Death of an adolescent boy due to a fatal stabbing in January 2020. Learning includes: professionals tackling child criminal exploitation need to know and understand the serious youth violence strategy, engage with families, have a comprehensive knowledge of the National Referral Mechanism and be alert to a 'reachable moment' for a child; professionals need to understand the impact of adverse childhood experiences on children and how to deal with these using a trauma informed approach; professionals need to understand what 'place' means to a child and how that influences their lives; preventing school exclusion is a good preventative move because being in education is a safe place for children to be; educate children as to the dangers of knives and being involved in gangs and serious youth violence because this can prevent future exploitation; consider using a 'think family' approach; health agencies have limited occasions to intervene and so should capitalise on them where possible; children who go missing should have a return home interview.
      
 Title:  Local child safeguarding practice review: BSCP 2019-20/02. LSCB: Birmingham Safeguarding Children Partnership Author: Russell Wate Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Local Child Safeguarding Practice Review  BSCP 2019-20/02 Lead Reviewer:  Dr Russell Wate QPM Published 21st September 2021   2 1.        Introduction  The subjects of this Child Safeguarding Practice Review (CSPR) are Child A and Child B.  Although a number of other young people are involved with them, they will only be referred to contextually within this report to ensure the focus for learning is from Child A and Child B’s lived experiences.               In January 2020, Child A and Child B and a third young man (aged 18) all from the Birmingham area, were together in a different area of the country and whilst there were involved in a violent assault.  The incident resulted in the fatal stabbing of Child A and serious injury to the 18-year-old, who sustained a stab injury to his torso damaging his liver. Child B was able to get away from the scene of the incident and received no physical injury.               All three of these young people were believed to have been involved in an urban street gang from an inner-city neighbourhood in Birmingham.  It is strongly suspected by the police from their investigation that the purpose of the young people’s visit concerned the supply of controlled substances in a method that is frequently and now commonly referred to as ‘County Lines’.1 The Police undertook a criminal investigation to establish the circumstances surrounding the incident. Further details of this incident are not detailed within this report other than to identify the extent of the influences that these children appear to have been under at the time of the death of Child A. The perpetrator has been brought to justice, together with three individuals who have been convicted of perverting the course of justice.  All four received substantive custodial sentences.                 The aim of this review is to identify learning improvements that can be made to help safeguard children and to prevent, or reduce the risk of recurrence of, similar incidents. The review team and the author have undertaken an objective analysis of what happened and why, suggesting learning, bearing in mind that the criminal exploitation of children quickly evolves at the hands of organised crime gangs.               In supporting the terms of reference and gaining an understanding of the national as well as local perspective, the author has considered the County Lines Exploitation non-statutory guidance for practitioners published by the Ministry of Justice in 2019 and the legislation in respect of modern slavery, in particular the statutory defences. This states that:              Child Criminal Exploitation is common in County Lines and occurs where an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child or young person under the age of 18. The victim may have been criminally exploited even if the activity appears consensual. Child Criminal Exploitation does not always involve physical contact; it can also occur through the use of technology.”  1 County Lines is defined in the Serious Violence Strategy 2018 as a term used to describe gangs and organised criminal networks involved in exporting illegal drugs into one or more importing areas within the UK, using dedicated mobile phone lines or other form of ‘deal line’. They are likely to exploit children and vulnerable adults to move and store the drugs and money, and they will often use coercion, intimidation, violence (including sexual violence) and weapons.   3 2.   Terms of Reference, Contributions and Methodology A Child Safeguarding Practice Review (previously known as a Serious Case Review) is governed by Chapter 4 of Working Together 2018, which states:  When a serious incident becomes known to the safeguarding partners, they must consider whether the case meets the criteria for a local review. This includes whether the case: • Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified. • Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children. • Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children.  The BSCP Serious Cases Sub-Group agreed that the period to be examined within this review will be from early 2018 up until the incident in early 2020, looking at the extent and impact of agency involvement with Child A and Child B and their families during the last two years leading up to the incident which culminated in the death of Child A.    Key Issues to be addressed by the review agreed by the Serious Cases Sub-Group:   • Is Birmingham’s current approach to young people involved in ‘County Lines’ working? • Where there is a discontinuance of criminal proceedings (National Referral Mechanism, NRM), what intervention should this trigger? • How effective is the Birmingham Community Safety Partnership ‘One Day One Conversation’ in identifying and managing risk? • What can we learn about the interface between criminal exploitation and young people’s affiliation with gangs and knife crime?     Contributors to the review  A number of agencies from Birmingham have contributed to this review. The review author was very taken with their knowledge, passion, and commitment to make a difference for the   children of Birmingham involved in similar circumstances. The compilation of this report also benefited greatly from the two practitioner events held with individual professionals that had worked with both Child A and Child B.      4 Membership of the Review Team  Birmingham Safeguarding Children Partnership commissioned an independent author to carry out the review. The review is supplied by RJW Associates and the lead reviewer is Dr Russell Wate QPM. He is independent of any agency within Birmingham. He is a retired senior police detective, who is very experienced in the investigation of homicide and in particular child death. He has contributed to a number of national reviews, inspections, and inquiries, as well as being nationally experienced in all aspects of safeguarding children. He was one of the reviewers of the National Child Safeguarding Practice Review Panel report ‘It was hard to escape - Safeguarding children at risk from criminal exploitation’ (March 2020). He has carried out a large number of Serious Case Reviews (SCRs) and is also an independent chair of a Safeguarding Children Partnership.  Review Team members  The review team members were all really experienced and supported the review author greatly in the production of this report and the learning developed.  Agency Team Manager, CASS & MASH Education Officer, Birmingham City Council (BCC) Head of Service, Birmingham Children’s Trust (BCT) Deputy Designated Nurse, Birmingham & Solihull CCG Head of Service, Contextual Safeguarding Hub, BCT Assistant Head of Service, Youth Offending Service, BCT Detective Inspector, West Midlands Police Independent Author  The review process was also supported by two practitioner learning events (one each for Child A and Child B). The review process was strengthened further by the benchmarking exercise which was held with the Gangs, Violence and Serious Organised Crime Strategic Board.   3. Summary of the case: What happened in the lives of Child A and Child B? Child A: Background  Child A was the eldest in his family, and he lived with them in an inner-city neighbourhood in Birmingham. At infant and junior School, he had a fluctuating attendance with a large number of unauthorised absences. Birmingham Children’s Trust (BCT) received a referral that he and his mother presented as homeless following eviction: she had rent arrears and the housing team felt she had deliberately made herself homeless from her previous address. BCT provided temporary bed and breakfast pending permanent accommodation. Mother also had concerns during his primary years that Child A had ADHD and he was taken to the GP who made a CAMHS referral for him. Mother was concerned about his ‘hyperactive’ behaviour, with violent outbursts at school and no sense of danger. He attended CAMHS once after which he ‘was not brought’.   5  Child A attended primary and secondary education provision ending when he was 16 years old. Since that time, he appeared to have been NEET.2 His siblings are all younger and currently of school age.   Child A in 2016 started at an engineering academy, albeit his attendance was extremely poor, dropping to a little over 50% by the end of his time there. The school indicated that Child A effectively disengaged from school life. Despite pastoral intervention it was not clear what had motivated this lack of engagement for him.  Child A was registered intermittently as requiring Special Educational Needs (SEN) support whilst at school. This support was to require management in school only, with no need to refer to other professionals and was required for his Behavioural, Emotional and Social Difficulty. It is recorded that there were periods where no support was provided at all.   Child A was known to several agencies during his life. In summary of his involvement in criminal activity, police records indicate that Child A first became known to the West Midlands Police (WMP) due to the theft of a pedal cycle when aged 13 years old. A pattern of significant and rapidly escalating offending follows, and it is unknown if any referrals were made to other agencies. This continued and he was involved in several incidents where there was evidence of violence and weapons. Those occurrences were in spring 2018 and late summer 2018 although no action was taken against Child A.  Early in 2019, Child A was searched following a report made to the police. A large hunting knife and bags of herbal cannabis were discovered in his possession. He failed to make his first court appearance following him being charged with those offences and he was arrested before being further bailed. Child A was subsequently convicted of both offences and received a 12-month referral order and a fine.  In Spring 2019, Child A was one of several young people arrested following the pursuit of a stolen vehicle and which was also linked to another violent crime. A large machete was found after they fled the scene. Child A was arrested. He was subject of bail and curfew checks by the police. At the time of his death, the offences remained under investigation and review by the Crown Prosecution Service. From Summer 2019 Child A’s case was managed by the Police Offender Management Team as a ‘Deter Youth Offender’ (DYO) and continued as a DYO from Autumn 2019. This included additional wrap-around management based on his emerging risk around re-offending.  He was also referred into ‘One Day One Conversation’ offender management system, which resulted in allocation of the Police Offender Manager working with him and his family alongside the Youth Offending Service Case Manager, Substance Misuse Worker and Youth Offending Service Training and Employment Officer.  He was not known to Birmingham Children’s Trust (BCT) but was open to one of the Birmingham Youth Offending Teams and had an appointment scheduled for the day after his tragic murder.   2 Not in Education, Employment or Training   6 In summer 2019, Child A ran off upon seeing police officers, was pursued, and stopped.  He was found to be in possession of two ‘joints’ of cannabis.  A Community Resolution was administered but subsequently rejected as Child A had been convicted earlier in 2019 of the same offence.  This case was then raised for a postal charge, but this action was never taken, and the matter remains outstanding.  The common thread of many of those recorded occurrences is that Child A was apparently associating with other males of a similar age to himself and the underlying issues involved violent crime, weapons, and the supply of illegal drugs. These incidents are indicative of potential ‘gang’ involvement although not specifically directly indicative of ‘County Lines’ criminality.    Child B: Background  Child B is the second child of siblings living with their mother, a single parent. In 2016, the family moved to Birmingham from another local authority area. He had poor school attendance and was excluded for an assault on a teacher. The family came to the UK from a European country and would appear to be currently here illegally, with no right to remain. Whilst living in Birmingham several concerns manifested themselves in respect of neglect, poor hygiene and home conditions and the permanent school exclusion of Child B.  There is significant evidence of Child B being involved in ‘County Lines’ with him being located by the police in different regions of the country. This happened on five separate occasions where on each occasion, he was found with a combination of quantities of Class A drugs, money, and offensive weapons. In respect of each of those occasions Child B was missing from home, and it should also be noted that he had never been reported as missing by his family.  Early in 2018 Child B (15 years old) was found at an address away from his home area following the execution of a drugs search warrant.   As a consequence of a number of safeguarding concerns, a strategy meeting concerning the family was held in Spring 2018 and an Initial Child Protection Conference held where all the children of the family were made subjects of a Child Protection (CP) plan. The mother was reported to be “hostile” to agencies and refused to engage with the plan, as did the eldest sibling.  Shortly after the CP plan commenced, Child B went missing from home and on this occasion, was found by the police in another area some distance from his home area in possession of Class A drugs and money. He was charged with a number of offences. The case against him was discontinued in winter 2018 following a positive response to the request for him to be awarded a National Referral Mechanism status (NRM)3.  3 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. Further information about the NRM is available here: https://www.gov.uk/government/publications/humantrafficking-victims-referral-and-assessment-forms/guidance-on-the-national-referral-mechanism-for-potential-adult-victims-of-modern-slaveryengland-and-wales   7  In summer 2018, Child B was arrested on suspicion of robbery, possession of drugs and possession of an offensive weapon as a passenger in a vehicle, which had been stolen in a car-jacking the previous day when a firearm was used.  Child B was found to be in possession of cannabis and a knife. Child B received a youth conditional caution for possession of cannabis and possession of a bladed article in a public place. No further action was taken against him for other offences owing to insufficient evidence.  Early in 2019, Child B was arrested in a different area of the country and it was identified that there were concerns he was being exploited and involved in ‘County Lines’ drug dealing.  In spring 2019, Child B was arrested in another different area of the country on suspicion of supplying Class A controlled drugs.   The information presented suggests that there is unequivocal evidence to show that Child B was immersed in criminality, specifically the supply of Class A controlled drugs. This is indicative of behaviours typically associated with exploitation of children in ‘County Lines.’   Child A and Child B associating together  There is some evidence that Child A and Child B associated with each other and this is known to have dated back to winter 2017. On that occasion, they were part of a larger group of males stopped and searched by police officers following a report of a group of teenagers seen with a large knife.   It is also apparent that there is commonality in that the two of them were frequently either directly involved in criminality or on the periphery of crime committed by associates. It is not apparent that there was any inference of County Lines influences on either of them at this time in late 2017, but this definitely started to develop for Child B shortly afterwards.  It is of note that there was an inference of gang affiliation and influences exercised from a very young age on both Child A and Child B which may be a pre-cursor to the wider coercion and control experienced by them both as they grew older. This applies in particular to Child B, whose immersion within County Lines appears far greater than that of Child A, taking account of the information provided to the review.    4. Analysis of the Terms of Reference Is Birmingham’s current approach to young people involved in ‘County Lines’ working?  Birmingham’s current approach is extremely extensive, particularly if you consider it from a strategic perspective. The approach is that Birmingham Children’s Partnership has a strategic responsibility for the coordination and continuing development of the City’s response to   8 contextual safeguarding.4,5  The Chief Executive of the Birmingham Children’s Trust is the strategic lead for the Children Partnership intervention through the Contextual Safeguarding Board which they co-chair with the East Birmingham Area Commander and Children’s lead. The board includes the Birmingham Community Safety Partnership sub-group and the Gangs, Violence and Serious Organised Crime Strategic Board, and work in conjunction with the Youth Offending Service.  There is also the Violence Reduction Unit operating across the West Midlands area, which also operates extensively in Birmingham.  The Birmingham Safeguarding Children Partnership and the Gangs, Violence and Serious Organised Crime Strategic Board jointly commissioned an independent ‘Deep Dive’ review relating to two ‘County Line’ cases. The review was completed in June 2019 and identified important learning around the death of a young male in Oxford and a second young male who sustained life changing injures. The findings have helped inform the on-going development of the City’s response to knife crime and ‘County Lines’.  This review has taken account of the findings of this ‘Deep Dive’ and the action plan that resulted from it.  In October 2019, the partnership established a Contextual Safeguarding Hub (now called EMPOWER U Hub) in order to maximise real-time information and intelligence sharing, with the aim to better target inter-agency intervention.  Birmingham has also successfully applied to be part of the Department for Education (DfE) ‘Tackling Child Exploitation’ programme, working alongside Research in Practice, The Children’s Society, and the University of Bedfordshire. This work will inform the continued development of the City’s approach to tackling County Lines and Contextual Safeguarding.  It is clear to the review author from an operational perspective that a great deal of work and effort went into trying to help the children and the families of both Child A and Child B. The EMPOWER U Hub at the front door of Children’s Services is beginning to make a difference, but more needs to be done to link up with young people. EMPOWER U is the official name of the Exploitation and Missing Hub based within MASH and includes representatives from Birmingham Children’s Trust (Exploitation and Missing Co-Ordinators, Youth Offending Service and Social Care) as well as West Midlands Police, Health, Education, and other agencies such as Barnardo’s, The Children’s Society and Probation.  The result of all the effort though was limited in protecting Child B from involvement in ‘County Lines’, as highlighted by one of the professionals at the practitioner event, who suggested that the current approach needs to be more pre-emptive or proactive and procedures need to be clear and robust with more contextual assessment; they are still, in the main, reactive to specific incidents. That said, it must be acknowledged that those endeavours reflect the complexities that are involved in these situations and how crucial it is that a much wider intervention requiring key stakeholders and others, including family and third-party influences, is needed. It is of note that the formation of the EMPOWER U Hub  4 Contextual Safeguarding as a concept was developed by Carlene Firmin at the University of Bedfordshire to inform policy and practice approaches to safeguarding adolescents. It is an approach to understanding and responding to young people’s experiences of significant harm caused from outside their families. 5 As well as threats to the welfare of children from within their families, children may be vulnerable to abuse or exploitation from outside their families (Working together 2018).   9 came towards the end of this review period and if it had been in place earlier, may have made a difference to these two boys, Child A and Child B.   In Child A’s case, his offending profile was somewhat different from that of Child B as he was not discovered in other areas of the country like Child B was. Although there is information that they associated with each other, there is little evidence that they were close associates, and their association does appear to be by influence rather than their own design.  ‘County Lines’ is a significant national issue and the complexity and organisation behind the criminality involved goes considerably beyond looking at the individual circumstances of Child A and Child B.   The review author is fully aware of the issues that Birmingham and the West Midlands face and feels that this should be taken into consideration, as the analysis needs to be balanced, take account of the context that agencies and professionals are working in and must also avoid hindsight bias.   A National Crime Agency publication regarding ‘County Lines’ (2019) states:   …that currently, the biggest [drug] exportation area outside of the Greater London area, is the West Midlands and there is little doubt that this is influenced by a number of factors which reflect the scale of the population, income deprivation and the ability of the criminals to influence young people quickly and effectively within communities who are vulnerable to the lure and promises of rewards. This is an additional problem to ‘gang’ culture, which although closely allied to drugs and drug supply and adds another layer to the vulnerabilities of young people, County Lines are well-organised and a growing problem.   The influences of home life can be critical to assist professionals early on in tackling vulnerabilities within the Child A and Child B age group. For example, there is evidence that Child B’s mother was frequently hostile to professional support and the apparent limits of her parenting ability to safeguard her children are recorded by agencies. This seems likely to have enabled Child B’s associates to further undermine and exploit him and use this to take advantage of these vulnerabilities and become the dominant figures in his life.  When the Child Protection plan was made, Birmingham Children's Trust attempted to engage Child B’s mother in the plan by ascertaining her understanding of risk posed to the children, considering all the concerns. In his own mother’s words, Child B was able to “do his own thing”. Critically, this was from a remarkably young age where he would frequently be missing from home without being reported. The suggestion that he was ‘doing his own thing’ may be an example, not only for these two young people but in general, of the parental lack of understanding about the external risks of contextual safeguarding that children are vulnerable to.   A key time for professionals to intervene further and more strongly was when Child B’s immersion into being involved in ‘County Lines’ first started, under the influence of other adults. This could have been explored when he was frequently found ‘missing from home’.   10 His mother rarely, if ever, reported him as ‘missing’. This reporting could have helped to target diversionary support and interventions that the police and other agencies could then perhaps have influenced. This might possibly have explored his movements and given an indication of his lifestyle. The numerous occasions that Child B went missing are, on analysis, closely allied to his offending profile and there is no obvious indication that these were of his own volition, but rather a product of his exploitation.      The Government approach to youth justice continues to recognise and promote the safeguarding of children as the primary objective. The vision is to see the child first and them as an offender second. On analysis, it is not clear that this has been true in all the incidents involving Child B. It is essential that all the relevant information from areas around the country concerning those children found operating within ‘County Lines’ is fed back to the home area of the young person. This will enable a holistic profile to be formed concerning them, and the incidents must not just be seen as happening elsewhere, where the focus of the individual children’s issues may be overlooked. The review author notes that when Child B was released on bail by the police in early 2019, he was put on a train to Birmingham when his family were, in fact, in a different part of the West Midlands region. There is no indication that any bail checks were made before or following his release on bail. Although, a strategy discussion was held by this area of the West Midlands Children’s Services and Birmingham Children’s Trust, they then only ‘become re-involved’ in respect of Child B’s whereabouts and accommodation needs. It wasn’t until spring 2019 that Birmingham Children’s Trust were confirmed to be responsible for Child B given that he had previously been their Child Looked After.  The ‘County Lines’ guidance is clear in that ‘The home area of the child always retains responsibility for the child, wherever they are found.’6  In spring 2019 Youth B was residing in a different area of the West Midlands region in a hotel with his mother. He was also reported as missing. In the summer of 2019 Child B was issued with a Youth Conditional Caution (YCC) and the YOT for the area he was living in agreed to take the case on behalf of Birmingham as it was established Child B was a Birmingham ‘relevant’ child.  In respect of Child A, his offending profile is considerably less than that of Child B. Child A’s second possession of drugs (Class B) offence took place less than halfway into the period of his referral order. A referral order requires the individual to attend a youth offender panel which will set a contract that seeks to address the causes of the offending behaviours. It is appropriate to consider that the existence of a referral order issued only five months previously may have enabled the Court and partner agencies to make more informed decisions about Child A. There is an indication that the work with Child A, as records show, was more productive than that of the agency’s experiences with Child B. Child A engaged on four occasions with the Youth Offending Team (YOT) and it is recorded and confirmed by his workers at the practitioner event, that contact was positive and encouraging, suggesting that Child A was  6 County Lines Exploitation practice guidance 2019.   11 working with YOT to prevent re-offending. The negative inference is that Child A may have been showing disguised compliance. The safeguarding ‘traditionally-based’ structures for children are thoroughly established and based on the ‘Working Together’ guidance published in July 2018. ‘County Lines’ seemed to be seen within it as emerging so relatively little was written in ‘Working Together’ in relation to safeguarding those children involved. Consequently, current approaches nationally to safeguarding do not take into specific account the criminality and exploitation ‘explosion’ that has arisen in a comparatively short time, and certainly since the 2018 iteration of ‘Working Together’. Birmingham, though, have implemented robust procedures that they are building on.  There will be occasions when children are released under investigation (RUI) for offences aligned to exploitation and ‘County Lines’. It is imperative that safeguarding services are triggered immediately with a full and factual referral and that there is a dynamic approach to maintaining communications with the ‘host’ area. This should happen in Birmingham through its EMPOWER U Hub.  In answer to the terms of reference question ‘Is Birmingham’s current approach to young people involved in ‘County Lines’ working?’, the review author feels in relation to Child A and Child B the answer must be no. As of July 2020, over six months after the death of Child A, Child B is still actively involved in ‘County Lines’. In terms of what the author has learned from the partnership, indications are that the current structures are beginning to work, and this will only increase into the future.   In support of this view a review team member stated that “Birmingham’s current approach is in its infancy of establishing a robust response and offer to the issues around criminal exploitation”. The individual history goes back many years for both children who would have been assessed and responded to within the traditional safeguarding approach within statutory legislation. It is now recognised that approach is outdated and does not lend itself well to criminal exploitation. The exploitation of Child B is long standing and the behaviour presented is entrenched. More preventative action is needed early on which recognises indicators and engages to prevent behaviours becoming entrenched and reduces the need for reactive responses.    Where there is a discontinuance of criminal proceedings (NRM) what intervention should this trigger?  The review author considers it may be helpful to summarise here what ‘County Lines’ involves and use of the National Referral Mechanism: In summary terms these are:  • County Lines is a major, cross-cutting issue involving drugs, violence (including sexual violence), gangs, safeguarding, criminal and sexual exploitation, modern slavery, and missing persons. The response to tackle it involves the police, the National Crime Agency, a wide range of Government departments, local government agencies, and voluntary and community sector organisations.   12 • Although Class A drug supply underpins County Lines offending, exploitation remains integral to the business model of the organised crime groups who recruit, transport, and exploit children and vulnerable adults to carry out activity including preparing, moving, storing, and dealing illegal drugs. Children in the 15-177 age group are, statistically, more likely to be exploited although the ages of the victims to this vary considerably.  • The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. Modern slavery is a complex crime and may involve multiple forms of exploitation and encompasses: - Human trafficking - Slavery, servitude and forced or compulsory labour An individual could have been a victim of human trafficking and/or slavery, servitude and forced or compulsory labour. Victims may not be aware that they are being trafficked or exploited and may have consented to elements of their exploitation or accepted their situation. A potential victim of modern slavery is a potential victim of a crime.  NRM referrals should be made by the first responder/frontline worker and referred to the police to consider what crime is to be recorded and what action is to be taken. If the potential victim is under 18, or may be under 18, an NRM referral must be made, and child victims do not have to consent to be referred into the NRM. They must first be safeguarded and then referred into the NRM process. The process involved is that once criminal proceedings have been commenced the NRM will be ‘triggered’ by a referral to the UK Human Trafficking Centre. Any decision to make a discontinuance of charges utilising the Section 45 Modern Slavery Act 2015 defence, will generally be a decision based on a clear judicial direction or decision, a legal defence or a decision made by the Crown Prosecution Service (CPS) to discontinue the case. ‘Ownership’ of the prosecution case will usually be that of the CPS as the prosecuting authority, with the casework led by the respective law enforcement agency which in the case of Child B would appear to be a Constabulary in the South West of the Country.  To clarify the legal context, Section 45 states that a defendant, when faced with criminal liability, can raise a defence that they were a victim of trafficking. This does not apply to every criminal offence but drug offences synonymous with ‘County Lines’ have been more prevalent for the raising of this defence in more recent years.   For children, less is required for the defence to be raised than adults, primarily based on vulnerabilities, and will succeed if the child can show that: a. They committed an offence as a direct consequence of being a victim of slavery or relevant exploitation; and  7 Ministry of justice 2019.   13 b. A reasonable person in the same situation and having the person’s relevant characteristics (including their age) would have committed the offence. Child B’s case was discontinued by the judge at Crown Court in winter 2018 due to the NRM status, and when a different area Magistrates Court discontinued their proceedings shortly afterwards, Child B therefore went to release with no statutory Youth Offending Service supervision, and he then went to reside in a different area of the West Midlands region.  The Birmingham Children’s Trust, who had ‘responsibility’ for him whilst on remand kept his case open. In effect, Child B walked out of custody in winter 2018 and within a very short time frame was swept up into re-offending again as by late winter 2019 he was detained in Northern England selling Class A drugs. When arrested, police officers from the West Midlands Police attended the family home to conduct a search only to discover that the family no longer resided at the address. There was a significant gap in agencies’ knowledge and at that time information does not appear to have been readily shared between the agencies.  It does highlight that Youth Offending Services in the respective areas that Child B was being dealt with for criminal offences did not appear to have effective communication with Birmingham Children’s Trust, the Local Authority children services who had responsibility for him. This does appear, on the face of it, to have highlighted gaps in national rather than local practice. The discontinuance under the statutory defence also highlights the complexities of County Lines in that where cases are discontinued, the individual could be at that time at greater risk of re-offending. There is an argument that the success of the defence does, in effect, enable (and almost empower) the criminals to continue the exploitation by further exploitation in the knowledge that the defence can be used to their advantage. In Child B’s case it is less than two months before he is shown to be active again. This emphasises the need for services to be able to take appropriate actions to safeguard the young person.    Young people who are being criminally exploited are often referred to the NRM in the expectation that it will give them protection. This is not the case in practice as protection relies on local safeguarding arrangements. Modern slavery, seen as ‘County Lines’ in this case, should also be seen as a child safeguarding issue so a referral into the NRM by a first responder8 does not replace or supersede established child protection processes, which should continue as parallel processes whatever the outcome of criminal proceedings. This will include the processes such as a Section 47 or Section 17 enquiry. The critical part of this is, therefore, that following this NRM decision, the child’s safeguarding must be appropriately embedded into practice through existing and acknowledged safeguarding processes, protocols, and arrangements by the local authority in accordance with the Children’s Act 1989 and Working Together.9 The key for professionals is  8 The list of first responders Includes the Police, Local authority and local authority children’s services. 9 All children, irrespective of their immigration status, are entitled to safeguarding and protection under the law. Where there is reason to believe a victim could be a child, the individual must be given the benefit of the doubt and treated as a child until an assessment is carried out.     14 that this must not be lost sight of at any stage, regardless of the NRM process. In the case of Child B, at the end of 2018 and thereafter, it unfortunately did seem to be. On spring 2019, a West Midlands region Youth Offending Team indicated that they were unable to establish contact with Child B due to an address change and this restricted the delivery of the out of court outcome. Consent to refer to the NRM is not required for children under 18, but it is nevertheless important to explain the process to them (and their parents/carers) and the duty to notify is satisfied by the NRM in all children’s cases. There is no specific timescale for when an NRM referral should be made but it is advisable that it is made as soon as possible to assist in the safeguarding interests of the child.  The National Child Safeguarding Practice Review Panel published a report10 in March 2020 into child criminal exploitation. Their thoughts on the NRM which is relevant to this review were:  The National Referral Mechanism (NRM) is not well understood and is inconsistently used. Young people who are being criminally exploited are often referred to the NRM in the hope that it will give them protection. The review found that the NRM’s original purpose does not always fit well with the circumstances of this group of children and that understanding and use of the NRM was patchy. Looking specifically at the case of Child B, he was subject to sentencing at the end of 2018 at Crown Court for possession of a class A drug with intent to supply and other offences, which appeared to be related to relevant exploitation. The trial judge had originally adjourned this matter for a pre-sentencing report in autumn 2018. Child B remained in youth custody on remand pending the trial. Child B received a positive grounds decision the end of 2018, with the judge discontinuing the case in accordance with the defence under S45, Modern Day Slavery Act.   Child B was released with no court orders or conditions around him. The NRM was therefore closed. The Youth Offending Service, therefore, did not have a statutory role with him, but some liaison did take place with the other area’s YOT as Child B was still to be dealt with for an out-of-court disposal for possession of a knife and cannabis. Child B was released from remand and returned to his mother who was now living in temporary accommodation. Given he was out of the Birmingham area, as well as being released with no controls, restrictions or management of his ongoing risks, the resulting engagement appears to have been voluntary and both he and his mother seem to have been resistant to offers of support.  This resistance may be indicative that this continued behaviour was being externally influenced. A little over two months later, in winter 2019, Child B was arrested in the North of England for similar drug-related offences. By this time, the out of court disposal remained incomplete but there was a clear indication that Child B’s offending was continuing, and this should have heightened awareness of his safeguarding needs.  10 The Child Safeguarding Practice Review Panel (March 2020,) It was hard to escape - Safeguarding children at risk from criminal exploitation.   15 At the review team meeting in mid-2020 the members queried what role the Magistrates and Crown Court should play in keeping children safe from criminal exploitation. In the case of Child B, it appeared to be a revolving door as the court clearly felt that, or were not asked to consider, remand in custody was a method of keeping him safe from the influence of ‘County Lines’ and gangs. The judge, by discharging Child B of all offences, unintentionally made it possible for him to continue being exploited. A further comment made in The National Child Safeguarding Practice Review Panel report stated that:  An unintended consequence of the application of the NRM was the removal of statutory orders which might have been helping to control the child’s risk-taking behaviour. For example, a tag was removed for a child as a result of a referral to the NRM being successful. The grandmother looking after the child was concerned because she saw the tag as the only thing that was curbing her grandson’s risk-taking behaviour.  This does seem to mirror Child B’s circumstances following his acquittal in at the end of 2018. How effective is the Birmingham Community Safety Partnership/West Midlands Police ‘One Day One Conversation’ in identifying and managing risk?  Child A was referred into the ‘One Day One Conversation’ (ODOC) offender management process which resulted in allocation of a Police Offender Manager working with him and his family alongside the Youth Offending Service Case Manager, Substance Misuse Worker and Youth Offending Service Training and Employment Officer.  Child B has continued since the incident in early 2020 to offend, breach orders and is suspected of being involved in ‘County Lines’. For example, he has subsequently been arrested in a house, supplying controlled drugs in south of England. Child B was discussed and nominated at the ODOC meeting in July 2020.   The review author has been supplied with the Pan Birmingham Youth ‘One Day One Conversation’ Operating Standards from June 2020. Obviously, this is post January 2020 but  it would appear that it is fundamentally the same as what was in operation during the key time frame period for this review.  To inform the review author and to help with the completion of this report, he was invited to attend (remotely) the ODOC meeting in July 2020. This review is also helped as one of its review team members is a co-chair of the ODOC meeting and process.  The ODOC is a monthly multi-agency meeting of statutory and voluntary organisations responsible for the effective management of the cohort of children who are considered suitable for an integrated offender management approach. This cohort is either:       16 1) Prolific and Priority Offenders: PPOs are those young people where there is a high likelihood of re-offending and/or serious harm to others, which may be evidenced by the following:  - Current statutory intervention - A young person committing a disproportionate amount of crime - An established pattern of offending which requires active multi-agency risk-management strategies to mitigate the risk posed by that young person - Recent intelligence which indicates a high or increasing risk of re-offending and/or harm to others - Further arrests, charges, and convictions whilst subject to statutory supervision  - Harm and re-offending factors identified by the Youth Justice Asset Plus assessment or  2) Deter Young Offenders: DYOs are those young people below the age of 18 where there is identified and increasing likelihood of re-offending and/or serious harm to others. It is likely that these young people will continue to commit crime and without targeted resources may become prolific and/or priority offenders (PPOs). These may be evidenced by the following emerging patterns of concern:  - Current statutory intervention - An increase in offending, including arrests, charges, and convictions  - Intelligence patterns identifying an increasing level of re-offending and/or harm-related behaviour - Identification of emerging patterns of offending and risk via the Youth Justice Asset Plus assessment  The ODOC meeting monitors those cases that have been adopted, decides whether to de-select, and then considers new cases. The cases adopted are managed by four strategies: control, change, diversion, and safeguarding. They are then risk assessed at different levels: either red, amber, green, or clear.  The ODOC meeting that the review author attended worked exactly as described in the Operating Standards. The review author was extremely impressed and identified several strengths: the chairing of the meeting; the thoroughness of the examination of each individual child during the meeting; the passion and engagement of the multi-agency professionals involved in each of the child’s lives who were discussed; and the actions which were multi-agency and multi-faceted in design. The sharing of information was comprehensive and readily supplied. The review author was also told by the review team and practitioners at the learning events that information-sharing is working effectively between agencies and the EMPOWER U Hub on a daily basis.  The review author felt that those practitioners who spoke about the children they were working with were constantly trying to establish moments in the life of the children when they might have been amenable to make changes to their behaviour and lifestyle. Some research calls this a ‘reachable moment’, or in Education a ‘teachable moment’. In the National Child Safeguarding Practice Review Panel’s report on safeguarding children at risk from criminal exploitation (March 2020) it is called a ‘critical moment’.    17 There is a concept in systemic theory literature described as a critical moment which changes social worlds. Systemic therapists promote the importance of acting wisely to identify when the words used at a particular critical moment can have a powerful influence on the direction taken after the conversation has ended. In a similar vein, the notion of the teachable moment is well established in education, youth offending and health sectors.  The review author believes that this ‘reachable moment’ for Child A and Child B might have been after their arrests, in particular the first time it happened, and for Child B when arrested in another part of the country and needed to be conveyed back to the West Midlands. Another moment may have been for Child A when he attended the hospital Emergency Department (ED) after being assaulted. The inclusion of Redthread11 in EDs now may help in the future.  The review author is not able to state exactly why professionals were not able to capitalise on potential ‘reachable moments’ in Child A and Child B’s lives, and possibly alter the events that followed. It may be that these were not recognised as such by professionals in involved at the time.  There may be some possible gaps with the ODOC process. The review author feels that there needs to be a robust process to capture those that are emerging or do not have a current statutory intervention. For example, when Child B had his intervention concluded in at the end of 2018, what could have been put in place to safeguard and manage him? Another example is that not a lot was being learnt by professionals in relation to Child A. At around the same time, his offending profile was either well-hidden or emerging, but this changed when he was adopted by the ODOC meeting. More possibly could have been done earlier to prevent him getting to the stage of being an ODOC nominal.  This activity appears to be something that the EMPOWER U Hub would now action out. The EMPOWER U Hub was established in October 2019 by the partnership to provide enough contextual information to the partnership in real time. The review author has been told that the Ofsted visit in February 2020 reported it was an innovative initiative that was a strong and effective addition to front door services.   From the information the review author has received the actions from the Hub’s daily meeting would include disruption activity, which includes the young person being considered at a disruption planning meeting ensuring MASH consideration for safeguarding, safety planning using a ‘Think Family approach’, understanding what the police activity is in relation to crimes committed, and making sure information is provided for One Day One Conversations (ODOC), Multi-Agency Child Exploitation (MACE) and Chief Officer Group (COG).  The rapid review for Child A states that this approach could be good but must be delivered in practice. This will assist the partnerships in moving forward in respect of “maximising real- 11 A youth work charity aiming to support and enable young people to lead healthy, safe and happy lives.   18 time information and intelligence sharing”, in particular a more consistent and comprehensive completion by professionals of the locally adopted screening tool.  What can we learn about the interface between criminal exploitation and young people’s affiliation with gangs and knife crime?  There are two main child Urban Street Gangs operating in the relevant inner-city neighbourhood of Birmingham. These two groups are made up of children and young people who are 14 to 19-year-olds. The youth gangs appear to be the testing ground before taking on roles in the adult Urban Street Gang. The ‘B19’ task these two young urban street gangs to carry out street robberies, car theft, burglary, drug dealing and to get them involved in the ‘County Lines’ drug dealing. There are high levels of violence in the offending patterns.   Child A had been assessed by the Youth Offending Service as being associated with one of these children gangs. There is no specific mention in the information received by the review of Child B’s involvement in a specific gang. However, a number of agencies, for example school and Youth Offending Service, believed he was a member of a gang, and strategy and mapping exercises were looked at for him.  At the practitioner event for Child A, some of the practitioners that worked with him said they found him a nice young person, but because he was from the relevant inner-city neighbourhood in Birmingham and the people in these gangs were his peers and friends who he had grown up with, in their opinion his membership of a gang seemed to be an inevitable consequence.   Dr Carlene Firmin, from the University of Bedfordshire and the Contextual Safeguarding Network, often talks about safeguarding organisations needing to tackle ‘Place’ to break young people’s cycle of being harmed through involvement with gangs.         19 For Child A, the ‘Place’ influence was the inner-city neighbourhood in Birmingham where he grew up. Child B was also said to have many friends in this same neighbourhood and visited frequently. There is a history of gang violence (generational) within this area. The community state to professionals working there that they are living in fear and there are also the issues of poverty within this area. Moving victims and families should be considered as a last resort (although this may be necessary in specific circumstances, for instance where there is a threat to life).  It is believed to only serve to misplace the family and by the same token can place the victims in a much more vulnerable position by exposing their vulnerabilities and possibly making them retreat to familiarity and fall-back into similar home area networking.  The moving of people should only take place after an individual risk assessment. However, in this case this may have helped Child A at the time he was adopted by the ODOC meeting as this might have helped to divert him and protect him from his peers and organised criminal gangs operating in the relevant inner-city neighbourhood in Birmingham.  Location based assessments should take place prior to any move. There needs to be a concerted effort to tackle the gangs operating in the relevant inner-city neighbourhood in Birmingham. The work of all agencies on individual cases may be successful but the gangs will just recruit the next young person to take their place unless their network can be successfully disrupted. This is where the crucial work of the Birmingham Community Safety Partnership and the Serious Youth Violence Strategy should, can and will make a difference. Child A moved to a university school academy to break out of the local school environment, but he had attendance issues in education. This was the same for Child B and despite interventions by education and other services, the deterioration of attendance and lack of engagement with the support offered to them made them vulnerable to peer pressure which, in turn, exposed them to criminal gangs who exploit children and young males.   Educating children and young people to the dangers of both gangs and ‘County Lines’ needs to be co-ordinated and targeted to those of secondary school age, but with consideration to those in their last years of primary school. It would be prudent for this to be a multi-agency approach which needs to be managed and able to draw on current and emerging themes as the organised crime behind this becomes more sophisticated. This needs to be ‘hard-hitting’ and serve to deter and may best be demonstrated by actual case studies that show the raw realities. The reality is that to criminals the child is purely a commodity and worthless whether or not they have exhausted their usefulness.   Educational exclusion may well only have served to increase their exposure to a criminal gang. It is a fact that the networking within organised crime is significant and that like law enforcement agencies, criminals have their own ‘intelligence’ systems targeting young and vulnerable victims. To many this can result in a devastating impact on their lives within a very short time frame having been lured by promises of significant rewards which quickly transpose to threats of assault, intimidation and invariably threats to their family’s lives, with drugs debts building up. Weapons are a common feature of ‘gang culture’; knives or other   20 bladed weapons appear to be the weapon of choice, although access to and the use of firearms is not uncommon.    For Child A, his exclusions appear to have happened during times where he was not receiving SEN support for Behavioural, Emotional and Social Difficulty. It is unclear what parental engagement with the schools was like, although the school have shared that parents were hard to contact and failed to attend meetings during 2018. What led to the exclusions of both Child A and Child B and were those decisions made subjectively and in the best interest of them at the time? Were there alternative considerations made in looking at the risks associated with excluding them from mainstream education and their peer group? Being in education is seen as a safe place for children, and any efforts to prevent exclusion where possible would be a good preventative move.   Keeping the momentum of changes to the law, for example the amendments to legislation in respect of weapons (Offensive Weapons Act 2019), are key opportunities in working in partnership to ensure that each of the agencies are aware of their powers to deal with offences and make appropriate and timely interventions. Changes included in the offensive weapons legislation (not all provisions are enacted) has created powers to act against individuals in private premises. These are important changes and could have a real-time effect on knife crime. Taking victims out of contact with perpetrators by using legislative opportunities whilst on one hand may be considered as criminalising the individual, but it may also offer diversionary and disruption tactics that will in fact safeguard them and place them at the forefront of statutory responsibilities by agencies.   Child A was on bail for offences at the time of his death. The conclusion to the investigations and subsequent prosecutions appears to have been adversely protracted in consideration by the prosecuting agency and appear not to have served the best interest of the child. Safeguarding of the child remains a primary consideration and delays in decision making that adversely affect the safeguarding processes should be escalated to the prosecuting agencies.    Another key area to consider is ensuring that partnerships pay appropriate value to the missing persons reports of individuals within the 14-17 age group and that all missing/return home interviews are conducted with due diligence. Although it is recognised that not all parents/carers will report missing episodes (the case of Child B is no exception to this) gaining an immediate indication from the child of where they have been and who they have been associating with at the earliest opportunity is crucial to build up an intelligence picture of these gangs, whilst such opportunities exist for that young person. These opportunities will diminish rapidly as the exploitation into gangs and County Lines takes control.   5.0 Conclusions and Learning Themes  The review author has been extremely impressed by the efforts and structures that Birmingham have put in place to tackle child criminal exploitation. There is no doubt that this structure involves a high level of sophistication to the arrangements. This builds in at the same time, a degree of complexity, which has the unintended consequence of creating some duplication but also some gaps.    21  The structure relies on the commitment and strategic leadership of the Birmingham Children’s Partnership and effective collaborative input from key partnerships including the Birmingham Safeguarding Children Partnership, the Community Safety Partnership, their subgroup the Gangs, Violence and Serious Organised Crime Strategic Board, and The Youth Offending Service Management Board. The commitment and input from agencies including Birmingham City Council, Birmingham Children’s Trust, Health commissioners and providers, West Midlands Police, National Crime Agency, Regional Organised Crime Unit, and the Voluntary Sector. The partnership also needs to work closely and in conjunction with the West Midlands Violence Reduction Unit.  A key aspect of learning from the death of Child A and the case of Child B is that this sophisticated system needs hierarchical governance which is currently being provided by the Contextual Safeguarding Board which is co-chaired by the Chief Executive of the Children’s Trust and the East Birmingham Area Commander and Children’s lead. This should be maintained and strengthened to provide system leadership, governance, and direction.  The Birmingham Gangs, Violence and Serious Organised Crime Strategic Board is in the process of undertaking a separate review of partnership intervention. It will also look at all known nominals in the particular Urban Street Gang involved with Child A and Child B and the gang that is a young faction of this urban street gang.   The Youth Offending Service Management Board are undertaking a separate Serious Incident Review into the death of A as prescribed by the Youth Justice Board; the findings will be shared with the Birmingham Safeguarding Children Partnership.    The involvement of definitely Child B, and most probably Child A, in ‘County Lines’ drug dealing, was a real issue for professionals attempting to work with them and divert them from criminality. One of the key learning themes from this review is ensuring the engagement and support of a child’s family to assist professionals.  In the case of Child A, the practitioner event revealed that both his parents were very guarded and whilst mother appeared to want to help Child A get out of trouble, she was distrustful of the police and youth offending service, and the father wanted the support of services, but remained reluctant to engage. The parents live separately and although they said they wanted to work with services they often didn’t attend booked appointments.  In relation to Child B the information received for the purposes of the review was that mother was hostile and resistant to any attempt by professionals to engage positively with him. The practitioner event supports this stating that mother is very resistant in terms of talking to agencies and regarding who is allowed to talk to the children; she wants to be involved in everything. Mother is seen as obstructive, and fearful of cooperating with agencies. An added problem for Child B was that his mother has no access to funds due to probably not having the right to remain in the UK. Child B, it was believed, was involved in crime to support his mother and siblings. His father and an older sibling returned to the European country they had left for the UK from, four years previously, so his father is not present to support Child B, the family and professionals.     22 Consideration also needs to take place in relation to the fear faced by parents. Child B’s mother is a woman with no recourse to public funds or an asylum seeker, who also may have a different view of people in authority due to experiences in her country of origin. Could professionals have used someone from within her own cultural group to support them with engaging her to better understand her experiences and the experiences of the children thereby understanding the behaviour presented? Her hostility is possibly due to fear.  A ‘Think Family approach’ may not have helped Child B but might more probably have helped Child A which was also highlighted in the rapid review for him, and this approach could help other current and future children who are getting involved in ‘County Lines’ and criminal exploitation.   Another learning point in relation to Child B was that he was constantly going missing from home. He was almost never reported missing by his mother. One of the practitioners advised there has been a continuing concern around his mother not declaring Child B missing when he had missing episodes. When a previous social worker reported Child B missing in mid-2018, his mother was angry saying that if she had not reported him missing, no-one else should. He had been reported missing by his mother only once that particular year.  The Department for Education (DfE) ‘Statutory guidance on children who run away or go missing from home or care’ makes it a requirement that when a missing child is found, they must be offered an independent return interview. The review author has seen very little evidence that these return home interviews took place on a regular basis and even if they did take place, what positive action took place following them?  The review author’s view is that more importance should be placed on the carrying out of the interviews and the value of completing them for the child themselves and any information they can also offer to safeguard themselves and others.  The National Referral Mechanism (NRM) is the appropriate mechanism for ensuring that any discontinuance of a prosecution under Section 45 Modern Slavery Act can be addressed with immediacy by the local authority in order that appropriate safeguarding, other interventions, and agency activity can continue with the child and family.  The learning from this review is that professionals should have an unambiguous understanding of the NRM mechanism. They should also ensure there is a link to address child safeguarding and if appropriate, a disruption plan to ensure it is taken following a positive NRM reasonable grounds decision.   The review author is of the opinion in respect of Child B and his involvement with the NRM that it was the right thing for professionals to do in his case at that time. The learning arising from his involvement in the NRM process is that a more comprehensive knowledge of the NRM is required by all professionals involved in safeguarding. The review author also feels that there is very relevant learning from the two points raised earlier in this report in relation to NRM that he has included from the Child Safeguarding Practice Review Panel report ‘It was hard to escape’.   The One Day One Conversation is a strength for the partnership as is the EMPOWER U Hub. The learning from this review for the partnership is to ensure those young people who are   23 emerging into criminal exploitation or don’t have a current statutory intervention, have a method of being tracked with appropriate interventions actioned. Ensure appropriate use of the County Lines Vulnerability Tracker (CLVT) is being used as a live tracking of the risk that these young people are exposed to.  Further learning is that all professionals look out for and understand when there is a ‘reachable moment’ in the young person’s lives. In order to understand this, further learning of Adverse Childhood Experiences12 and a trauma-informed approach may be of assistance.   The influence of the two main youth urban street gangs in the relevant inner-city neighbourhood in Birmingham, were too great for Child A to resist. These two groups are made up of young people who are 14 to 19-year-olds. These young people were his peers and school friends that he had grown up with. These two youth gangs appear to be tasked by the adult Urban Street Gang and therefore also involve these children like Child A and Child B in ‘County Lines’ activity. Learning from this review makes it clear that partnership activity, including action to tackle serious youth violence and other activity that also involves agencies that operate outside of the immediate partnership such as the National Crime Agency and the Regional Organised Crime Unit, needs to robustly pursue adult gangs. If not, Child A and Child B will easily be replaced by the next children that the gangs can exploit.   The Magistrates and Crown Court should be involved in keeping children safe from criminal exploitation. In the case of Child B, it appeared to be a revolving door as the court clearly felt or were not asked to consider remand in custody as a method of keeping him safe from the influence of ‘County Lines’ and gangs. The judge, by discharging Child B of all offences, just made it possible for him to continue being exploited. The Partnership should try and engage with Magistrates, the Judiciary and CPS through the Local Criminal Justice Board to discover and establish what role they can play in tackling Child Criminal Exploitation.  The importance and powerful influence of what Carlene Firmin describes as ‘Place’ for where children live, visit, and grow up is important for professionals to understand in order to try and safeguard them from criminal exploitation and to divert them from getting involved in criminality.  The strategic targeting of the ‘Place’, in this case is the relevant inner-city neighbourhood in Birmingham and is important in order to improve the environment for children in that area to safeguard them from CCE.   Careful consideration of the moving of children and their families should take place, as just replacing the ‘place’ with another ‘place’ or where the draw of the original one might be too great for the child to resist, so they are continually returning. This was what happened in the case of Child B. It can of course be the best option to safeguard that child and their family for a move to take place.  Although the review author fully understands why some exclusions take place with the overarching need to safeguard other pupils and staff from the behaviour of a child, educational exclusions are often a bad thing for that individual child. Other reviews and  12 The term 'Adverse Childhood Experiences ' is credited to Dr Vincent Filletti who carried out a study in the United States of over 17,000 people in the 1980's.  His study was the first to identify the relationship between experiences in childhood and problems with health and social integration throughout a lifetime   24 research suggest that those excluded children are even more vulnerable to CCE. Both Child A and Child B were at significant times not in school. Another consideration could be the movement of the child to a school outside of the area, this may help to break friendship and gang groups, and it may also help to ensure that the child is kept in education. However, we also need to recognise the risk involved in this in terms of postcode and other gangs in other areas when you enter into their area could cause further risk.   A review team member emphasises this further with a need for legal safeguarding processes to be in place to safeguard children from being excluded from school when there are links to criminal exploitation. So, they are not forced to leave school for behaviour that directly links to the exploitation. Within school there is also a need to recognise the impact of adverse childhood experiences by teachers and understanding of trauma on behaviour.  Although not specific learning from the lives of Child A and Child B, it is important that learning from the review emphasises the importance of educating children to the dangers of both gangs and ‘County Lines’ needs to be co-ordinated and targeted to those of secondary school age, but with consideration to those in their last years of primary school.   Another key feature of learning is the absence of any meaningful or insightful data from health agencies. This isn’t because the review didn’t look for it; this was because there was very little interaction by these boys with health agencies. The learning must be for health agencies to acknowledge that their time with the majority of children being subjected to criminal exploitation or part of a gang will probably be fleeting.  They must ensure staff are aware of the signs of CCE, Gangs and Knife crime and try to intervene in those fleeting moments. That is why initiatives such as ‘Redthread’ are a credit to the partnership.  Learning themes • The system to tackle Child Criminal Exploitation (CCE) needs hierarchical governance which is currently being provided by safeguarding children partnership and the community safety partnership through their co-chairing of the Contextual Safeguarding Board. Taking account of the drivers of exploitation and the overlay of Serious Youth Violence there needs a clear and effective strategy and operational response to tackle perpetrators of CCE and Serious Youth Violence. There needs to be agreement that this is then maintained and strengthened to provide system leadership, governance, and direction.  • Professionals that work with tackling CCE to also know and understand the Serious Youth Violence strategy. • Keeping children safe from CCE involves engaging with their families to assist professionals to work with them. • The use of a ‘Think Family Approach’ is an important one to consider. • Children who go missing should have a return home interview, especially important in cases that it is suspected involve CCE. The information gained by BCT and the WMP should be shared with partners through the EMPOWER U Hub in a timely manner. •  A more comprehensive knowledge of the NRM is required by all professionals involved in safeguarding children from CCE. The NRM decision should be made locally.   25 • The ‘One Day One Conversation’ is a strength for the partnership. Those children that fall outside the criteria for inclusion also need a similar robust process to safeguard them. • Professionals need to be alert to a ‘reachable moment’ for a child involved in CCE. • Professionals need to understand Adverse Childhood Experiences whilst they are still children and how to deal with these in a trauma informed approach. • The partnership and those agencies operating alongside them including regional resources need to ensure pursuit of adult gangs operating in the relevant inner-city area of Birmingham. • Professionals need to understand what ‘Place’ means to a child and how that influences their lives. • Being in education is seen as a safe place for children to be in, and any efforts to prevent exclusion where possible would be a good preventative move.  • Educating children as to the dangers of knives and being involved in gangs and serious youth violence can be beneficial to prevent future exploitation. If necessary, this awareness raising to take place in the last years of primary school as well as secondary schools. • The Partnership would benefit from engaging with Magistrates, the Judiciary and Crown Prosecution Services through the Local Criminal Justice Board to discover and establish what role they can play in tackling Child Criminal Exploitation. • Health Agencies will only have limited occasions to intervene, and if possible, should capitalise on them. • The ‘benchmarking exercise’ against the national review it was ‘hard to escape’ findings was important to assess what needs to be done in the short term and long term, with reviews required during the next 12 months to chart progress against the action plan developed and establish the learning further.  