The harmful sexual behaviour of a 16-year-old child. Child N was briefly made subject to a children in need plan following two allegations of child sexual abuse. The second allegation led to Child N's conviction and imprisonment for the sexual assault of an under 13-year-old. Child N had a history of: disrupted education due to difficulties in concentration and attainment; diagnosis of Attention Deficit Disorder (ADHD) ; Statement of Special Educational Needs; concerns about inappropriate sexual behaviour and going missing from home. Identifies significant learning about responding to children at risk of sexually harmful behaviour, including: a lack of supervision for vulnerable children using shared school transport; interviewing child witnesses was not a shared agency activity; lack of shared assessment of risk and response; health care staff involved with Child N were not informed of the sexual assault allegations; outcome of assessment overly influenced by view of positive parenting by the mother and not focused on the key risk issues; lack of policy and procedures to guide children's social care professionals; limited professional understanding of sexually harmful behaviour. Recommendations include: ensure that multi-agency practitioners are better equipped to work as part of a multi-agency approach in cases of harmful sexual behaviour; make sure early indicators of sexually harmful behaviour are recorded and shared across education settings; review the risk and safety for children who use local authority school transport.
      
    Serious Case Review No:  2016/C6286  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.   Final Child N SCR June 16 1        Serious Case Review   Child N             This report is written for publication in line with statutory guidance. In order to preserve the anonymity as far as is possible, the author has:  used letters to reflect each child and adult  made limited reference to the gender of person, other than where not to do so would compromise the reader’s understanding of the report  avoided the use of exact dates  Final Child N SCR June 16 2     1.           The circumstances which led to the Serious Case Review  1.1    Chid N is a young person who was 16 years old when convicted and imprisoned for the sexual assault of a child under the age of 13 years.  1.2    Child N lived with the mother MH and step-father SFN together with two half siblings. Child N had irregular contact with the father FN with relationship between MN and FN ending before Child N was born.  1.3   Child N was referred to Children’s Social Care twice aged 9 and 10 years old. Both referrals resulted in Initial Assessment although neither resulted in longer intervention. The referrals related to Child N’s relationship with MN, SFN and FN.  1.4   Whilst in primary education, Child N was referred to an Educational Psychologist. At the age of 12 years, Child N was diagnosed as having Attention Deficit Hyperactivity Disorder and moved to a school (school 3) which met the needs of children with moderate learning difficulties. At this time, Child N’s reading and writing ability was at a level expected of a child aged 9 years.  1.5   Following a Statement of Special Educational Needs, Child N moved to School 4 in September 2012.  Within the first month Child N was excluded following an allegation of sexual assault against a fellow pupil who shared school transport arrangements.  A criminal investigation commenced, however, charging decisions were not confirmed until the summer of the following year. Children’s Social Care undertook an assessment which concluded that MN was in a position to offer support to Child N and protection to the younger children within the family. For this reason, a longer term intervention was not considered necessary.  1.6   Following the alleged incident, Child N had approximately six months out of school before commencing temporarily at School 5. Following a Review of the Statement Final Child N SCR June 16 3  of Educational Needs, Child N commenced School 6 in September 2013 which catered specifically for children with social, educational and behavioural difficulties. 1.7   Child N completed a full school year at School 6 prior to being arrested in the summer holiday period. In December 2014, Child N was charged with four counts of sexual assault which included Rape, Sexual Assault and Assault by Penetration.  The offences took place over a ten month period. Following Child N’s arrest, Children’s Social Care undertook a further assessment and, after a brief period of intervention, the case was closed shortly before Child N was formally charged. Child N denied the offences and maintained that position until the trial and beyond.  1.8 Whilst awaiting trial, Child N continued to attend School 6 up until school leaving age. Child N was sentenced in the summer to seven years and six months of custody which was later reduced to six years on appeal.   1.9 Working Together 2013 outlines specific criteria under which a Serious Case Review must always be undertaken and this Review does not fall within that scope. The Serious Case Review Subgroup did however consider that Regulation 5(2) (b) (ii) of the LSCB Regulations 2006 did apply, namely that the abuse or neglect of a child is known or suspected and serious harm is caused and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.  1.10 In considering the circumstances of this case, the Independent Chair of  the Local Safeguarding Children Board decided that there was potential for learning with regard to the single and multi-agency responses to sexually harmful behaviour in children. The Serious Case Review commenced in August 2015 with the first meeting taking pace in October 2015.   2. Methodology 2.1           Working Together 2015 requires that Serious Case Reviews are conducted in such a way which:   Final Child N SCR June 16 4   recognises the complex circumstances in which professionals work together to safeguard children  seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight  is transparent about the way that data is collected and analysed, and   makes use of relevant research and case evidence to inform the findings.  2.2          The Assistant Director of Safeguarding and Quality Assurance was appointed to chair the Review and an Independent Author experienced in undertaking Serious Case Reviews and not connected to any  local agencies in was commissioned to support the learning and write an Overview Report.   2.3          A Review Panel of senior officers from agencies who had worked with Child N and the family was established. This included:  Detective Chief Inspector                    Police            Designated Doctor, Safeguarding Children     Clinical Commissioning Group            Designated Nurse, Safeguarding Children      Clinical Commissioning Group    Head of Service     Child Protection and Children in Need             Children’s Social Care                   Senior Solicitor                Council     Education Improvement Officer                Council    Service Manger               Youth Offending Service    The panel was supported by the Local Safeguarding Children Business Unit.   Achieving consistent attendance at the Panel meeting proved to be problematic; this was in part due to the competing demands of three other Serious Case Reviews as well as the competing demands on time faced by senior officers working in a Local Authority that is under an improvement plan. In order to mitigate against the Final Child N SCR June 16 5  potential problems, panel members were communicative and supportive in assisting the Author between meetings.    2.4 The Review Panel members coordinated their agency engagement with the Review; this included providing a written timeline of significant actions, undertaking an analysis of their actions and interventions, coordinating the gathering of information, and identifying and supporting the professionals involved with the family who could contribute directly to the Review.    2.5 Although the Review was keen to involve practitioners who had direct involvement with the family, the passage of time from some of the key professional activities meant this was not always possible. The Author was able to have structured conversations with a range of professionals from each key agency, and those professionals were brought together in one meeting to consider the findings, what could be learnt, and how this could be used to develop safer responses to children who present a sexual risk to other children.  2.6 In order to make sense of the child’s journey through services, the Author accessed some case work documents as well as professional assessments completed for the criminal court. The data used to inform this Review therefore has been collected through the Agency Reports, meeting with practitioners directly involved in the case and some specifically sourced documentation.  In addition, the Author was able to meet with MN along with a current  Family & Victim Engagement Officer from the Youth Offending Service .       Final Child N SCR June 16 6    3. Scope and Key Lines of Enquiry 3.1 The Review Panel determined that the Review should cover a timeline of September 2012 to June 2015.  This was specifically to incorporate the response to the two significant allegation/incidents of sexually harmful behaviour.  3.2 The Panel agreed that in order to stay focussed on the purpose of the Review,  the key lines for enquiry should include the following:  1. An analysis of agency involvement with the child to address:  Were services delivered appropriately according to organisation/statutory guidance  Were there any indicators of concerns for Child N and how were these responded to To specifically include: Indicators of sexualised behaviour  Assessment of risk of sexually harmful behaviour Parental support to child and engagement with services Any factors that impacted upon organisation/team/individual practice   2. What assessments were undertaken and how were these used to inform practice?  3. Were judgements in respect of safeguarding and promoting the welfare of children sound and supported by firm evidence? To specifically address:  Was risk to all children sufficiently identified and acted upon  Were the needs of all children identified and responded to   4. What multi-agency processes were utilised and was information shared across agencies at appropriate points? If not, did systems prevent this from happening?     Final Child N SCR June 16 7  4. Family engagement  4.1 The Review was keen to speak to engage with the family to include a service user perspective. The victim of the offence for which Child N was convicted is an extended family member, and this has resulted in extremely tense and difficult relationships between some extended family members. The victim child came within the jurisdiction of another Local Authority area and given that that family had received no services through the local authority, it was agreed that they would not be asked to contribute directly to the Review. Consideration will however be given to consulting with the family if appropriate with regard to the issue of publication.  4.2   It was agreed that Child N would be invited to contribute directly as would MN. It was arranged that the current Youth Offending Service Case Manager would be asked to talk to Child N about the purpose of the Review and seek the child’s view on whether, and how, they wished to be involved. During the timeframe of undertaking the Review, Child N moved from a young person’s secure unit to a young offender’s institution. The professionals around Child N were extremely concerned about how Child N would adapt and wanted to ensure that Child N was in a more settled position before broaching this subject. However, at the point of completing this Review, Child N’s emotional health is highly vulnerable and it is not considered safe or appropriate to seek a direct engagement on the matters relating to the review.  4.3   Through the facilitation and attendance of the current Youth Offending Service Family & Victim Engagement Officer who works with MN, the Author was able to meet directly with MN. MN offered an honest recollection of events relating to the involvement of safeguarding agencies with the family. MN remains of the view that the allegation made in 2012 is not true, but has over time come to accept the guilty verdict for the substantive offence.  Final Child N SCR June 16 8  4.4   MN advised that Child N had always struggled with school, but that she, MN, had experienced little difficulty at home. MN said that Child N had willingly complied with the medication regime for ADHD but she had not always agreed with the school allocations. MN recalled that after the alleged incident in 2012, a social worker completed a report and the case was closed because the social worker didn’t believe the incident as described had happened.  4.5   MN said that she did not find the period of time that Child N was out of school as particularly stressful as there were no management difficulties at home, although she did find it hard to provide the support that Child N needed to complete the schoolwork that was sent home. MN commented that the time taken by the CPS to reach a charging decision was long but she always expected the outcome that was delivered.  4.6   MN stated that she never perceived Child N to present a risk to the younger siblings and therefore did not have any specific management strategies in place. MN considered the fact the no social worker remained involved after assessments as an indicator that they also believed there was no reason to be concerned.  4.7   MN explained that in her view, the missing from home episodes were Child N’s response to her vigilance and the restrictions she placed on the child so as not to get involved with peers that could lead into difficulty. MN considered that when Child N did have freedom, Child N would not want it to end and that it was for this reason that they did not return home. MN said after the alleged incident in 2012, she felt that Child N was safer at home where she could know what was happening.  4.8   MN recalled that she became aware that Child N was curious about their sexuality, and had accessed pornography sites. When MN talked about this with Child N, Child N indicated that she was being stupid and there was nothing to be discussed.        4.9   MN remains a highly supportive mother to Child N and wishes for Child N to return to her home after completion of the sentence. The YOS Family & Victim Engagement Officer is working steadily with MN to increase her understanding of Final Child N SCR June 16 9  risk to enable her to support Child N whilst protecting the younger children of the family.  4.10   MN stated that the only message she would give to others in her position is to take support when it is needed. MN is finding the support of the YOS Family & Victim  Engagement Officer invaluable, but had perceived having official agencies involved in the family as a negative experience and one to be avoided. It should be noted that MN was always cooperative with Children’s Social Care and took their closure of the case twice as confidence that there was nothing to worry about.                                    5. Overview of what was known to Agencies 5.1 Child N had experienced difficulties in concentration and attainment since commencing school which resulted in a disrupted history of education.  Child N attended several primary schools and a Pupil Referral Unit at the point as Child N was diagnosed with ADHD in June 2011.  Information from medical records indicates that MN was vigilant in attending all medical appointments with Child N and in monitoring and reporting the effects of the prescribed medication. Child N was regularly overseen by the hospital based team, on occasion was seen by the Paediatrician and on occasion by a Nurse Specialist.  5.2 Following a Statement of Special Educational Needs, School 4 was identified as appropriate to Child N’s needs by the Local Education Authority. The Head Teacher School 4 was concerned from the outset about this determination, in particular, because he was aware that Child N had exhibited a level of challenging behaviour that could place other pupils at some risk. The Head was aware that at the previous school setting, some staff had indicated that they had felt uncomfortable when Child N sought physical affection and considered that Child N was seeking out a level of inappropriate relationship with female staff.  5.3 The staff at School 4 considered they were just beginning to get to know Child N when, four weeks into term, a parent of a child who shared transport contacted the school to indicate that their child had alleged a serious assault by Child N and that Final Child N SCR June 16 10  this had been recorded by mobile telephone.  A Strategy Discussion between Police and Children’s Social Care resulted in a Section 47 investigation from which the police investigated the alleged crime and Children’s Social Care undertook a Core Assessment of Child N’s needs.   5.4 The police investigation concluded in December 2013 and a file was submitted for consideration by the Crown Prosecution Service (CPS) in January 2014. The police undertook an interview under Achieving Best Evidence conditions of the alleged victim and Child N was voluntarily interviewed by the Police. The Police Officer recalled that the alleged victim struggled to engage in the interview but did confirm the description of the assault as previously stated and that consent had been refused.  The police attempted to interview the three other people present, the taxi driver and two other children also sharing the transport. The taxi was a hackney cab, the driver stated that they were unable to see when happened in the back and  had not known of an incident; whilst the parents of the potential child witnesses did not give consent for the children to be interviewed. The school were able to advise the police that the two children present had spoken about such an incident, and one had alleged that Child N had made a video recording on a telephone. Interrogation of the mobile phone did not reveal that any video footage had occurred. Child N was interviewed voluntarily and denied that any such incident occurred. Once the file was submitted to the CPS, it was six months before a decision was made that Child N would not be subject to charges because the evidence would not support a realistic chance of conviction.  5.5 Children’s Social Care commenced an assessment which considered whether Child N posed any risk to the younger siblings and children in the community.  The assessment concluded that MN was able to respond to any needs for Child N and a written agreement was drawn up which required that MN would not allow Child N to have unsupervised contact with the younger siblings. The matter of potential risk to children beyond the family unit was not addressed. The case was closed to Final Child N SCR June 16 11  Children’s Social Care with no further actions whilst the police were still investigating the allegation. 5.6 When the allegation occurred, School 4 undertook a risk assessment which concluded that Child N could not safely remain in the school setting. In the first instance, the school was attended by the alleged victim with a police investigation and later CPS decision regarding charging awaited. Secondly, the school considered that their group of children were too vulnerable to take a managed approach to Child N remaining in that school. The school communicated their decision to the Local Education Authority, and a protracted situation occurred whereby the Schools Safeguarding Advisor was seeking to support a reviewed risk assessment whilst the school considered their judgement to be made. Child N remained out of any school setting for six months, before being placed temporarily in school 5 by arrangement of the Head teacher from School 4. Child N started at School 6 in September 2014 after a review of the Statement of Special Educational Needs. School 6 specifically provided for children with educational, behavioural and social difficulties.  5.7 The senior staff at School 6 were made aware of the allegation that had occurred at School 4 and the outcomes of police and Children’s Social Care investigations. During the first year at School 6, Child N on occasions visited the School Nurse who provided a sexual health clinic at school.  Child N shared with the School Nurse that they were experiencing uncertainty with regard to sexuality. Child N had presented to the School Nurse as a calmer child than peers in the school. The school year passed without incident and the school had got to know Child N. Child N was considered to be a generally compliant child other than in matters relating to cigarettes, Child N was described as always having possession of cigarettes and on occasions leaving the classroom to smoke.  5.8 In August 2014, the allegation that Child N was later convicted for occurred. The investigation of this allegation was co-ordinated across Local Authority areas and the Police investigation quickly established strong evidence that the offence had been committed. Children’s Social Care commenced a single assessment which Final Child N SCR June 16 12  recognised that this constituted a second serious allegation and that Child N was a child in need. Although a Child in Need Plan was formulated, it is not clear whether any multi-agency meeting took place with MN in attendance. The Plan stated that there was ‘a need for Child N to undertake some work with support staff which will specifically look at work around relationships and what Child N deems as appropriate with  peers and also some work around good sexual health and Child N's understanding of this.’ A Family Support Worker from the Family Centre undertook a short piece of direct work and Children’s Social Care closed the case five days after Child N was charged with rape and sexual assault.  The assessment indicated that MN had agreed to adhere to a written agreement that Child N would not have any unsupervised contact the younger siblings or any other children, until the police and Children’s Social Care had completed their investigations. The specialist medical support for Child N in respect of ADHD was not contacted to discuss the allegations.  5.9 School 6 contacted the Education Safeguarding Officer for support to manage the risks in school. The Education Safeguarding Officer contacted the YOS Operational Manager for advice who recommended the need for a Keep Safe Plan, and to build on the positive and resilient factors exhibited by Child N. Child N was maintained in School 6 until statutory education was completed.  5.10 In October 2014, MN reported that Child N was missing from home after stealing cash and a bank card which was used to withdraw cash, upon return, Child N revealed having stayed at the home of an older male. In April 2014, MN twice contacted the police to report that Child N had stayed out all night and refused to say where they had been. This information was shared with Children’s Social Care who sent a letter to MN advising that she could contact the Department if she needed to access support. A further missing from home incident was reported to the police in May 2014. Child N was missing for two days on this occasion before being located by FN hiding in the home of a male from the community. In the context of this being a third missing from home incident, the Police discussed the matter with Children’s Social Care and made a referral for an assessment under Final Child N SCR June 16 13  Section 17 Children Act 1989.  Concerned about the missing episodes, the unwillingness to discuss the circumstances by Child N and the contacts with older males, the police expressed concern about the possibility that Child N could be exposed to child sexual exploitation. 5.11 This referral was allocated to a Social Worker who commenced a Single Assessment. Due to difficulties in achieving contact with MN, a further month elapsed before the social worker met with the Child N and MA to commence the assessment. The assessment process was not completed before Child N was found guilty at trial for the offences of rape and sexual assault.  6.  Analysis The examination of practice leading up to, and including, the response to the precipitating incident of this Serious Case Review has identified significant learning about the strengths and vulnerabilities of the individual agencies and multi-agency partnership in responding to children who present a risk of sexually harmful behaviour. The analysis is structured around the key lines of enquiry and is drawn from the agency’s written contributions to the Review, the reflections of practitioners, and the Reviewers own contribution.  6.1   Children who develop sexually harmful behaviours harm themselves and others. Responding to sexually harmful behaviour in children is a particularly challenging aspect of work for childcare professionals in that it requires practitioners to regard children as perpetrators as well as victims. The definition of sexually harmful behaviours by children is essentially the same as for adults and the prevalence of abuse is characterised by the lack of consent and the presence of an imbalance of power and exploitation. It is true to say however that there are significant differences in assessing and working with children who sexually harm as opposed to assessing and working with adults. Calder (2001) cites some of those differences as follows:   that children have less sexual knowledge Final Child N SCR June 16 14   the role of the family is more critical  that children are more influenced by situational and opportunity factors and less by internal cognitive processes  that children have greater developmental fluidity and are therefore more likely to have victims of both gender   that children may be closer to abusive experiences as victims themselves.   6.2   Several studies have led to a belief that approximately one third of harmful behaviours against children have been committed by children. Identification of children that have the potential to sexually harm others is therefore critical to the protection of children from sexual abuse.  Whilst many  studies looking at recidivism rates for children who sexually harm indicate this is lower than more general offending, it is also indicated that those who do re-offend typically have a high number of victims so that a small number of re-offenders cause a great deal of harm.  In addition, it is also believed as demonstrated by a study by Hackett et al (2013) found that two thirds of children exhibiting sexually harmful behaviour had experienced some kind of abuse or trauma, and around half had experienced sexual abuse themselves. For both reasons identification of children who sexually harm is essential to meet both their needs for support and protection and those of other children.  6.3    For professionals responding to indicators of sexually harmful behaviour, it is necessary to have a reference point from which to make determinations about what falls within the boundaries of ‘normal’ sexual development and exploration. Until 2015  did not have such guidance available to practitioners. From 2015, the introduction of a policy and procedure Children and Young People who display Inappropriate and Harmful Sexual Behaviour has guided practitioners to use the Brook Traffic Light Tool to assist in the analysis of indicators of sexually harmful behaviour and appropriate levels of responses.  The Traffic Light Tools is designed to support practitioners to identify which sexual behaviours are potentially harmful Final Child N SCR June 16 15  and which represent appropriate sexual development and apply this in a consistent manner which transcends matters of culture, faith, and personal beliefs and values.  6.4   The earliest identification of concern in relation to Child N were not indicators that were committed to formal consideration or even record, but did become an anecdotal reference point when Child N moved across school settings. There is a sense that some teachers felt an ‘unease’ about how Child N presented with regard to personal space and relationships. The first formal response to Child N’s risk from sexually harmful behaviours arose from the incident alleged in 2012.  6.5    The examination of this incident led the Author to consider and discuss with practitioners the arrangements for shared school transport. It was notable that a group of four vulnerable children travelled together without any arrangements for their supervision yet in contrast, the same group of children would have clear supervision arrangements in a school setting.  The driver of the taxi was in no way able to offer supervision by virtue of the fact he/she was driving, but also because there was a partition between where the four children sat together and the drivers cab.  6.6   The response to the alleged incident included a police interview of the alleged victim under Achieving Best Evidence Conditions. The interview was conducted by an experienced Police Officer who demonstrated a thoughtful approach to interviewing children. The Officer was aware that the alleged victim had additional needs arising from a cognitive disability and undertook a visit to meet the child prior to the interview taking place. There is provision under the guidance for achieving best evidence to use an intermediary to assist a Police Officer to assess the child witness, help the Police Officer assess the best way of communicating during the interview and also the intermediary will then complete a report to assist a trial judge to set ground rules with the advocates on how to examine the witness. A joint inspection of Achieving Best Evidence in Child Sexual Abuse by HM Crown Prosecution Service Inspectorate and HM inspectorate of Constabulary in 2015 found that of 69 interviews examined, no intermediaries were used and in many Final Child N SCR June 16 16  cases there was no indication that this was considered. The inspection found two reasons for this, firstly that interviewers had over-estimated their own skills and secondly because the use of an intermediary was considered to have a delaying factor in competing the interview. The interview of the alleged victim of Child N proved to be difficult; the Police Officer said he was concerned that he was in danger of the questions becoming leading in order to establish the alleged victim’s statement. Given that this child had significant communication difficulties and cognitive delay, a better outcome could possibly been achieved if an intermediary had been used.  6.7   In order to implement the Achieving Best Evidence guidance, the local Council and Police have a joint working protocol in place in respect of investigating where children are believed to be at risk of significant harm under Section 47 Children Act 1989.  This protocol outlines that although the police are responsible for any criminal investigation, having responsibility does not mean that the police should always take the lead in the investigative interview of a child witness. The protocol indicates that a discussion should take place between the two agencies and possibly others as to which professional (suitably qualified social workers and police officers) is best qualified to lead the interview, and who to act as a second interviewer/observer present to support that interview. The choice should take into account:   the preference of the child  any strong gender or ethnic preferences of the child  ability to establish rapport with the child  ability to communicate effectively with the child, either directly or through an intermediary  knowledge of the rules of evidence and points to prove. The presence of a second interviewer/observer should be considered and their role clearly defined. From the meetings with practitioners, it is apparent that generally the guidance in this protocol is not impacting on practice and that interviewing of child witnesses is more often a single agency activity by the police.  Final Child N SCR June 16 17  6.8    A consequence of the alleged incident for Child N was that School 4 considered it was no longer safe for Child N to attend the school. The school had a high percentage of very vulnerable pupils by virtue of their disability alone, but also significantly continued to provide education to the alleged victim. In any circumstance, it was inappropriate for the school setting to provide the circumstances within which the children could have contact, and the school was particularly mindful that the alleged victim had experienced trauma and that charging decisions had not yet been made. Prioritising the needs of the alleged victim was an appropriate course of action for the school but the needs of Child N became overlooked in this process. The Head Teacher found the response of the Local Education Authority frustrating, and there is a sense that the Local Education Authority believed that the school was not meeting its full obligation to Child N. There is evidence of much protracted and frustrated correspondence between the parties before ultimately a review of Child N’s statement resulted in a change of provision from a school for moderate and specific learning difficulties to one for emotional and behavioural difficulties. The Head Teacher at School 4 maintained a strong stance to safeguarding all pupils and the Local Education Authority was slow to respond to the needs of Child N when an earlier review of the Statement of Special Educational Needs could have resulted in Child N accessing School 6 at an earlier point.    6.9   During this 6 months period, Child N was not formally excluded from school. The law governing exclusions from Schools, Academies and Pupil Referral Units is covered by Section 52 of the Education Act 2002, with updated guidance issued in 2012. Children with additional vulnerabilities such as those with Special Educational Needs or those Looked After, are especially vulnerable to exclusion. In order to avoid a situation of permanent exclusion, it is generally expected that a school would request an early Review of the Statement or Education and Health Care Plan.   This is eventually what occurred for Child N however, this was unnecessarily protracted. The absence of a formal exclusion approach is illegal and denies access to the process of consideration by the school governors and the opportunity of Final Child N SCR June 16 18  challenge by the parent. Both the school and the Local Education Authority were fully appraised of Child N’s situation, but were also struggling to respond appropriately without the direction and support of a Lead Professional.  6.10   The response by agencies to Child N’s needs arising from the incident was not assisted by the response taken by Children’s Social Care who should have provided greater direction as the lead agency and professionals. Although a strategy discussion was held to determine that an investigation under Section 47 of Children Act 1989 took place, there is no ongoing co-ordinated multi-agency response to the investigation of assessment of risk.  The social worker has advised the Review that this case was memorable because at that time neither she nor                           the Team Manager had experience of sexually harmful behaviour and in the absence of any available guidance or policy she had searched the internet to seek knowledge and direct work materials that could be used by the family support worker. The closure of the case however left the education service and school without the support of social work assessment and perhaps falsely re-assured the Education Department that the incident should have been treated as a manageable risk.       6.11   The assessment did not sufficiently consider the issue of risk and the case closure prior to a final criminal disposal and resolution of education matters suggests it was not taken as part of a multi-agency approach to ensuring Child N’s needs were fully addressed. The assessment in simple terms should have identified                           what factors moderated the effects of exposure to risk and promoted Child N’ s                           resilience. Maintaining a resilient education is beneficial to a child who is a risk of sexual offending, however, this must be done in a safe manner which addressed all children’s needs responsibly.  6.12   The testimony of MN does not reflect how her understanding of risk is assessed in the social work assessment. MN was clear that she has never considered Child N to be a risk to her younger children and her actions will undoubtedly have reflected this. The social work file indicates that a written agreement was put in place that Final Child N SCR June 16 19  MN would not allow Child N unsupervised contact with the younger children and there are a number of issues in relation to this. Firstly this approach was not shared with any other agency and therefore there was no way of even tacitly monitoring this agreement, secondly no such document was located on the file and there is therefore no evidence that it actually existed and thirdly, consideration that this was necessary suggests that a risk was determined as present but addressed in an inadequate manner. Beyond the alleged incident, there is no indication that the assessment addressed Child N’s wider circumstances, and because of this, Child N remained at continuing risk of harm.  In addition, the absence of any multi-agency meeting meant that there was no shared assessment of risk or response. 6.13   The decision by CPS six months after submission of evidence by the police resulted in Child N commencing School 6 without any specific risk assessment in relation to sexual harm. Although that decision makes no finding with regard to the alleged incident, the decision not to proceed with a criminal charge can often be translated into a view that the incident did not occur as stated by the alleged victim or did not happen at all. The decision of the CPS was based on a criminal test of the likelihood of prosecution faced with a test of beyond reasonable doubt, whereas the focus on risk from a safeguarding perspective must be based on a test of probability and likelihood.  6.14   School 6 provided for a small number of pupils, many of whom were disruptive in the education setting. In this context, Child N was not perceived as a troublesome child and other than issues relating to  smoking, Child N was considered to be polite and responsive to staff. Child N visited the School Nurse as did many children in the school setting, and it was in this setting that Child N disclosed some confusion about emerging sexuality. The School Nurse gave a supportive response and offered further counselling should this be needed. Child N did on occasions take barrier contraception from the School Nurse but did not indicate a sexual relationship. The School Nurse considered that within the peer group of children there may well have been some kudos to accepting contraception whether or not it was needed.  Final Child N SCR June 16 20  6.15   Child N competed the first school year without significant incident at School 6. During the first term, MN had kept Child N off school in protest against the allocation of that school but this was quickly resolved and Child N became a regular school attender. MN stated she had been concerned about this school because it carried a reputation for unruly children and she did not want Child N to be in that environment. The Deputy Head Teacher was informed of the allegation against Child N in August 2014 when he had gone into school to be available for exam results. School 6 immediately recognised that this was a very serious allegation, and it is to their credit that they did not shy away from the issues and dilemmas of supporting Child N to remain in School 6.  6.16   Once again, Child N was interviewed for an alleged sexual offence of a child under 13 years. The police investigation quickly revealed strong evidence that Child N had committed this offence and the charge was formally made in December 2014.  A pattern is demonstrated in that for a second time, although a Strategy Meeting occurred to plan the investigative approach, the ongoing assessment by Children’s Social Care quickly came adrift from the police investigation and outcome.  The assessment provides a very limited insight into the risks indicated by Child N’s behaviour. Whilst it draws on the fact that Child N is now facing a second criminal investigation for sexually harmful behaviour, it then goes on to conclude that Child N needs to undertake a piece of work with a Family Support Worker to specifically look at work around relationships, what Child N considers to be appropriate as well as work with MN and SFN as Child N has a history of running away from home. The assessment identified that Child N was supervised whilst in school on a one to one basis and did not have any unsupervised contact with the younger siblings or any other children. Again it was indicated that a written agreement was in place to ensure MN complied with this requirement.   6.17   Although Child N was regularly seen by a Paediatrician or Specialist Nurse Practitioner in relation to ADHD, the Nurse Practitioner was not informed of either of the incidents. The Specialist Nurse Practitioners advised this was not indicative of his general experience of working with Children’s Social Care. The Nurse Final Child N SCR June 16 21  Practitioner advised that he would have wished to be informed for two reasons, firstly so the service could give consideration to the management of any potential risks in a clinical setting with other vulnerable  children and secondly because he could have considered changes to Child N’s medication that may have contributed to management of risk. The Nurse Practitioner suggested for example that Child N’s medication could have been changed to a 24 hour release dose which could have diminished any impulsive behaviours.  6.18   The assessment process was flawed in that it did not recognise the particular risks associated with sexually harmful behaviour in children. The outcome of the assessment was overly influenced by the assessment of positive parenting by MN, despite a recognition that the relationship between Child N and SFN was troubled. The assessment did not however focus on the key risk issues and the reason for convening the assessment, that being that Child N presented a known but unassessed risk to other children. There were a number of facts that should have alerted Children’s Social Care to the presence of risk, these included:  that investigating Police Officers were able to gather evidence that indicated that a sexual offence had occurred  (in light of above) that Child N was denying that an offence had occurred   that Child N was previously alleged to have assaulted a child   that MN as Child N’s and primary carer did not consider there was a risk to her younger children  that a protection plan that required MN to solely supervise Child N in the presence of any child outside of the school environment without any ongoing oversight or support was neither realistic nor achievable.  6.19 Given the facts of the situation, and the presence of other risk factors such as Child N’s understanding and cognitive functioning, episodes of missing from home (which appear to have been unreported) it is difficult to appreciate why a threshold was not met for a Child Protection Conference in respect of Child N and the younger siblings. Without the opportunity of consulting with the practitioners concerned, Final Child N SCR June 16 22  one can only conclude that there was insufficient knowledge of sexually harmful behaviour and the risks indicated to the Child N as perpetrator and victim as well as the risk to younger children in the household.  It is evident through this Review that there is considerable knowledge and experience within the Youth Offending Service of sexually harmful behaviour, however, at the time of this incident, the service was notified by the police for information only. The Team would than track the case from a criminal perspective in order to be prepared for any sentencing reports that could be requested. This approach meant that there was no opportunity within established processes to access the specialist knowledge in the Youth Offending Service , although there is a reference to the social worker contacting the YOS Operational  Manager for general advice. The YOS Operational Manager recommended a Keep Safe Plan, in the context of a multi-agency plan subject to regular review.  Although the assessment concluded that Child N should be considered as a Child In Need the case was closed within two months and at a time that anxiety was raised for Child N and MN because a formal charge was made. Once again, this left School 6 in an isolated position managing risk in school.  6.20 Safety planning for a young person who has displayed harmful sexual behavior requires a multi-disciplinary plan to ensure optimized support to the child and to ensure no one agency is left managing a risk in isolation. Safety planning for young people is complex and can be fraught with difficulties because of the young person's developmental age, potential peer group pressures and the young person’s strive for independence. All of these factors need to be addressed in partnership with the parent, whose attitudes and responses will have a key impact on the reliability of the plan. It is well documented that MN struggled to see and accept that Child N presented a risk to other children, and it is apparent that MN needed support to take a constructive approach which held Child N accountable for their actions. Had MN received a more comprehensive approach to the first incident, arguably she could have been encouraged to address the situational and contextual factors that may have contributed to the Child N’s choices when the second incident occurred.  Final Child N SCR June 16 23  6.21 School 6 should be commended for their determination to keep the school placement stable for Child N. The School was aware that Child N presented a significant risk, and they worked closely with the Education Officer to achieve a risk assessment that was safe and achievable in the school setting.  The Deputy Head Teacher recalled that they had received good support by the social worker prior to the case being closed, and other practitioners have reflected that they believed the social worker to be under pressure to close the case.  6.22  The incidents of missing from home reported to the police in April and May raised several aspects of concern. The police referred each incident to Children’s Social Care and the agencies first response was to send a standard letter to MN advising she could seek help if necessary. This is suggestive of a standardised approach to assessing the contact as much as the standard letter, because a review of the case records should have alerted Children’s Social Care to the fact that MN was unable to supervise Child N as per the basis of the agreement on which the case was closed four months earlier. The referral from Police to Children’s Social Care in May raised a concern about the possibility of sexual exploitation, and this was entirely appropriate to the circumstances surrounding the missing from home episodes. Each referral presented an opportunity to review the risk assessment and response to Child N who was charged with indictable sexual offences, remained an unassessed risk and whose whereabouts were unknown. This created circumstances which optimised the risks of further offending. 6.23 The failure by Children’s Social Care to grasp the issues of risk over several episodes of intervention is significant to how this case was managed from a multi-agency perspective. Children’s Social Care had a duty under Section 47 Children 1989 to assess the risk of significant harm, and in line with local threshold criteria take appropriate action and lead appropriate multi-agency intervention. There are a number of factors that got in the way of this, the absence of a policy and procedure to guide and support professionals but also limitations in the understanding of sexually harmful behaviour and how such risk needs to be addressed. The use of a written agreement intended to place responsibility on MN for the supervision of Final Child N SCR June 16 24  Child N was referenced at both episodes.  In safeguarding terms, this was both impractical and unenforceable, yet on each occasion it was considered to the basis on which it was appropriate to close the period of intervention by Children’s Social Care. The use of a written agreement was effectively a statement of the Local Authority’s concerns, and used to formalise and give emphasis to the expectations on MN and how she exercised her parental responsibility. They were not an agreement in the sense that there is no requirement for MN to sign to indicate her understanding or agreement. Whilst the use of a written agreement has a place in working with situations that require clarity of expectations, particularly for instance when applying the Public Law Outline, it should never be used as a sole approach to achieving safety, and never without a multi-agency plan to monitor the effectiveness of the arrangement.  In both instances, it appears that a written agreement was used more to defend the Department’s position on the exercising of parental responsibility rather than a genuine approach to supporting the safeguarding arrangements around Child N.  6.24 As stated, a Policy and Procedure was introduced in September 2015, and the Author was keen to review the actions of this case against that policy. The policy notes that completing robust assessments of sexually harmful behaviour requires a high level of specialist training and skill in implementing it. The policy introduces the following requirements/processes that may have altered the pathway of how the response to Child N:  that a member of the Youth Offending Service is present at any Strategy Meeting which considers sexually harmful behaviour of a child  if the child is under 12 years or the assessment by Children’s Social Care identifies a risk of significant harm then the child’s needs should be considered within child protection procedures  a Risk Management Panel with representatives from Children’s Social Care, Youth Offending Service and Health can be convened as required to make a decision as to whether a Risk Management Route is appropriate  Final Child N SCR June 16 25   the introduction of a Risk Management process which mirrors the Child Protection process with a focus on the management of risk associated with sexually harmful behaviour.  6.25 The above developments support safer decision consideration of the needs of children affected by sexually harmful behaviour and place increased safety mechanisms through strengthening multi-agency working in this respect. There does appear to be a weakness however in that entry into all multi-agency processes relies on the assessments of Children’s Social Care as a sole agency. So whilst systemically whilst there is multi-agency input at Strategy Meetings and points of determining process and closure, the decision to pursue a multi-agency approach to Risk Management or Child Protection remains with Children’s Social Care. Given the complexity and expertise required in this area of assessment, the policy would be strengthened by a second agency reviewing the assessment which determines risk and response. To consider the feasibility of this, consideration is given to the number of cases known to Children’s Social Care for Sexually Harmful Behaviour over the past 6 months and the direction each case took. The data indicated that 8 cases were known to Children’s Social Care, 3 of which are supported by early help, one through Children Looked After, and 1 was referred to the Risk Management Panel. It would appear that in order to maximise safe decisions, increase the opportunity for challenge and support it would be beneficial for assessments in relation to sexually harmful behaviour to have co-management oversight by a designated officer in the Youth Offending Service.  7.      Learning Outcome and Recommendations 7.1 This Review has found that there have been significant weaknesses and omissions in responding to sexually harmful behaviour in the local area. The commissioning of this Serious Case Review, whilst not mandatory in respect of national guidance, is a demonstration of the commitment by the Local Safeguarding Children Board to recognising and responding to the issue more effectively.  The Operational Manager of the Youth Offending Service has raised this matter within partner Final Child N SCR June 16 26  agencies and was instrumental in co-ordinating the development of the policy and procedure in respect of Children and Young People who display Inappropriate and Harmful Sexual Behaviour.  7.2 Whilst the introduction of the policy and procedure goes some way to addressing the weaknesses in guidance, practitioners are clear that there remains a need to develop awareness, knowledge and skill in this aspect of work. In January 2016, the Local Safeguarding Children Board was presented with a briefing paper to seek approval for a multi-agency task and finish group to devise a plan for addressing and responding to sexually harmful behaviour in children. The briefing paper outlined that this work was necessitated by an escalating need.    7.3 As part of the implementation Plan, additional support is being commissioned for schools to deliver effective education in respect of healthy relationships through the Personal Social and Health Education curriculum.  7.4 For professionals tasked with assessing risk, the training of the AIM model of assessment has been commissioned during 2016. The training will target social workers and social work managers as well as the Youth Offending Service. It is intended that the training will significantly increase awareness of risks in relation to sexually harmful behaviour and equip social worker and managers to respond with confidence.  7.5 From this Review, a number of learning outcomes are evident. These are addressed in the paragraphs below and recommendations to the Board are made where indicated.  7.5.1   A commonly understood Policy and Procedure to support practitioners to identify and respond to sexually inappropriate and harmful behaviour is necessary to maximise the welfare and protection of children who are affected as both victims and perpetrators of sexual abuse.                 Working with young people who are displaying harmful sexual behavior is a Final Child N SCR June 16 27  complex area of work. Providing a coordinated response that includes consultation with those with expertise and robust family and young person focused safety planning is essential. The examination of the case clearly indicates that beyond the immediate challenges, the risks associated with sexually harmful behaviour was not well understood within the multi-agency partnership or responded to by multi-agency practitioners. Whilst there has been a recent impetus to profile sexually harmful behaviour, there is also concern that this has not generated the level of response to be satisfied that sufficient professional awareness has been developed.  The content and findings of this Review will be shared through multi-agency training to serve as an instructive case scenario as to the pitfalls of poor recognition and to illustrate the need for adherence to the newly established procedure and guidance.   Although the Policy and Procedure is an important development, the examination of the circumstances of this case against that document indicate that it could be strengthened to promote access to additional expertise and challenge at crucial points of decision making which the Author and practitioners in this case believe would enhance practitioners ability to safeguard well. In addition, the policy refers specifically to children over 12 years. The Review Panel considered that placing such an age determination created an unnecessary barrier to helping children at the earliest possible identification of risk when the most effective outcomes are achievable.  Recommendation  1. To review the policy and procedure on Children and Young People who display Inappropriate and Sexually Harmful Behavior to ensure that specialist support and change is built into each point of critical decision making and at early opportunities for intervention. 7.5.2   The investigation and response to sexually abusive behaviour is  best delivered through multi-agency partnerships that involve  core and specialist agencies relevant to the individual child Final Child N SCR June 16 28  Whatever the presenting reason for a child being subject to a Child in Need Plan, this should always be delivered through a multi-agency process that supports the coming together of professionals and family, shares information and addresses risk in a transparent manner. It is reasonable to expect that children subject to police bail for reason of sexually harmful behaviour should always be considered as a child in need and that a Lead Professional should be in place to co-ordinate and manage the approach to risk and resilience. This case demonstrates that professionals did not have enough knowledge to challenge the deficits in approach and to this end there is clearly a need to increase knowledge amongst professionals about sexually harmful behaviour.  The Local Authority does have in place a training plan to increase the number of social workers and YOS case managers and associated line managers trained specifically in the AIM methodology.  Recommendation 2. That the Board prioritises the need to better equip multi-agency practitioners to work as part of a multi-agency approach with children who demonstrate sexually harmful behaviour.  7.5.3   Children who display sexually harmful behaviour will be best supported by early recognition that enables effective interventions to address and reduce risk.  There is some evidence through this Review, that early indicators of sexually harmful behaviours in school settings were not recorded as such, and that this resulted anecdotal information between school settings which presented risks in relation to accuracy and appropriate responses. In order to equip practitioners to respond appropriately to sexually harmful behaviours, it is important to work with schools in particular to consider how early indictors will be recorded in school safeguarding records that move across any school moves with the child.    Recommendation  Final Child N SCR June 16 29  3. The Board to request that the task and finish group responding to sexually harmful behaviour in children consider with school representatives how early indicators for children are recorded and shared across education settings and to identify good practice to be shared across all schools.   7.5.4   For children with additional needs, school transport arrangements should be subject to a risk assessment that  considers the welfare of the individual and group of children The arrangements for transporting children for education purposes need to be safe, with any known risks assessed and managed. The Local Authority Transport Policy which focuses on the circumstances within which school transport is appropriate, does not require any form of risk assessment to be assured that the arrangements are appropriate to the needs of the individual and group of children. It is suggested school transport is increasingly provided by a bus and escort arrangement; however, there is a need to review how safety is built into the planning.  Recommendation 4. That the Board request a review of how safety and assessed risk is and can be further assured for children who use school transport provided by the Local Authority.  7.5.5   In order to achieve best evidence who are victims of crime, the arrangements for joint working between Police and Children’s Social Care need to be integral and embedded into general practice. For children with additional needs, the use of skilled intermediaries should always be given consideration  Whilst there will be tendency to work at optimum pace in investigating allegations of sexual abuse, it must also be recognised that trading time at the expense of best practice procedures may have a detrimental impact on an outcome which is the opposite to what is intended. To this end, the Board should ensure that the partner’s agencies are guided by the findings of the Joint Inspection of Achieving Final Child N SCR June 16 30  Best Evidence in Child Sexual Abuse by HM Crown Prosecution Service Inspectorate and HM inspectorate of Constabulary in 2015 alongside a re-affirmation of the existing joint agency protocol Recommendation 5. That the Board seek re-assurance that the findings of the Joint Inspection in Achieving Best Evidence in Child Sexual Abuse by HM Crown Prosecution Service Inspectorate and HM inspectorate of Constabulary in 2015 has been implemented by partner agencies. In particular that Intermediaries are considered and used where appropriate and that the rationale and decision for their use or not is recorded.  6. That the Board should undertake a thematic audit with a focus on the joint working arrangements between Police and Social Care from Section 47 initiation to outcome to identify and address the strengths and vulnerabilities of the local arrangements.  7.5.6 The use of written agreements as a single agency approach and without a multi-agency process for review cannot be considered as a tool that will keep children safe. Conversely, they may give the impression of a protective action being taken without any foundation in fact.   The use of written agreements can be a helpful tool in achieving clarity of expectation as a contributory factor to achieving change.  Their common use, particularly at points of case closure, can however be indicative of defensive rather than pro-active safeguarding responses. For families, such documents should be transparent and used to support ongoing engagement to be meaningful.      Final Child N SCR June 16 31  Recommendation  7 That the Board request Children’s Social Care to undertake a review of the use of written agreements to ensure that their purpose is meaningful and implemented as part of a multi-agency approach to working with a family.   