33    5.3.1   Against this background of continuing risk to the children that has been discussed in KLOE 1 and 2, the challenge for both single and multi-agency working was to develop robust plans which primarily protected the children of the family from sexual abuse at the hands of Father, and in addition protecting them and Mother from the risk of domestic abuse by him.    5.3.2   Overall the panel felt that the plans put in place lacked robustness, primarily because they relied almost entirely upon Mother complying with written agreements not to allow Father to have contact with the children.  The evidence is that these agreements were frequently breached.  Written agreements should set out simply what sort of behaviour is acceptable and what is not; over time, they have become part of the accepted social work toolkit.  When used correctly, written agreements can have value.  However, in this case the panel felt their use failed to protect the children in the family for a number of reasons.  5.3.3   The first reference to an agreement being put in place was in December 2007 following the allegation of sexual assault by Ash.  The reason for this agreement was clear and that was to ensure Father did not have contact with the children while under investigation for this allegation.  Although no charges were brought against Father, a review child protection conference in March 2008 determined that he should continue to have no contact with the children.  It was at this meeting that the child protection category was changed from ‘sexual’ to ‘physical’ abuse.   5.3.4   The panel were supplied with copies of the six separate agreements that were subsequently made between Mother and CSC between 2008 and 2015 each of which contained a specific need to ensure Father should not have contact with the children and/or should not visit the family home.  Over time the content of these agreements varied from a few handwritten lines to a document set out in a template form.   5.3.5   However, none of the documents specified why the agreement was being made nor how the agreement would be monitored.  In most of the agreements there is no specific reference as to who is at risk from what, nor how the agreement was intended to remove or reduce that risk. For example the agreement from May 2008 refers to Mother; ‘continuing to prioritise the needs of Ash and the siblings. I will not allow their father into the house or allow unsupervised contact with him’  5.3.6   Exactly the same wording in respect of Father was used in the next agreement that was made in September 2008 following the assault upon Mother in June 2008.  It is unclear what was meant by ‘prioritising need’?  Neither was the risk clear-was it sexual abuse, physical abuse or both?  5.3.7   By September 2009 the agreement had changed. It stated that Mother would not allow Father to have contact with the children and that Mother was to inform the police if he came to the family home.  It also stated that Father would contact CSC for support with his violent behaviour if he wished to have contact with the children. The agreement specifically stated that; ‘the local authority will seek a gate keeping meeting if Mother continues to allow contact between Father and the above-named children’  Page 21 of 33    5.3.8   There is no evidence that Father ever made any attempts to seek support for his violent behaviour and in general he was uncooperative and misled agencies when he had contact with them.  By January 2010 this agreement had been breached.  Despite the clear terms of the previous agreement the records do not indicate any rationale as to why legal advice was not taken.  Instead it appears that the professionals involved took Mother’s word when she denied the contents of the police report.  Rather than escalating the issue it seems Mother was simply ‘advised of the importance of honesty’.   5.3.9   The breach of this agreement resulted in the making of a further agreement in March 2010. This was identical to the previous agreement except that the paragraph about seeking a legal gate-keeping meeting had been struck through.  Hence it was unclear what measures would be taken to escalate a response and manage the risk to the children if the agreement was breached.  5.3.10 Following the incident in September 2011 a further agreement was made with Mother.  This comprised a hand written note that stated;  ‘I agree that I will not under any circumstances allow my children to have face to face contact with their father….’I have been informed that failure to comply may result in a child protection conference being convened’   5.3.11  As discussed in paragraph 5.2.14, the panel believe this was a missed opportunity to seriously question Mother’s ability to protect her children.  This was a serious matter and Father had been arrested and cautioned for child neglect.  Making a further agreement in the light of the many broken ones in the past lacked any robustness. It was highly likely that it would fail to protect the children and it was therefore an inappropriate response.   5.3.12 The final written agreement was made in July 2015.  There is no indication within the agreement as to why it had been made although the inclusion of the term ‘unborn’ suggests it was made as a consequence of Mother’s pregnancy with Denny.  Despite the previous written agreements made by Mother that she would have no contact, he was now the father of her new baby.  Given the number of times that previous agreements had been broken, this latest agreement contains no specific reference as to what would be done differently this time given there had been no compliance with previous agreements.   5.3.13 The panel felt there was a repeated reliance by professionals on the information provided by Mother that she would not have contact with Father.  It maybe that in many other respects Mother was compliant.  For example she cooperated with CSC and health and presented well in her contact with some agencies. For example in respect of the first agreement attending a number of intervention activities such as Sure Start and the Freedom Programme.9  5.3.14 While cooperation with health and education was an important part of parenting, the greatest risk the children faced was from Father.  There is little evidence within the notes that professionals from CSC really challenged Mother or probed any deeper                                            9 a programme for women as victims of domestic violence, www.freedomprogramme.co.uk  Page 22 of 33    when all the evidence indicated that she continued to allow Father to have access to the children.  It is not clear why professionals allowed this to happen and left the panel questioning how many chances should someone be given when an agreement that is made to protect children is breached?    Learning point 10: When there is a failure to comply with the terms of a written agreement professionals need to ensure they do not simply repeat the same agreement and instead have measures in place to respond to that breach which provide a robust means of protecting children and removing or reducing the risk they face.       5.3.15 Since these events happened, Ofsted, along with fellow inspectorates for health, police and probation, have published a joint report about domestic abuse10.  One of the issues considered within there was the use of written agreements to help deal with domestic abuse.  A recent Ofsted blog suggests the time is now right to have a conversation about how and when written agreements should be used11. This research suggests written agreements are sometimes used in cases of coercive control, where responsibility for managing the risk to children is placed with the victim or they are made responsible for policing the behaviour of the perpetrator.  5.3.16 The report17 suggests that some agreements include terms like ‘the victim will not continue a relationship with her abusive partner’, ‘she will not allow him into the house’, ‘she will not be in contact with him’, and so on. Inspectors saw no evidence these agreements were effective and there is an argument that they may amount to putting the blame on the victim given the focus is not on the perpetrator.    5.3.17 Given the domestic abuse and coercive control that Mother experienced from Father, it may well be that Mother was in a situation where she also found it very hard to comply with the agreements for those reasons.  There is little, if any evidence, within the notes and information supplied to the panel that any professional discussed this possibility with Mother or considered the extent to which this may have been the case.  5.3.18 The research12 also found that many other serious case reviews criticised how written agreements were used. In particular that they placed unrealistic expectations upon the victim and; ‘One case highlighted that an agreement almost seemed to be a means of protecting the agency involved, rather than having the child’s safety at heart’  5.3.19 The research suggest that written agreements need to have the following key ingredients:  • Be specific and have clear expectations which parents genuinely understand;                                             10 ‘The response to children living with domestic abuse - Prevent, protect and repair’:  https://www.gov.uk/government/publications/joint-inspections-of-the-response-to-children-livingwith-domestic-abuse  11 https://socialcareinspection.blog.gov.uk/2018/01/23/effective-written-agreements/ 17 Ibid  12 Op cit ‘The response to children living with domestic abuse - Prevent, protect and repair’:  Page 23 of 33    • Underpinned by thorough assessment that is clear about risk and protective factors of all relevant adults and family members;  • They should be produced with parents who are equally committed to changing their behaviour  • There must be clarity on how the written agreement will be monitored and reviewed in accordance with multi-agency plans and how this will inform the assessment of risk and action taken;  • A clear focus should be on the work undertaken with family members to effectively manage risk and protect children - in particular work to change the behaviour of the perpetrator;  • The limitations of these agreements should be made clear.  5.3.20 It seems that in the case of this family, the written agreements provided no guarantee that the children would be protected from risk.  Far from the actions of Mother keeping them safe, her actions exposed them to increased risk by ‘allowing’ them to have repeated contact with Father.  This was not just unplanned passing contact, for example passing Father in the street, rather on at least two occasions Father had custody of one or more of her children with Mother’s knowledge.  5.3.21 Some professionals, such as a family worker who saw Father’s clothing in the house, appear to have had suspicions that Mother was not complying with the agreements.  Others, such as the manager who declined to sign off and approve the pre-birth assessment documented their concerns which led to a child in need meeting.  However, in most cases professionals appeared to fail to recognise the evidence that was available: that for whatever reason [and coercive controlling behaviour by Father was a strong possibility] Mother had consistently failed to comply with previous agreements.   5.3.22 The following passage succinctly summarises the dangers of relying upon written agreements;  ‘they [sic] were not found to be effective in reducing domestic violence incidents or indeed reducing risk and in some circumstances actually increased risk, giving false assurance to professionals about the safety of children….only the actions of parents and professionals can keep children safe - an agreement on paper provides no guarantee. But if professionals think children are safer than they are because an agreement is in place, there is a possibility they might take less action to mitigate risks13’      Learning point 11: The issue of written agreements has been raised in a previous SCR in this local authority area. Professionals need to exercise caution when using written agreements.  They should ensure they comply with the principles set out in the recent joint inspection concerning children who live with domestic abuse.  They should also guard against relying wholly on such an agreement as a means of protecting children and should ensure there are other plans or actions in place that ensure that if the agreement fails children are not exposed to increased risk.                                              13 Ibid  Page 24 of 33    5.4  KLOE 4: What evidence is there that professionals recognised sexually harmful behaviour in the children?  If they did, what evidence is there that they knew what do with that information?  Are there now robust multiagency processes in place for recognising, receiving and responding to such information?  5.4.1   There was one occasion of known sexually harmful behaviour. This occurred in November 2014 and involved Jordan. The panel scrutinised this event. The referral was made by a support worker who acted in accordance with their policy and training. It was clear the support worker recognised the seriousness of what they heard and demonstrated they knew what to do in response by referring the information into CSC.     5.4.2   Agencies then worked jointly to investigate the matter and in accordance with policies and procedures then in place. This included an initial assessment, convening Child Sexual Exploitation [CSE] meetings and a detailed, searching and robust criminal investigation. The panel did not find any failings or weaknesses in the way this was conducted.   5.4.3   A comprehensive multi-agency policy [published in 2018] is in place to ensure a robust response to the recognition, receipt and response to information concerning suspected or known CSE.  A detailed assessment of the extent to which agencies comply with this protocol is beyond the scope of this review. However, the panel noted that the SCB have internal arrangements in place for quality assurance. In addition there are both joint and single agency inspections by a number of external bodies in relation to child sexual exploitation in the area.   5.4.4   The panel were told that the SCB does not have a policy in place at the moment as to how professionals should respond to young people who display signs of sexualised harmful behaviour.  This issue has occurred in at least one other referral that has been made to the SCB. The panel felt it was important that professional understanding of this issue is increased and that training will form a fundamental part of improving knowledge. The panel heard that work has started on drafting the policy, which they welcomed, and they encouraged the SCB to identify a target date as soon as possible for completing this work.    5.5  KLOE 5: To consider if there were organisational or contextual obstacles or difficulties in this case which prevented agencies from fulfilling their duties.  For example, was there a loss of focus in this case because the emphasis was upon training professionals to recognise and respond to child sexual exploitation?  Did the multiple handovers between staff in this case have an impact?    5.5.1   The panel did not feel there were any organisational issues that prevented agencies fulfilling their duties in this case. This review has already acknowledged that many of the events go back some years. Consequently individual agency structures, posts and personnel have changed.   5.5.2   Although inter-agency cooperation and working together was in place at the time of these events, the panel were told that contemporary practice is that safeguarding Page 25 of 33    concerns such as these are now shared and discussed by agencies at a much earlier stage. There is also now a greater emphasis on joint investigations involving CCS and the police.   5.5.3   The principle failings in this case relate to the fact that, despite known and documented concerns that Father posed a threat of sexual harm to the children, he continued to gain access to them over a period of almost twenty years. The plan to protect the children relied almost entirely upon Mother fulfilling an agreement that she would not allow Father to visit her home or have access to the children. This failed, but not because of organisational issues.   5.5.4   As discussed within KLOE 3, that agreement was repeatedly breached. Part of the plan, if the agreement was breached, was to escalate the case and take legal advice about care proceedings. That never happened. No procedural or legal obstacle have been identified to which would have prevented such action being taken.     5.5.5   As discussed earlier, professionals knew that Mother was the victim of domestic abuse at the hands of Father. Her abuse was an enduring feature, and it was right to try and protect her and the children from it. However it was not the most significant risk. There was a loss of focus upon the risk of sexual harm to the children and instead a shift towards regarding the risks they faced from Father as being only physical.   5.5.6   It is not clear why that loss of focus occurred. There are several possibilities. One is that its genesis was in the decision made in March 2008 to change the category of harm in the Child Protection Plan from ‘sexual’ to ‘physical’. That in turn may have led to a shift in focus when the decision to remove the children from the Child Protection Plan in 2009 was made.  5.5.7   Here there is no reference within the notes of the meeting to any allegations or suspicions of sexual abuse. Instead, under the heading of ‘Continuing Risk of Significant Harm’ the notes refer to; ‘The children had become subjects of Child Protection Plans due to concerns that they were at risk of physical abuse not only from Father but also from Mother’s new friends who had assaulted her’.  5.5.8   A further possibility is that, because several years passed between the first allegations made by Ash and then those made by Casey [that led to the conviction of Father], the risk of sexual abuse of the children somehow slipped down the order of risk in the mindsets of some professionals.  One reason for this may have been that over those years there were a number of changes in the professionals who had responsibility for responding to the needs of the family.   5.5.9   Such changes are inevitable and unavoidable in such a large and complex service as CSC.  In such a situation it is easy to understand how the detail that one professional can pass to another in a face to face briefing is replaced by reliance upon much briefer and less contextualised entries from a computer system.  In such a scenario it is easy to see how, for example, the decision to change the category of harm in a Child Protection Plan [for whatever reason] from ‘sexual’ to ‘physical’ harm might have implications some years later.     Page 26 of 33    5.5.10 A further factor that may have impacted upon a loss of focus in this case was Mother.  While the professionals who dealt with her changed, the consistent voice over the years was Mother herself.  It is possible that, rather than checking back over the facts contained in records, professionals relied too much upon Mother’s version of events when decisions were made.    5.5.11 As discussed in KLOE 1, Mother made a conscious decision not to tell the locum doctor that Casey was being sexually abused by Father.  There are many reasons she may have done that, one being that she was subject to coercive and controlling behaviour by Father as part of a pattern of domestic abuse.  There are other examples within this case when Mother seems to have failed to disclose important or relevant information. For example when attending the ante-natal appointment and denying she had any previous involvement with social care.   5.5.12 Whether Mother acted in the way she did because she was subject to coercion and control, the fact is that she was undependable.  Over the years this may have led to important facts being omitted by her in order to steer professionals away from concerns about them.  As such professionals should have exercised a much higher degree of scrutiny about what she said and the undertakings she made.  They should have looked for other information which they could use to test the veracity of what Mother said.    5.5.13 There is no evidence from within the records that Mother was ever referred or offered support by an independent domestic violence advocate [IDVA]14.  Some of the events in this case pre-date the introduction of IDVA’s.  As a repeat victim of domestic abuse, access to a professional with a good understanding of the dynamics of coercive and controlling behaviour, may have helped explain and understand why Mother acted in the way she did.     Learning point 12: Providing the victims of domestic abuse with access to an IDVA, will help other professionals recognise and respond to the impact of coercive and controlling behaviour.     5.6  KLOE 6: To review and consider: the procedures in place for referral of potential serious case reviews to the unnamed local authority SCB Critical Group; the professional’s understanding of these procedures; why it took over two years for this family to be referred to the Critical Group.  5.6.1   Within the SCB area there is a SCB Sub Group responsible for undertaking and establishing the need for a Serious Case Review (SCR). This group is made up of representatives from all of the agencies within the SCB.                                              14 Independent Domestic Abuse Advisors (Idvas) support victims of domestic abuse to become safer, sooner. They work tirelessly to be an advocate for victims at their most vulnerable. When someone discloses about an abusive partner/ex-partner/family member – they may need to engage with a whole host of confusing and sometimes conflicting services: the courts, probation, housing, mental health, children services, substance misuse. It is never as simple as ‘just leave’. Idvas are their rock; they navigate these services. They work with local specialist services to provide longer-term support for women. They don’t talk for victims of domestic abuse, but in partnership with them.   http://www.safelives.org.uk/news-views/16days/why-idvas-are-so-important  Page 27 of 33    5.6.2   The SCB has procedures which are available on line as an open source document. The panel viewed these and they clearly set out the criteria and processes for notifying and undertaking an SCR. Referral of cases to the group is set out within that document. In summary, the process starts in one of two ways. In the first case where a strategy meeting is held, at the summary of the meeting, attendees should be asked whether they consider that the circumstances of the case requires consideration by this group for the undertaking of a serious case review. If it is agreed that the case warrants referral the Chair is responsible for sending the SCR Request for Consideration form to the Chair of the SCB Sub Group and SCB Business Manager.   5.6.3   In other cases if a professional, following review with their agency safeguarding lead, consider that a case requires consideration by SCB Sub Group to undertake a CSR, the agency safeguarding lead should refer a summary of the case using the CSR Request for Consideration form to the Chair of the SCB Sub Group and the SCB Business Manager.   5.6.4   The review panel heard that it was Youth Services who submitted a referral notification to the sub group in this case.  The panel heard that a number of other agencies held much more information which should have led to these agencies submitting notifications much earlier.  The panel were not able to identify why that did not happen.  The panel heard there is a general lack of understanding about the referral process among local professionals; this is borne out by the disproportionately low number of referrals that the SCB Sub Group receives for the size of the SCB. The review panel felt this identified a need to train professionals in understanding how the referral process works.       Learning point 13: Appropriate and timely use of the procedures in place for referral of potential serious case reviews to the SCB Sub Group ensures that opportunities for learning and improving the safeguarding of children are not lost.    5.7  Is there any evidence that professionals and/or agencies worked in isolation?  What evidence is there that professionals recognised the value of isolated pieces of information and the impact such information may have had on assessing the risk children faced?  Did professionals know how to share information that impacted upon risk with other agencies?   5.7.1   Overall there appears to be evidence of good interagency cooperation and working together.  As discussed earlier, these events span a period of nearly twenty years during which there have been significant changes to the way in which agencies work together to protect children.  While there were some instances where information was not shared, for example the incident in January 1998, there were many other examples of good joint working with agencies engaging in the child protection conferencing process and undertaking joint visits.   5.7.2   On most occasions relevant information was shared between agencies.  For example the police made referrals to CSC on all of the occasions that they were called to attend incidents of domestic abuse or neglect.  There were also examples of individual professionals recognising the importance of discrete pieces of information Page 28 of 33    and then sharing it. For example, the occasion when Mother attended a booking in connection with the birth of Denny and denied any previous contact with CSC.     5.7.3   However there were some examples when agencies did not recognise the value of information and how to share it.  A significant example of this was when Mother disclosed to a social worker and health visitor that Father had tried to strangle her.    5.8  Were the conditions for children to disclose information about abuse supportive towards them?  Were there any barriers in place that might have prevented the children disclosing abuse?    5.8.1   Some of the events in this case predate the Children Act 2004 which places a duty on local authorities to ascertain the child’s wishes and feelings and the framework for involving children in Working Together to Safeguard Children (2010).  The principles of which are15;  • Developing a direct relationship with the child and gather information from the child about his or her needs or situation;  • Eliciting the child’s wishes and feelings;  • Providing children with honest and accurate information about what is happening and future possible actions;  • Inviting children to make recommendations about services and support they need;  • Ensuring that children have access to independent advice and support that enable children to express their views and influence decisions.  5.8.2   In this case it appears to be the voice of Mother that is the most prominent and there are few examples of the voices of the children shining through.  There is limited evidence that the children were spoken to when key events occurred although there were missed opportunities to be on the front foot by speaking to the children first.  For example when Blaire was locked in the house by Father.  There was an immediate response from the police and the out of hours service.  There is reference in the notes to the children ‘presenting well’ and a recommendation a further assessment takes place.  There is no information in the notes to indicate the opportunity was taken to speak with them individually that night. That meeting did not take place for a further three weeks by which time it is possible that Father’s continued coercive and controlling behaviour limited the children’s ability to express what they felt.  Overall, the picture presented within the notes and chronologies provided to the panel are that the relationship was predominantly with Mother.  5.8.3 For example the notes of the February 2009 Child Protection Conference contain information about Mother’s attendance at various courses and her home conditions. In the minutes Mother is ‘congratulated on her achievements’.  The heading ‘Views of Children/Participation in Conference’ contains the single sentence; ‘The views of the children were not heard at conference’                                             15 The voice of the child in the child protection: Ivana La Valle, Lisa Payne and Helena Jelicic, NCB Research Centre June 2012  Page 29 of 33    5.8.4   Although Mother received counselling, until the arrest of Father in 2016, there was only one occasion when any of the children were offered it or any form of independent advocacy.  This was when Ash was offered anger management and sexual abuse counselling following the allegation they made against Father in 2007.  While Ash attended the anger management element they declined to attend sexual abuse counselling.  There is no information in the notes to indicate why they made this decision.  In the light of what is now known about Father’s coercive and controlling behaviour this raises the question as to whether Ash was making a free choice in this matter.      5.8.5   A member of the panel shared important research that they felt would help understand the barriers children can face in such cases16; ‘Professionals need to keep in mind that any child could be attempting to disclose, but certain children may face additional barriers to disclosure because of their disability, gender, ethnicity and/or sexual orientation. The act of disclosing sexual abuse can heighten shame and guilt. Other negative reactions to disclosures may compound these impacts. This should not stop professionals from providing opportunities to children to disclose, but it is essential that children and their families receive appropriate support following disclosure. A range of complex and interacting individual, relational and social barriers may prevent children from disclosing abuse, to professionals or anyone else’. It appears the greatest barrier to the children making disclosures was the continued presence of Father in their lives and the ever-present issue of him perpetrating domestic abuse upon Mother and the children’s exposure to this. This issue has been explored earlier when, for example, Ash told a social worker that they were worried about Mother knowing what had been disclosed and of violence between their parents.  5.8.6   We now know that some twelve months before Father was arrested and finally prosecuted, Casey had disclosed to Mother that they had been raped. Mother chose to deal with the matter herself keeping it within the family and taking Casey to see the GP.  The reason Mother chose to do so is not clear although it is possible she was in fear of Father17.  This may also have placed a barrier before Casey, who may have been fearful of what Mother or Father would do if they made a disclosure.  The presence of Mother in the GP surgery when Casey was seen by the doctor would also have been a barrier to Casey disclosing their victimisation.  This reinforces the importance of understanding the impact that coercive and controlling behaviour has in a relationship, not just upon the victim, but also upon the children in the family as well.                                              16 ‘Key messages from research on identifying and responding to disclosures of child sexual abuse’: September 2009 Debra Allnock, The International Centre: Researching child sexual exploitation, trafficking and violence (University of Bedfordshire), Pam Miller and Helen Baker, NSPCC www.csacentre.  17 ‘Much abuse in the family remains undisclosed. Children may fear their abuser, not want their abuser to get into trouble, feel that the abuse was ‘their fault’, and feel responsible for what will happen to their family if they tell…Abuse by a family member may be particularly traumatic because it involves high levels of betrayal, stigma and secrecy’   Page 30 of 33              Learning point 14: Professionals need to recognise the impact that coercive and controlling behaviour can have upon both the victim and the children in a family.  It is important to understand the impact this may have upon the voices of the children and their ability to offer an accurate picture of what is going on within their lives.      Concluding Remarks   6.1 The key events set out in this case cover nearly twenty years during which there have been considerable changes in the way in which single and multi-agency working safeguards children which would now mean professionals approach these events in a different way. The case has not identified a significant contravention or action by any professional that was a critical factor that exposed the children in the family to the risk of abuse at the hands of Father.    6.2 The learning in this review centres around a theme seen in many other SCRs: the need for professionals to scrutinise and challenge the evidence before them and exercise professional responsibility.  In this case, despite repeated agreements to ensure Father did not have contact with the children, this continued to happen.  Rather than challenging Mother, professionals seemed to accept her word that she would comply and agreements were simply repeated without any escalation to alternative methods to protect the children.                                                             6.3 The other piece of significant learning concerns the need for a better understanding of domestic abuse and the impact of coercive and controlling behaviour upon the voices of both the victims and children in these cases.  Again, professional training and understanding of domestic abuse has advanced significantly since the earliest events in this case.  6.4 Despite the changes that have taken place over the years, the learning from this review invites contemporary professionals to reflect on their practice and ensure that, if faced with these events now, they would recognise the opportunities to act in different ways so as to safeguard children such as those in this family.    7. Summary of Learning and Recommendations  7.1 Learning  Learning point 1: It is important to ensure that records contain sufficient detail and a rationale as to the actions and decisions professionals take when undertaking visits and investigations.  Key messages from research on intra-familial child sexual abuse: June 2018 Di McNeish and Sara  Scott, DMSS Research www.csacentre.org.uk   Learning point 2: All professionals need to act with caution when a victim makes a ‘retraction’ statement.  They may have made this statement because they felt under duress or for other reasons.  Just because a victim makes a retraction statement Page 31 of 33    does not mean that they are no longer at risk.  Professionals need to assess risk based upon all the information and evidence available.  Learning point 3: Sexual abuse is a possible cause of vaginal discharge. Professionals should have regard to NICE guidance [Child maltreatment: when to suspect maltreatment in under 18s], consider the possibility of sexual abuse in such cases and ask questions about the family history so as to elicit or exclude any relevant information that may lead to the making of a referral.      Learning point 4: Timely sharing and/or recording of information about relevant incidents ensures that professionals can respond promptly to assess risk and protect vulnerable persons.  Learning point 5: Placing hands around a victim's throat and/or attempted strangulation significantly increases the risk of harm to a victim.  Professionals need to recognise all facets of domestic abuse and know how to respond to such information and when such information should be shared with other agencies.  Learning point 6: Undertaking a recognised risk assessment process allows behaviour such as this to be recognised and then a referral made to MARAC.  Consideration at MARAC allows all relevant information to be triangulated and protective measures to be put in place which may include criminal justice sanctions.   Learning point 7: Perpetrators of domestic abuse will sometimes make false reports to agencies claiming that they are the victim of abuse in an attempt to mitigate their previous actions or make agencies doubt the word of the victim.  Learning point 8: Professionals need to be able to recognise the indicators of abuse and be able to accurately assess and document the risks that children face. They need to understand that when risk escalates appropriate responses are identified and put in place so that risk is reduced or can be managed at an acceptable level.  Learning point 9: Professionals need to recognise when they come into possession of information concerning historical sexual abuse which should be shared with other agencies.  Professionals need to understand the processes for responding to such information.  Learning point 10: When there is a failure to comply with the terms of a written agreement professionals need to ensure they do not simply repeat the same agreement and instead have measures in place to respond to that breach which provide a robust means of protecting children and removing or reducing the risk they face.    Learning point 11: The issue of written agreements has been raised in a previous SCR in this local authority area. Professionals need to exercise caution when using written agreements.  They should ensure they comply with the principles set out in the recent joint inspection concerning children who live with domestic abuse.  They should also guard against relying wholly on such an agreement as a means of protecting children and should ensure there are other plans or actions in place that ensure that if the agreement fails children are not exposed to increased risk.  Page 32 of 33    Learning point 12: Providing the victims of domestic abuse with access to an IDVA, will help other professionals recognise and respond to the impact of coercive and controlling behaviour.  Learning point 13: Appropriate and timely use of the procedures in place for referral of potential serious case reviews to the SCB Sub Group ensures that opportunities for learning and improving the safeguarding of children are not lost.  Learning point 14: Professionals need to recognise the impact that coercive and controlling behaviour can have upon both the victim and the children in a family.  It is important to understand the impact this may have upon the voices of the children and their ability to offer an accurate picture of what is going on within their lives.  7.2  Recommendations  Recommendation 1 [Learning points 1 and 4]:  The SCB Board seeks written evidence from partner agencies that they have processes in place to ensure their records capture the detail and rationale for actions and decisions made by professionals when undertaking visits and investigations in respect of the safeguarding of children and have processes for timely sharing of information about these incidents with other agencies.  Recommendation 2 [Learning point 2]:  The SCB Board seeks assurance from the police force in their area that when the word ‘retraction’ is used in connection with an investigation, the reasoning behind that decision is documented in police records and when shared with other agencies.  Recommendation 3 [Learning point 2]:  Agencies belonging to the SCB ensure that professionals responsible for the safeguarding of children receive training on the issue of ‘retraction’ so that they understand why victims may follow this path and the impact ‘retraction’ may have upon any criminal justice processes.  Recommendation 4 [Learning point 3]  The SCB Board seeks assurance from the CCG in their area that the NICE Guidance around child maltreatment and when to suspect maltreatment in under 18s has been implemented.  Recommendation 5 [Learning point 5, 6, 7, 12 and 14]  Agencies belonging to the SCB ensure that professionals receive training in the following aspects of domestic abuse;  [i] The use of risk assessment for domestic abuse including an understand of the issue of placing hands around victims’ throats and how this can increase risk;   [ii] The fact that perpetrators of domestic abuse may make false reports of domestic abuse and the impact upon victims;   Page 33 of 33    [iii] The recognition of coercive and controlling behaviour as a facet of domestic abuse and how it can impact upon the risk to children and their voices;   [iv] The IDVA and MARAC processes, and how to refer victims.   Recommendation 6 [Learning points 8, 10 and 11]  The SCB Board seeks evidence from partner agencies that their professionals understand how to recognise, assess and respond to indicators of, and escalation of, risk to children.  This should include assurance that professionals understand how to make appropriate use of written agreements as a means of protecting children and how to respond when agreements are breached.    Recommendation 7 [Learning points 10 and 11]  The SCB Board undertakes an audit so as to ensure that written agreements as a means of protecting children are being used appropriately and in accordance with the guidance issues by Ofsted.   Recommendation 8 [Learning point 9]  The SCB Board seeks assurances from partner agencies that they have processes in place for receiving, recording and responding to cases of historical child sexual abuse.   Recommendation 9 [Learning point 14]  The SCB Board seeks assurance that partner agencies have trained professionals in the timely use of the procedures in place for referral of potential serious case reviews to the SCB Sub Group.   