Siblings J and K (aged 16-years-old and 12-years-old) reported missing in September 2021.The referrer expressed concerns about their safety, stating their father had taken the children from the UK and they might be entered into a forced marriage. Learning includes: practitioners' confidence and skills in recognising the warning signs for forced marriage and how to respond; understanding how Forced Marriage Protection Orders (FMPOs) should be used and which agency should take the lead in making an application; raising awareness of both the issue and the warning signs of forced marriage with young people in a school environment; raising awareness of the support that is available from the national Forced Marriage Unit; and ensuring widespread understanding of the 'One Chance Rule' - that practitioners may only have one chance to speak to a potential victim and therefore one chance to safeguard the child. Learning will be developed into formal recommendations. Action taken includes: children's social care to lead on FMPO applications related to children; training for the social care workforce to ensure all workers have an up-to-date understanding of the risks and indicators for forced marriage; a whole system transformation in the local authority to prevent multiple handovers; improved processes by police within the Force Control Centre to enhance safeguarding and ensure warning markers are accurate; education safeguarding leads to ensure warning signs of forced marriage are increased across education settings; and steps taken by the Intensive Prevention Service to disseminate national guidance on forced marriage and raise the profile of the Forced Marriage Unit.
      
 Title:  Recognising and responding to warning signs for forced marriage: the importance of the ‘One Chance Rule’: local child safeguarding practice review of J and K. LSCB: Staffordshire Safeguarding Children Board Author: Zoë Cookson Date of publication: 2022  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.                                 Recognising and responding to warning signs for forced marriage: the importance of the  ‘One Chance Rule’  Local Child Safeguarding Practice Review of J and K              Independent Lead Reviewer: Dr Zoë Cookson December 2022  1  Contents 1. Introduction and Executive Summary      2 1.1 Purpose of this Review        2 1.2 Overview of Case          2 1.3 Definition of Forced Marriage        3 1.4 Summary of Learning from this Review      3 2. Methodology and Process        5 3. Analysis and Identification of Learning      6 4. Recognising the warning signs        6 4.1 The warning signs for forced marriage      6 4.2  Survey results: knowledge and understanding of forced marriage   7 4.3 Knowledge and understanding within individual agencies    8 4.4 Warning signs in this case        8 5. Responding to the warning signs       10 5.1 Survey results: Confidence in responding to forced marriage   10 5.2 Initial response to warning signs in 2018      10 5.3  A missed opportunity to stop the children leaving the country   12 5.4 Forced Marriage Protection Orders (FMPOs)     12 5.4.1 About Forced Marriage Protection Orders (FMPOs)    12 5.4.2 No application for an FMPO in 2018      13 5.4.3 Application for a retrospective FMPO in 2021    14 5.4.4 Knowledge and understanding of FMPOs in Staffordshire 15 5.5 Limitations on action once children have left the country    15 5.6 The role of culture and religion       16 5.7 Responding to Warning Signs: Good Practice     17 6. Through the child’s eyes        18 6.1 Capturing the voice of the children       18 6.2 Disguised Compliance        19 6.3 The impact of Covid-19 restrictions       19 7. Multi-agency working and communication     20 7.1 Multi-agency working and communication      20 7.2 Closing the Case         21 7.3 Multi-agency working and communication: Good Practice    22 8. Advice, Guidance and Training       22 8.1 Understanding the role of the national Forced Marriage Unit (FMU)  22 8.2 Survey results: Guidance and Training in Staffordshire    23 8.2.1 Survey results: guidance       23 8.2.2 Survey results: training       23 8.3 Challenges to upskilling staff where there are capacity constraints and workforce instability          24 9. Actions Taken to Date        25 10. Conclusion          27 10.1 Developing the Recommendations       28 2  1. Introduction and Executive Summary 1.1 Purpose of this Review This purpose of a child safeguarding practice review is to explore how practice can be improved to prevent, or reduce the risk of, a repeat of similar incidents. Reviews seek to understand both what happened and whether this reflects systematic issues in either policy or practice that could be addressed to better safeguard children.  A review is not designed to hold individuals or organisations to account.1  1.2 Overview of Case  1.2.1 Reported Missing and Risk of Forced Marriage   Siblings – J (aged 16) and K (aged 12) – were reported missing to Staffordshire Police in September 2021. The referrer expressed concerns about their safety, stating their father had taken the children from the UK and the referrer believed they might be entered into a forced marriage.  Police checks confirmed that the two siblings had boarded a plane one month earlier and had subsequently travelled onwards to another country and remained outside of the UK. Multi-agency action was initiated to attempt to retrieve the children, including a Forced Marriage Protection Order.  At the time of concluding this review in December 2022 the Forced Marriage Protection Order had been unsuccessful at persuading father to return the children to the UK. It was not known whether the children had been married.  However, following liaison with agencies, both children returned to the UK in January 2023. There is no evidence that they have been married.  1.2.2 Prior Agency Involvement  J (then aged 13) and K (then aged 9) first came to the attention of agencies in May 2018 when father’s abusive and violent behaviour towards the children was reported. The referrer also said that father was planning to take the children abroad over the summer and the referrer suspected the intention was for J to be married.  This led to a Section 47 enquiry and the children being removed from father’s care via an Emergency Protection Order. The children were initially placed in foster care and then with their aunt and uncle. (Mother died in 2017.) A subsequent assessment found significant gaps in father’s parenting capacity. There was no mention of forced marriage in this assessment.  Father engaged well with parenting work and the children returned to his care under Placement with Parents regulations in March 2019. Progress appeared to be positive and a Children in Care Review agreed to revoke the Care Order in December 2019: due to Covid restrictions this did not take place until July 2020.  No concerns were identified in the period the children were registered as Children in Need and their case was closed in January 2021.   1 There are other processes for this purpose including employment law, disciplinary procedures, professional regulation and – in exceptional cases – criminal proceedings. 3  1.3 Definition of Forced Marriage2 A forced marriage is a marriage that takes place without the full and free consent of both parties. Force can include physical force, as well as being pressurised emotionally, being threatened or being a victim of psychological abuse.  Forced marriages are not the same as arranged marriages. In an arranged marriage families take the lead in selecting a marriage partner but the couple have the free will and choice to accept or decline the arrangement. Forced marriage is recognised in the UK as a form of domestic or child abuse and a serious abuse of human rights. 1.4 Summary of Learning from this Review  NOTE: At the time of concluding this review in December 2022, the children remained outside of the UK and it was not known whether they had been married. The children returned in January 2023 and there is no evidence that either has been married. While this case has not resulted in a forced marriage, the learning identified by examining the case remains relevant and should be considered in order to ensure children in Staffordshire are safeguarded in the future.   Recognising the Warning Signs  • Many warning signs for forced marriage were evident in 2018 and identified by practitioners at the time. Unfortunately, the issues around forced marriage were lost when the case transferred to another social work team after the Interim Care Order was obtained. Indeed, social care staff involved in taking the case forward were not aware of any warning signs for forced marriage. • Given practitioners frequently have ‘one chance’ to prevent forced marriage this is concerning. There is a need to ensure all practitioners in Staffordshire understand the warning signs and indicators for forced marriage. It is equally important that warning signs are appropriately logged and information shared between teams and agencies so all practitioners remain vigilant about potential risks. Responding to warning signs • There was a missed opportunity to apply for a Forced Marriage Protection Order (FMPO) in 2018. A confusion over “threshold” requirements demonstrates that some practitioners in Staffordshire do not understand what is required to obtain a FMPO and do not understand how they work. Whilst it is probably not practical for every practitioner to be knowledgeable about the detail of this uncommon area of practice, it is crucial that all have a basic understanding and know how and where to seek accurate advice.  • The decision to use an Emergency Protection Order (EPO) to address both the issue of physical/emotional abuse and forced marriage allowed the concerns around forced marriage to be lost, especially as these issues were not explicitly recorded in any of the formal case documentation. The Staffordshire Safeguarding  2 This definition is taken from government guidance: https://www.gov.uk/government/publications/forced-marriage-protection-orders-fl701/forced-marriage-protection-orders 4  Children Board multi-agency guidance on forced marriages that has been referenced to support the use of an EPO was withdrawn by the Board in November 2021 but is still being used by children’s social care. Children’s social care are developing their own guidance with the Safeguarding Board now signposting practitioners to best practice that sits within national guidance.  • A more formal and robust approach needs to be agreed within Staffordshire regarding which agency will lead on FMPO applications related to children. Unless there is good reason, this should be children’s social care. • Historical information about potential risks around forced marriage was not considered when children’s social care responded to an enquiry from Greater Manchester Police via the MASH (multi-agency safeguarding hub). Case files were reviewed but these did not explicitly record concerns around forced marriage. This was a missed opportunity to stop the children travelling in 2021. This also highlights the importance of good case recording. • There was a lack of appreciation amongst partner agencies of the one chance rule (see section 5.5). The lengthy discussions regarding possible ways to retrieve the children demonstrates the commitment of practitioners from all agencies to safeguarding the children. However, it also reveals a lack of understanding of the harsh reality that very little can be done once children have left the UK. The importance of prevention – and the implications when this fails – needs to be highlighted to practitioners. Through the child’s eyes  • In 2018, the children told practitioners that they did not want to travel to the country of father’s origin. They were not asked whether this was still the case in 2020/21 and were not given the opportunity to express a view of who should have care of their passports. Where historical concerns have been raised, there would be benefit in exploring the child’s views on these before a case is closed. • It would also be worth considering how to raise awareness of the warning signs and indicators for forced marriage with children in schools so they know what to watch for and are confident to share any concerns with teachers. Multi-agency working and communication • Representatives from the children’s schools and from health do not appear to have been invited to Strategy meetings and did not, therefore, have the opportunity to contribute. The rapid application for an Emergency Protection Order also meant that the normal multi-agency child protection processes were effectively skipped and the children moved directly into the looked after system. In Staffordshire, other agencies can contribute in writing to Child In Care Reviews but are not invited to attend meetings about looked after children. This limited opportunities for multi-agency discussion in this case. Children’s social care are planning to hold meetings with other agencies about looked after children in between Child In Care reviews and this was welcomed by agencies participating in this review. • The issue of forced marriage was not revisited at the time of the discharge of the Care Order or the closure of the case. Where historical concerns have been raised, it is crucial that these are revisited before a case is closed. 5  Advice, Guidance and Training • The experience of this case would suggest that there is a need to raise the profile of the national Forced Marriage Unit (FMU) with safeguarding partners in local areas. Advice from the FMU’s helpline regarding whether the children were likely to be at risk of forced marriage (based on the evidence available at the time) may have led practitioners to be more professionally curious and prompted them to pro-actively follow up risks of forced marriage alongside the serious abuse and neglect that the children were suffering.  • However, any actions to raise the profile of the FMU in local areas needs to be very clear regarding the Unit’s remit. Staffordshire’s experience demonstrates the importance of making safeguarding practitioners aware of the limitations of what can be done once children have left the country. • At a local level, relevant guidance and training is needed to ensure all practitioners in Staffordshire are able to recognise the warning signs for forced marriage and are confident in how they respond. This can only be effective if practitioners have the time to both attend training and to reflect on potential warning signs when they encounter them. 2. Methodology and Process 2.1 A systems-based approach, consistent with Working Together to Safeguard Children 2018, was adopted for this case. Throughout the review efforts have been made to understand how actions and events were perceived at the time and to avoid hindsight bias. 2.2 An Independent Reviewer (Dr Zoë Cookson) was appointed to lead the review process, chair all relevant meetings, facilitate the Practitioner Learning Workshops and author the final report. She was supported by a Review Team made up of local safeguarding practitioners from key agencies and representatives from the national Forced Marriage Unit. 2.3 The Review Team agreed the review would cover the period 1st May 2018 to 31st March 2022. This timeframe covers two distinct time periods:  • the period from when J and K first came to the attention of agencies to the date when they were reported missing, and  • the period where agencies sought to take action after the children left the UK. 2.4 The review drew on the initial scoping information submitted by agencies to the Rapid Review alongside individual agency analysis of learning related to the agreed Key Lines of Enquiry, and a multi-agency chronology of events.  2.5 A short survey was distributed to practitioners involved in safeguarding across Staffordshire3 in order to ascertain their knowledge and confidence of issues around forced marriage. 297 responses were received.  This survey provides a snapshot and useful insight into the knowledge and confidence of the workforce around this unusual area of practice. However, it should be noted that there is a risk of bias as practitioners chose whether they wished to respond. There was also particularly high response rate from schools and a disappointingly low  3 The survey was cascaded via the representatives on the Review Team. The closing date was deliberately chosen to be before it was widely known that this review was taking place. 6  response from the local authority. The responses from the local authority were examined separately and it was found that responses to all questions largely mirror the overall survey responses. The only variance was the response to the question around awareness of forced marriage guidance, where 33% of overall respondents to the survey replied they were not aware of forced marriage guidance and 59% of the local authority respondents said they were not aware of such guidance.  2.6 Two reflective Practitioner Learning Workshops were held with frontline practitioners. The first sought to obtain first-hand experience from those working with the children and their family, and to also understand the context that practitioners were working within. The second gave these frontline practitioners the opportunity to comment on the emerging learning and explore the contextual factors in more depth.  2.7 The Independent Reviewer completed separate interviews with the Police and with representatives from the Forced Marriage Unit. 2.8 When the review commenced the older siblings of J and K were approached and invited to participate in the review. No response was received from them. When the children returned to the UK in January 2023, all members of the family were invited to participate in the review. They declined to be involved apart from one of the siblings. The Independent Reviewer subsequently had a brief telephone conversation with this sibling of J and K.  2.9 While it was not possible to engage with the children, the review did consider the extent to which their voice was heard by the practitioners interacting with them. 3. Analysis and Identification of Learning 3.1 Introduction Despite being an uncommon area of practice, it is crucial that practitioners across agencies are able to both recognise the warning signs for potential forced marriage and are confident how to respond.  The review of this case reveals a varying level of knowledge and confidence in the workforce in Staffordshire. There are examples of good practice but some evidence of a lack of understanding of both the warning signs and the tools available to respond to potential forced marriage. This includes a misunderstanding of Forced Marriage Protection Orders (FMPOs) and a failure to appreciate (before this case) the limitations on the actions that can be taken once children have left the country.  While this may paint a bleak picture, in responding to this review, many agencies have openly acknowledged the lack of knowledge and confidence amongst their staff and have displayed an eagerness to empower and upskill staff. Indeed, many actions have already been implemented to address this.  4. Recognising the warning signs  4.1 The warning signs for forced marriage The government’s multi-agency guidance on forced marriage4 lists a number of warning signs and indicators for forced marriage – these are summarised in the table  4 Foreign, Commonwealth and Development Office / Home Office ‘Multi-agency statutory guidance for 7  overpage.5 The guidance is clear that, whilst the factors set out in this diagram may be an indication that someone is facing forced marriage, it should not be assumed that it is a forced marriage simply on the basis that someone presents with one or more of these warning signs. These signs may indicate other types of abuse that will also require a multi-agency response, or in some cases they may indicate other issues. Summary of warning signs and indicators of forced marriage        4.2  Survey results: knowledge and understanding of forced marriage 76% of respondents (226 individuals) to the forced marriage survey conducted for this review felt they knew what warning signs and indicators to look for in relation to forced  dealing with forced marriage and Multi-agency practice guidelines: Handling cases of forced marriage’ (Updated 28 July 2022) 5 These tables are taken from the multi-agency training on forced marriage delivered via the Virtual College. 8  marriage. However, when asked about awareness of the ‘one chance’ rule, this dropped to just 27% (79 individuals).  Given the high proportion of respondents reporting knowledge of warning signs, it is slightly surprising that roughly the same number – 73% (218 individuals) – said they were not aware of the related ‘one chance’ rule.  The implications of this, and the ‘one chance’ rule, is considered later in this report.  4.3 Knowledge and understanding within individual agencies  As part of this review, agencies considered the knowledge and confidence of their workforce when encountering potential forced marriage. While some staff were found to be knowledgeable on the subject, often because they worked in specific roles or particular geographical areas, many other staff had limited or no understanding. All agencies identified that action needs to be taken to ensure all practitioners are confident responding to issues around forced marriage.  4.4 Warning signs in this case A number of the warning signs and indicators for forced marriage were evident in 20186: • Concerns about forced marriage were raised at the time of the initial referral in May 2018.  (It is worth noting that this is recorded differently by agencies: Police records state the referrer was “concerned that father is planning to marry off older sibling”, while social care records report him saying “father was planning to take them [the children] overseas in August 2018 but he didn’t know why”). • Father had plans to take the children to the country of his origin in the summer. • Father was reported to have purchased a valuable set of jewellery for the children – potentially a wedding set – and had arranged for the children to have ears pierced. • The original referral noted that the children were not allowed contact with their family and were not permitted to go out.  6 Other warning signs and indicators are evident in the information available to this review (such as a statement in 2021 that father disliked “westernised” culture): these have not been included as it is not clear whether this was known in 2018. 050100150200250300350Awareness of 'one chance' ruleKnowledge of warning signsKnowledge and understanding of Forced MarriageYesNo9  • Father was known to be applying for passports for the children. (He later denied he had received these and, when his possession was confirmed, was reluctant to hand these over). • There is a family history of making marriage matches at a young age.  • At a Strategy discussion in August 2018, concerns were noted about the attitudes of the children’s uncle and aunt, who were Regulation 25 foster carers for the children, to forced / arranged marriage. (It is worth noting that education and health representatives were not invited to join the Strategy meeting and were not, therefore, involved in these discussions).  When interviewed at school in May 2018 about the reported safeguarding issues, neither of the children mentioned potential forced marriage. However, this is not surprising as it is unlikely the children would have been told if this had been father’s intention.  The duty social worker who responded to this case has since left the local authority so it is not possible to establish which warning signs they identified. However, at the time of the referral, this duty social worker is reported in the records of several agencies to be actively following up potential forced marriage. The Police also identified the risk for forced marriage and followed the associated protocols (discussed below).  The actions by the duty social worker to follow up issues around forced marriage led to internal discussions around forced marriage within children’s social care (discussed in the next section). Unfortunately, the issues around forced marriage were lost when the case transferred to the Court and Care Planning team. The work of all subsequent social care practitioners, including the allocated social worker, was focused exclusively on the physical abuse and emotional harm the children were suffering. These practitioners were not aware that any warning signs for forced marriage had been identified in this case and were not informed of the previous conversations around forced marriage. Some of the warning signs are referenced in the formal parenting assessment but they were not recognised as indicators of potential forced marriage and the social worker responsible for this assessment was categorical that forced marriage was not considered.  Recognising the Warning Signs - Learning Many warning signs for forced marriage were evident in 2018 and identified by practitioners at the time. Unfortunately, the issues around forced marriage were lost when the case transferred to another social work team after the Interim Care Order was obtained. Indeed, social care staff involved in taking the case forward were not aware of any warning signs for forced marriage. Given practitioners frequently have ‘one chance’ to prevent forced marriage this is concerning. There is a need to ensure all practitioners in Staffordshire understand the warning signs and indicators for forced marriage. It is equally important that warning signs are appropriately logged and information shared between teams and agencies so all practitioners remain vigilant about potential risks.     10   5. Responding to the warning signs  5.1 Survey results: Confidence in responding to forced marriage When asked about their current confidence when dealing with a presenting or perceived concern around forced marriage, the majority of respondents selected the middle score (3). However, more reported relatively low confidence than reported high confidence.   5.2 Initial response to warning signs in 2018 The risk of a forced marriage was identified at the time of the initial referral. Despite this being an uncommon area of practice, some frontline practitioners were initially pro-active in their response.  In the joint action that followed the referral, the Police followed Karma Nirvana protocols which included taking fingerprints, photographs and DNA for ID purposes, and placing an alert onto the Police National Computer (PNC). Records of the schools attended by J and K respectively demonstrate that potential risks around forced marriage were effectively shared with key partners. The primary school recorded an allegation that father was planning to take the children overseas in the summer holidays for older sister to be married. The secondary school recorded that the social worker had shared concerns regarding father buying the children a lot of gold jewellery and planning to take them abroad in the holidays. Both schools were, therefore, able to watch for warning signs.  Cafcass were also sighted on the possibility of the eldest girl being at risk of forced marriage, noting at the time that father had applied for passports and purchased jewellery despite both children indicating they did not want to travel to the country of father’s origin. An initial Strategy discussion took place between the duty social worker and the police representative in the MASH (multi-agency safeguarding hub), with a follow up Strategy discussion attended by the duty social worker, social care team manager and three 327913344902040608010012014012345Confidence responding to Forced Marriage issues (1 being low and 5 high)11  representatives from Staffordshire Police CID.7 The outcome was an agreement to apply for an Emergency Protection Order (EPO).  This decision to apply for an EPO was in line with the with local guidance on forced marriage in place at the time which stated that: “If a child is in immediate danger, it may be necessary to consider removing them from the family home by means of Police Protection Powers or an Emergency Protection Order.”8  However, it is not possible to establish whether forced marriage was discussed at the Strategy meeting. There is no explicit reference to forced marriage in the notes of the meeting and the rationale for action refers to “disclosures of physical harm, verbal and emotional abuse” and a “lack of protective factors within the home”.  An additional threat is noted of “children being taken overseas permanently with father”. If forced marriage was considered as part of these Strategy discussions (which appears likely), the fact that it was not mentioned in the formal records had significant consequences for the case. The initial focus on forced marriage was rapidly overshadowed by immediate safeguarding concerns for the children’s welfare based on the significance of the physical abuse and emotional harm the children were suffering. Indeed, key social care practitioners, including the allocated social worker, were not aware of any previous conversations around forced marriage and did not know that the police had followed Karma Nirvana protocols due to potential concerns. These practitioners pointed out that there was no mention of forced marriage in either of the children’s files. Although social care were no longer following up issues around forced marriage, the Cafcass Guardian was not satisfied by father’s assurances that he had no plans to take the children to the country of his origin. The Guardian, therefore, recommended that the children’s passports be held by the local authority for the duration of the time that the children remained subject of the Care Order. This action ensured that the risks in relation to forced marriage were managed during the period the children were in care.  The EPO and subsequent Interim Care Order meant that the normal multi-agency child protection processes were effectively skipped in order to protect the children. An unanticipated result of this was that inter-agency communication about the children shifted to focus solely on the looked after process, communication with the police stopped, and no further consideration was given to issues around forced marriage (see sections 5.4.2 and 7 below).  A breakdown in communication within the police also meant that some police officers were left believing that issues around potential forced marriage were still being  7 The notes of the Strategy meeting suggest that contact was also made in advance with the duty Safeguarding Nurse. The formal record of the Strategy meeting further states that “agencies such as education have been contacted to inform the strategy discussion and this is to be recorded” but it has not been possible to verify or establish the content of any conversations. 8 Staffordshire Safeguarding Children Board (joint guidance with Stoke-on-Trent Safeguarding Children Partnership), “Guidance for children who may be particularly vulnerable: forced marriages”. This guidance was removed from the Safeguarding Board website in November 2021 following a wholescale review of its multi-agency policies, procedures and guidance. This considered feedback from practitioners, data on the number of people accessing specific guidance, and capacity within the business team to ensure documents were relevant and up to date. The Board now signpost practitioners to best practice contained within national guidance on forced marriage. Children’s social care have chosen to keep this local guidance and have transferred it to their internal document library. They are, however, in the process of developing their own guidance.   12  explored. This led to some confusion over whether or not a Forced Marriage Protection Order was in place when the issue arose again in September 2021 when the children were reported missing.  5.3  A missed opportunity to stop the children leaving the country The PNC markers placed on the children’s records following the initial referral in 2018 were still in place when the children left the country in 2021.9 These alerts were picked up in August 2021 by police at Manchester Airport who contacted Staffordshire Police with information that father and the children were booked on a flight to a country outside of the UK.  Due to the imminent departure of the flight there was very little time to establish the full facts. However, the Staffordshire MASH confirmed that the case had been closed in January 2021 and there had been no concerns since. The social care files were reviewed but, as noted above, these did not explicitly mention forced marriage. Warning signs for forced marriage are mentioned in the file but, as with the parenting assessment, these were not recognised as such. No consideration was, therefore, given at this stage to the historical concerns around forced marriage that had led to the markers being placed on the PNC. However, children’s social care are confident that the assessment and evidence to support the ending of the Care Order would have meant that there was insufficient evidence to prevent the children travelling.   Police and social care in the MASH agreed that the markers should be removed. A request was made to speak to the family around their intentions and confirm there were no issues from the children. This request to speak to the family was, however, purely precautionary as there were no recorded concerns at the time.  This conversation did not happen: Greater Manchester Police have a large volume of requests and need to justify intervention, especially if this involves holding up a flight. The markers had been removed so it was assumed there was no reason to speak to the children. If the markers had still been in place, Greater Manchester Police would have held up the flight in order to speak to the children. A Forced Marriage Protection Order (FMPO) would have prevented the children being taken out of the country and made this conversation unnecessary.  5.4 Forced Marriage Protection Orders (FMPOs) 5.4.1 About Forced Marriage Protection Orders (FMPOs) A Forced Marriage Protection Order (FMPO) is unique to each case and contains legally binding conditions and directions that seek to change the behaviour of a person or persons trying to force someone into marriage. The aim of the order is to protect the person who has been, or is being, forced into marriage. The court can make an order in an emergency so that protection is in place straightaway.  9 There was an email exchange about the markers in October 2019 in which children’s social care responded to a query from the Police whether the markers were still required. In another demonstration of the fact that issues around forced marriage had been dropped, the social care team manager confirmed no risks had been identified with the girls and the markers could be removed. The Police Officer confirmed receipt of this message. However, due to an oversight, the markers were not removed. 13  Someone who disobeys a court order can be sent to prison for up to 2 years for contempt of court, while breach of a Forced Marriage Protection Order is also a criminal offence with a maximum sentence of 5 years’ imprisonment. The FMPO does not criminalise anyone unless it is breached. A FMPO is bespoke to the circumstances and each case is considered on its own merits. There is no national threshold and, although judges have different perspectives, the threshold they accept tends to be low. A description of the warning signs with a rationale for concerns is often sufficient. Hearsay is acceptable.  An applicant is expected to explain exactly what is requested and why. For example, removal of passports to prevent travel overseas.  There appears to be limited understanding of Forced Marriage Protection Orders among many agencies and practitioners in Staffordshire.10 This is evident in both the decision not to apply for a FMPO in 2018 and the delays obtaining a retrospective FMPO in 2021.  5.4.2 No application for an FMPO in 2018 In response to the warning signs identified by the duty social worker, children’s social care sought legal advice about a FMPO. The evidence for a FMPO was considered: given the age of the children, and the fact that the primary referral related to physical abuse, advice was given that the quickest way to safeguard the children would be to use an Emergency Protection Order (EPO).  As noted earlier, the use of an EPO was agreed at Strategy meetings between children’s social care and the police and this was in line with guidance at the time. The recording of the decision not to progress a FMPO was poor and created misunderstanding within a number of agencies. Formal police records were not amended to reflect the discussions at the Strategy meeting to apply for an EPO rather than a FMPO. Police records were, therefore, left stating that children’s social care were going to consider a FMPO and there was no further action for the police as no crime had been committed. This created some confusion when files were reviewed in 2021 following renewed concerns around forced marriage. The decision around a FMPO does not appear to have been shared with the girl’s schools. Records of the primary school that K attended were left noting an intention to apply for a FMPO, although they state the Police were going to lead the application. Children’s social care records did not make any reference to risks around forced marriage. The EPO was seen as a way of preventing possible flight risk and, to support this, father was required to handover the children’s passports and any identification documentation. However, the rationale for this was not recorded. Based on the information in the case files, the allocated social worker from the Court and Care Planning team understood that the requirement to handover the children’s passports was to prevent father taking the children out of the country while the local authority had  10 Those involved in this case, and this review, do now have a much better understanding. Some steps have already taken place to increase understanding in the workforce with other actions planned (see section 9 of this report). 14  concerns about his parenting. At no time was this social worker given any indication that the action had been taken in response to issues around forced marriage. All knowledge of the previous discussions around forced marriage appear to have ended at the point the Interim Care Order was obtained the case handed over to another social work team. Changes have been made within children’s social care that should prevent this happening in future. In October 2021, the local authority completed a whole system transformation that prevents multiple handovers. Under these new arrangements, the social worker who initiates the proceedings retains responsibility and, thereby, retains knowledge of the issues in the case. While this is a positive development, it does not replace the need for good case recording. The EPO did effectively safeguard the children from being taken abroad until after the Care Order had been discharged. However, the use of an EPO rather than a FMPO offered no protection when the original concerns about forced marriage were lost within the social care system. A FMPO with conditions that prevented overseas travel could have prevented the children being taken abroad in 2021.  5.4.3 Application for a retrospective FMPO in 2021 When the issue of potential forced marriage of J and K arose again in 2021, it took two months to obtain a FMPO. This suggests a lack of understanding of the options to tackle forced marriage, including FMPOs.  The national Forced Marriage Unit were approached on the day of the 2021 Strategy meeting and they advised Staffordshire practitioners to apply for a retrospective FMPO. Although this would have no legal status outside of the United Kingdom, there was a hope that it would act as a lever to persuade father to return the children. There was some reticence to do this due to concerns that a FMPO would place the children at heightened risk of harm. Instead, practitioners within Staffordshire tried to explore alternative actions to retrieve the children and the Police sought external advice from an independent specialist consultant. There were conversations about ‘children and families across borders’ and ‘international social services’. There was an initial belief that the Foreign, Commonwealth and Development Office would be able to complete ‘safe and well’ checks on the children, and a request for the British High Commission to intervene to retrieve the children.11 It took time to establish that none of the options discussed were practical. The reality is that father has not broken the law by taking the children out of the UK as he has parental responsibility. The situation would be different if the children were adults as they could say they were being held against their will. The children were made Wards of Court on 10 November 2021 and a FMPO was finally applied for (by children’s social care) and granted on 19 November 2021, almost two months after the children were reported missing. Challenges were then experienced serving the notice on father. On 16 December the High Court granted the order could be served by WhatsApp. Further confusion followed about how to implement the levers in the FMPO. For example, one of the main levers identified was to prevent father accessing money and his assets in the UK but there were challenges establishing what these are. This was due in part to misunderstanding  11 The Forced Marriage Unit had to explain that the British High Commission do not carry out welfare checks and any attempts to do so would be of limited value and could put the girls at risk. 15  of individual agency roles and the legal processes that they have to follow to obtain information. For example, as there was no criminality involved, the Police had to obtain a court order to identify what assets father has. 5.4.4 Knowledge and understanding of FMPOs in Staffordshire Feedback and informal conversations during this review revealed a lack of understanding of FMPOs amongst some staff in Staffordshire.  There are email records from police officers in 2018 stating that they felt there was sufficient evidence for a FMPO but the officers attending the Strategy meeting agreed an EPO. The legal advice to proceed with an EPO rather than a FMPO appears to have been around expediency and the fact that the primary concern was around the physical and emotional abuse the children were suffering. However, multiple participants in this review expressed a belief that a FMPO was not applied for in 2018 because “thresholds” could not be met. There are, in fact, no formal thresholds for FMPOs, and colleagues within the national Forced Marriage Unit believe it is likely that the warning signs identified at the time would have been sufficient for a judge to grant a FMPO.   FMPOs were discussed at the Learning Event held for this review and none of the practitioners present had  knowledge of the application process for FMPOs, their value or how they could be used.  Children’s social care managers believe this cohort of practitioners are not representative of the social care workforce. They cite the fact that seven FMPOs have been obtained in Staffordshire since 2016, with the most recent being obtained in October 2020. The Rapid Review for this case also identified confusion over who is responsible for applying for a FMPO in Staffordshire. There appears to be an informal understanding that children’s social care will apply where a child is concerned and the Police will apply on behalf of adults. At the time of the Rapid Review, it was thought that this may have led to neither organisation acting. Further investigation has established that action wasn’t taken because it was agreed by social care and police that an EPO should be applied for. However, this does not remove the need – identified in the Rapid Review – for a more formal and robust approach regarding who will lead on FMPO applications when they relate to children. 5.5 Limitations on action once children have left the country Whilst working together closely and sharing information between agencies, there was considerable confusion over the attempts to retrieve the children in 2021 which led to the significant delay in obtaining the retrospective FMPO. As outlined above, this was due to the wish from all agencies to take action and the time it took for practitioners to fully appreciate the limitations on what can be done once children have left the country.  The experiences of agencies trying – and failing – to find a solution to retrieve the children underlines the importance of taking action to prevent children from being taken out of the country in cases where there is a risk of forced marriage.  It also highlights the importance of the ‘One Chance’ rule – that practitioners working with victims of forced marriage and honour-based violence may only have one chance to speak to a potential victim and thus they may only have one chance to safeguard the child.12  12 More information on this ‘One Chance’ rule is available in the Forced Marriage resource pack 16  In the case of J and K practitioners had more than one chance but these were lost. This resulted in two British children being potentially at risk in a foreign country and UK agencies having no powers to return them to the UK. 5.6 The role of culture and religion 5.6.1 Consideration of culture and religion in this case This review explored the workforce’s awareness of the impact of culture and religion and considered whether there is any evidence of cultural bias in this case. This included consideration of whether the desire to be culturally sensitive led issues to be overlooked.13  Practitioners working on this case were sighted on issues of culture and religion. For example, the Intensive Prevention Service recognised that father had not always resided in the UK and that English was not his first language. This – coupled with advice from the social worker – led to the inclusion of work around what is deemed appropriate and legal in the UK in terms of parenting. Wherever possible, parenting programmes were translated into father’s language. To ensure religiously aware practice, visits were also arranged to avoid prayer times. Social workers described how they were required to challenge behaviours that father considered normal (such as the children sharing the same bedroom as father and K sharing the same bed). However, these practitioners stated they were also mindful of the need to be considerate of cultural practices such as the family tradition of arranged marriages, prompting a discussion of the distinction between a forced and arranged marriage.  There was a strong view from the social work practitioners that the use of a Forced Marriage Protection Order would have been disproportionate given the evidence available. This view was not shared by the Review Team. It is likely that the view of practitioners was shaped by their lack of understanding of FMPOs (see section 5.4.4). In written feedback after the Learning Event, several practitioners reflected on the need to be more inquisitive with families in order to better understand their culture and potential risks around forced marriage. This included a suggestion to formally explore past experiences of marriage within the family. 5.6.1 Consideration of cultural bias in the safeguarding workforce While issues of culture and religion were explored, there is insufficient evidence to conclude whether there was any cultural bias in this case, positive or negative. This prompted the Review Team to undertake a wider assessment of potential cultural bias in Staffordshire’s safeguarding workforce.  Each member of the Review Team agreed to investigate and gather a range of evidence that enables senior leaders, managers, and designated safeguarding leads to test assumptions/perceptions of cultural bias in their organisation. The following questions were used as a starting point: • Is there any evidence of cultural bias in your organisation (conscious or unconscious)?   13 This form of cultural bias is summarised in the NSPCC Learning briefing ‘Culture and faith: learning from case reviews’ (June 2014) 17  • How have issues of cultural bias been examined in your organisation? • Are there processes/systems in place or have any actions been taken to mitigate systemic cultural bias? • Are there any examples of good practice? • Are there any potential barriers that would limit the organisations ability to provide evidence of the above?  The evidence considered included: impact of supervision / peer support / case discussion; any dedicated audits examining this issue; case studies; feedback from children and young people; feedback from frontline practitioners; actions that have been taken to address potential cultural bias and any evaluation of these actions; impact of training; inspections / external peer reviews / QA visits etc; and evidence in minutes of meetings of issues around culture being actively considered. Various approaches were taken to completing this investigation. The exercise found that most organisations have comprehensive processes and procedures, including ways of mitigating cultural bias, and there was no evidence of systematic bias. In the strongest responses, there was a recognition of the fact that there will always be issues with individuals and most organisations had proactive ways of tackling this when it was identified. Many agencies also had specific initiatives around culture and religion, such as the national ‘Police Race Action Plan’ launched in May 2022 and the ‘Inclusion Schools’ programme delivered by North Staffordshire Combined Healthcare Trust on behalf of the Integrated Care System.  The only issue worth noting (from both the investigation by Review Team members and conversations with practitioners in relation to this case), was where the diversity of the workforce was sighted as a factor that can prevent cultural bias. Having members of a team from a similar background, and working in an area where staff are familiar with cultural practices and religious traditions, can aid understanding. However, it must not be seen as sufficient to mitigate cultural bias. Indeed, there is a danger that this can give a false sense of security, creating a risk that important safeguarding concerns are overlooked. 5.7 Responding to Warning Signs: Good Practice ✓ The duty social worker shared the concerns regarding potential forced marriage with both the children’s schools and this was clearly recorded. ✓ Good practice is also evident in the way Police followed the force policy in relation to possible honour-based violence/forced marriage in 2018. Responding to the Warning Signs - Learning There was a missed opportunity to apply for a Forced Marriage Protection Order (FMPO) in 2018. The confusion over “threshold” requirements demonstrates that some practitioners in Staffordshire do not understand what is required to obtain a FMPO and do not understand how they work. Whilst it is probably not practical for every practitioner to be knowledgeable about the detail of this uncommon area of practice, it is crucial that all have a basic understanding and know how and where to seek accurate advice. The decision to use an Emergency Protection Order (EPO) to address both the issue of physical/emotional abuse and forced marriage allowed the concerns around forced marriage to be lost, especially as these issues were not explicitly recorded in any of the formal case documentation. The Staffordshire Safeguarding Children Board multi-agency guidance on 18  forced marriages that has been referenced to support the use of an EPO was withdrawn by the Board in November 2021 but is still being used by children’s social care. Children’s social care are developing their own guidance with the Safeguarding Board signposting practitioners to national guidance.  A more formal and robust approach needs to be agreed within Staffordshire regarding which agency will lead on FMPO applications related to children. Unless there is good reason, this should be children’s social care. Historical information about potential risks around forced marriage wasn’t considered when children’s social care responded to the enquiry from Greater Manchester Police via the MASH (multi-agency safeguarding hub). Case files were reviewed but these did not explicitly record concerns around forced marriage. This was a missed opportunity to stop the children travelling in 2021. This also highlights the importance of good case recording. There was a lack of appreciation amongst partner agencies of the one chance rule. The lengthy discussions regarding possible ways to retrieve the children demonstrates the commitment of practitioners from all agencies to safeguarding the children. However, it also reveals a lack of understanding of the harsh reality that very little can be done once children have left the UK. The importance of prevention – and the implications when this fails – needs to be highlighted to practitioners.   6. Through the child’s eyes  6.1 Capturing the voice of the children When concerns were initially reported in 2018 consideration was given to the fact that the children may be scared that father would find out and may not feel comfortable speaking to police and the social worker. Interviews were held at their schools without father present.  Children’s social care responded quickly when the children confirmed abuse. The EPO to protect both children from further harm was based on their views. During their time in foster care, both children were spoken to regularly and seen on their own. The children’s views were used to inform the assessment and both children were very clear that they wanted to return to father’s care in 2020.  Cafcass identified strengths in the engagement of both children in care proceedings. They were visited by their Guardian and by the solicitor in the initial proceedings. The children also had the opportunity to write a letter to the Judge on both occasions.  The Intensive Prevention Service (IPS) reported that their practitioner regularly reviewed solution focused scaling with both children. Their views on family life were captured, specifically once they returned to father’s care. Both shared that their father was more relaxed, interacted better with them, and that they were enjoying family activities such as going shopping. The children were also less restricted with who they could see and were pleased to be able to have friends over. The IPS service confirmed that they spoke to the children on their own. However, this was only during visits to the family home. On reflection, they feel it would have been beneficial to also speak to the children outside of their home environment.  19  The children did not report any concerns about forced marriage but it was unlikely they would have known. One of the schools at the Learning Event suggested there could be benefits in highlighting the issues to pupils so they are mindful of warning signs and confident to share any concerns with teachers.  Practitioners working with the family – including Social Workers, their Independent Reviewing Officer and the Intensive Prevention Service – all felt confident that the children’s views guided the decisions being made about their future. 6.2 Disguised Compliance The Learning Event explored issues of disguised compliance. (Where parents appear to co-operate with practitioners in order to allay concerns and stop professional involvement). The front-line practitioners who worked directly with father and the children, strongly felt that the progress made by father was genuine and that the children’s interactions with father that they witnessed was entirely natural. The fact that both the children’s Guardian and the court supported the revocation of the Care Order would indicate that they agreed with this view.  These front-line practitioners pointed out that their work was focused on potential physical abuse and emotional harm to the children (as issues of forced marriage had not been shared with them and were not in the case files). They were not, therefore, looking at the issue of disguised compliance in relation to forced marriage.    In his interview with the Independent Reviewer the older sibling stated that, while he could understand why the narrative fitted with forced marriage, this was not father’s motivation for taking the children overseas and forced marriage was never an issue. Practitioners who were not directly involved in the case have questioned whether the children really wished to be with father, suggesting father’s controlling behaviour may have influenced what they said. The Review Team strongly felt that the timing of events supported a case for disguised compliance around the issue of forced marriage: the children’s case was closed to children’s social care in January 2021 when Covid-19 travel restrictions were in place and these were not lifted for most destinations until summer 2021 when the children left the country.  Social care managers have responded to this by pointing out that during 2019/20, prior to the decision to revoke the Care Order, there were four visits with both children where they were spoken to alone. Records show that the children were asked on every occasion if they had worries about anything and they said they did not. Cafcass noted a missed opportunity to speak to the children and their older siblings in 2020 when it was known to agencies that father was visiting family in the country of his origin. The issue of forced marriage was not revisited at the time of the discharge of the Care Order (see section 7.2 below). Cafcass noted another missed opportunity – to ask the children at this point who they felt would be best placed to have care of their passports.   6.3 The impact of Covid-19 restrictions The Covid-19 lockdown restricted the monitoring of the children and their relationship with father.  The children were offered a school place but father declined. When the primary school queried this, father’s decision not to send K to school was supported by the social 20  worker. This decision meant that Cafcass were only able to see the children at home where father was present. GP and Out of Hours services were also operating remotely using telephone consultations.  Social work contact was remote and the last statutory review was held virtually using Microsoft Teams. The children weren’t seen in person and were instead on the video call along with their father. The social worker reported that the children were as active in their participation as usual. However, this reliance on remote contact significantly limited the children’s opportunity to express any concerns or dissent. (Although, there is no evidence that they had concerns or dissenting views). The court hearing was adjourned more than once due to Covid. This caused a considerable delay in terms of permanency for the children but may have had the unanticipated consequence of protecting the children from being taken overseas. There is also one example of the pandemic affecting training opportunities. Twenty practitioners from children’s social care had been booked to attend a national Forced Marriage Conference in July 2020. It was intended that these staff would become practice champions for forced marriage in the service. Covid-19 restrictions meant the conference was cancelled. Through the child’s eyes - Learning In 2018, the children told practitioners that they did not want to travel to the country of father’s origin. They were not asked whether this was still the case in 2020/21 and were not given the opportunity to express a view of who should have care of their passports. Where historical concerns have been raised, there would be benefit in exploring the child’s views on these before a case is closed. It would also be worth considering how to raise awareness of the warning signs and indicators for forced marriage with young people in schools so they know what to watch for and are confident to share any concerns with teachers.   7. Multi-agency working and communication  7.1 Multi-agency working and communication There was good initial sharing of information between the police, children’s social care and the children’s schools about the potential risks around forced marriage.  There are also good examples of information sharing between social care and the schools during the period the children were subject to the Care Order. The schools raised their concerns as they occurred and escalated absences in a timely way. In August 2018, this led to a Strategy meeting to discuss father trying to speak to, and photograph, K outside school when his contact was supposed to be via phone. However, the schools do not appear to have been invited to attend the Strategy meeting.14  14 Notes from the social care team manager suggest that education were consulted in advance of Strategy meetings but there are no formal records on file. 21  Inter-agency information sharing during the attempts to retrieve the children in 2021 appears to be good, despite the confusion about the processes and actions that could be taken. There were, however, some significant gaps in inter-agency communication and information sharing. For example, the GP was aware they were looked after children from hospital records rather than formal notification.15 The GP did not know the children had been reported missing until the Designated Nurse requested information for the Rapid Review. Information had not been shared with the GP and he was not invited to Strategy discussions. The GP knew the family well and could have provided an insight into J’s health needs.  In terms of the specific issue of forced marriage, there was a significant breakdown in communication following the Strategy decision to apply for an EPO rather than a FMPO (see section 5.4.2).  The EPO and Interim Care Order meant that the normal multi-agency child protection processes were effectively skipped in order to protect the children. The move direct to an EPO moved the children into the looked after process, limiting multi-agency involvement. In Staffordshire Child In Care Reviews are attended by the child, parents, foster carer and IRO. The focus is on the review of the care plan and whether the placement is meeting the child’s needs. Other agencies can contribute to the report but they do not attend. Other partners questioned this at the Learning Event as they are active participants in equivalent meetings in other areas. For example, given their involvement in a child’s life, schools felt that they could add important insights. Other partner organisations felt that they could have contributed to this case and this may have helped ensure that issues of forced marriage were considered. Social care managers explained that Child In Care Reviews were established in this way in response to feedback from the Staffordshire Children in Care Council around 2015/16. Cared for children highlighted concerns about practitioners attending their meeting and wanted the process to be more child focused and child friendly. Agencies such as schools are not, therefore, invited to the meetings although they can contribute to the social work report that is shared with the IRO. They can also share information in Personal Education Plans (PEPs) and looked after child health assessments.  Children’s social care are currently developing plans to hold meetings with other agencies about looked after children in between Child In Care reviews. This was welcomed by agencies participating in this review. 7.2 Closing the Case The issue of forced marriage was lost when the duty social worker handed over the case in 2018. A potential risk of forced marriage was not, therefore, revisited at the time children’s social care came to close the children’s case. Cafcass had been aware of the original issues around forced marriage but their submissions to this review acknowledged that the risk of father taking the children out of the country was not considered when the Guardian recommended that the Care Order be revoked.   15 The name of the GP is included on the minutes of the Strategy meetings held in May 2018 but there is no evidence of engagement with him. The fact that the GP reported he was not aware the girls were Looked After would suggest there was no direct communication. 22  The other agencies who had been sighted on forced marriage as a potential issue (police and schools) were not involved in multi-agency discussions around the case and there was not, therefore, a forum for conversations to be held around this. Practitioners taking part in the Learning Events felt that processes should be in place to ensure all the issues that were raised as part of the original referral are reviewed whenever plans to revoke a Care Order or close a case are being developed. (However, as noted earlier in this report, several of these practitioners do not feel that there was any evidence at the time that would have prompted different action to be taken.) This should be standard practice. This did not happen in this case as discussions around forced marriage were not included in formal case documentation and were, therefore, overlooked.  7.3 Multi-agency working and communication: Good Practice ✓ Good initial sharing of information about the potential risks around forced marriage between the police, children’s social care and the children’s schools.  ✓ During the period the children were subject to the Care Order, the children’s schools raised their concerns with children’s social care as they occurred and escalated absences in a timely way. Multi-agency working and communication - Learning Representatives from the children’s schools and from health do not appear to have been invited to Strategy meetings and did not, therefore, have the opportunity to contribute. The rapid application for an Emergency Protection Order also meant that the normal multi-agency child protection processes were effectively skipped and the children moved directly into the looked after system. In Staffordshire, other agencies can contribute in writing to Child In Care Reviews but are not invited to attend meetings about looked after children. This limited opportunities for multi-agency discussion in this case. Children’s social care are planning to hold meetings with other agencies about looked after children in between Child In Care reviews and this was welcomed by agencies participating in this review. The issue of forced marriage was not revisited at the time of the discharge of the Care Order or the closure of the case. Where historical concerns have been raised, it is crucial that these are revisited before a case is closed.   8. Advice, Guidance and Training  8.1 Understanding the role of the national Forced Marriage Unit (FMU) The national Forced Marriage Unit (FMU) is a joint Foreign, Commonwealth and Development Office and Home Office unit which leads on the government’s forced marriage policy, outreach and casework. It does this by operating a public helpline to provide advice and support to both victims and potential victims of forced marriage and practitioners dealing with cases. The Unit also undertakes an extensive training and awareness programme targeting both practitioners and potential victims and carries out a range of work to raise awareness. The role of the national Forced Marriage Unit was not widely known in Staffordshire in 2018 and not fully understood when the Unit was contacted to help support the retrieval of the children in 2021.  23  As outlined earlier, there was surprise and confusion amongst practitioners in Staffordshire that the Unit was not able to take more proactive action to retrieve the children. While feedback shows the Unit’s advice in 2021 was helpful, this confusion highlights the importance of ensuring that local safeguarding practitioners understand the limitations on what can be done once children have left the country.  8.2 Survey results: Guidance and Training in Staffordshire The low profile of the FMU within Staffordshire may be partially due to limited guidance and training on this topic. While only a snapshot, and in no way statistically robust, the survey conducted for this review found that a third of respondents were not aware of any guidance on the topic while 70% had not received any training around forced marriage.  8.2.1 Survey results: guidance Only 17% (51 individuals) reported awareness of local guidance on forced marriage within their organisation, while half (147 individuals) stated that their organisation uses national guidance. One third of respondents (33%) said they were not aware of any guidance on forced marriage in their organisation.  8.2.2 Survey results: training The vast majority of respondents to the survey had not received any training around forced marriage. Those that had received training were split roughly equally between external and internal training.  Historically, Staffordshire Safeguarding Children Board has not offered specific training on forced marriage as there has never been any demand.  Organisation Forced Marriage guidance LocalNationalNone24   8.3 Challenges to upskilling staff where there are capacity constraints and workforce instability During discussions at the Learning Events, frontline practitioners involved in this case recognised that they need to improve their understanding of the warning signs around forced marriage. They agreed that it is important to upskill all staff on this topic and felt this needs to be ongoing and high-profile given the issue is relatively rare. Suggestions included high-visibility posters in offices and home screen messages on computers alongside formal training.  However, despite this desire to improve their understanding of issues around forced marriage, practitioners expressed concerns about how this could be achieved given current work pressures.  Staffordshire has recently implemented a transformation programme and frontline practitioners shared strong views that this has had a negative impact on practice. These practitioners described a working environment where managers are overstretched and, therefore, forced to focus on the front door and immediate safeguarding with limited or no time to consider cases that are being closed. Prior to transformation, practitioners felt they could access meaningful reflective supervision but stated that since transformation this is limited. Changes in working practices post Covid-19 have also reduced opportunities to share and learn from colleagues in an office environment as the majority of conversations now take place by phone and email. Practitioners reported that many experienced staff have left and there is an increasing reliance on agency workers. Practitioners felt that these pressures have created a working environment where meaningful training on topics such as forced marriage is impossible. Social care managers acknowledged that the significant changes following the implementation of the transformation programme have unsettled staff. However, they highlighted that there has been a year on year decline in referrals into children’s social care in the last five years and there are currently 200 less children in the system than previously. There has been a noticeable increase in the complexity of these referrals during and after the pandemic but managers feel the new structures put them in a better place to respond to these. 4247208050100150200250InternalExternalNoneTraining Recieved25  The changes were designed to reduce identified silo working and to reduce the number of times a case is handed over between teams. The changes should prevent children and families having to retell their story. Work is ongoing to fully embed the model. Schools shared that they also have capacity concerns due to funding constraints. For example, EAL (English as Additional Language) staff are now frequently working in classrooms as Teaching Assistants instead of their previous roles.  Advice, Guidance and Training - Learning The experience of this case would suggest that there is a need to raise the profile of the national Forced Marriage Unit (FMU) with safeguarding partners in local areas. Advice from the FMU’s helpline regarding whether the children were likely to be at risk of forced marriage (based on the evidence available at the time) may have led practitioners to be more professionally curious and prompted them to pro-actively follow up risks of forced marriage alongside the serious abuse and neglect that the children were suffering.  However, any actions to raise the profile of the FMU in local areas needs to be very clear regarding the Unit’s remit. Staffordshire’s experience demonstrates the importance of making safeguarding practitioners aware of the limitations of what can be done once children have left the country. At a local level, robust guidance and training is needed to ensure all practitioners in Staffordshire are able to recognise the warning signs for forced marriage and are confident in how they respond. This can only be effective if practitioners have the time to both attend training and to reflect on potential warning signs when they encounter them.  9. Actions Taken to Date Areas for immediate improvement have been identified by both the Review Team and individual agencies during the course of this review. Many actions have, therefore, already been taken: these are summarised in this section. 9.1 Lead agency when applying for a Forced Marriage Protection Order (FMPO) This review identified confusion within Staffordshire regarding which agency will lead on FMPO applications related to children. Unless there is good reason, it has been clarified and agreed that this should be children’s social care. 9.2 Children’s social care This review found a lack of knowledge around forced marriage amongst some social care staff. The Principle Social Worker will be holding a practice forum and learning lunches for the workforce to ensure all of the workforce have an up-to-date understanding of the risks and indicators for forced marriage. In October 2021, the local authority completed a whole system transformation that prevents multiple handovers. Under these new arrangements, the social worker who initiates the proceedings retains responsibility and, thereby, retains knowledge of the issues in the case. This should prevent the breakdown in communications that happened in this case and which allowed the issues of forced marriage to become lost once the Interim Care Order was obtained.  26  9.3 Police The markers on the Police National Computer were not updated during this case. Staffordshire Police have taken action to improve supervision and processes within the Force Control Centre to enhance safeguarding, including a detailed action around ensuring flags and warning markers are accurate. Supervisors are checking decisions and open incidents, escalating responses when necessary, and an audit process is in place to identify concerns and inform learning. 9.4 Education  9.4.1 Education Safeguarding Leads Education safeguarding leads have taken action to ensure that knowledge of both the warning signs for forced marriage and of FMPOs is increased across all education settings.  The forced marriage section on the Staffordshire Learning Net16 (which contains safeguarding information accessible to Designated Safeguarding Leads and deputies) has been expanded: • Forced marriage had formed part of a wider honour-based violence category but is now separate, making it more visible to users.  • The expanded content includes training links from the Virtual College, YouTube videos (to be shared with children as appropriate as part of a comprehensive PSHE package), posters which can be displayed in settings, and details of organisations and charities who provide support.  • A PowerPoint presentation provided by the Forced Marriage Unit (FMU) has been added to this section which includes clear definitions of a FMPO and the role, responsibilities and limitations of the FMU.  • Information from Staffordshire Police, and their guidance on how to report concerns directly to them, has been incorporated. A reminder has also been added that forced marriage is included in the threshold model and that any concerns must be referred into Staffordshire Children’s Advice and Support service.  Forced marriage has been added to the revised Level 4 DSL training slides for use from the 1 September 2022 for both new and existing DSLs. This training has been extended from half a day to a full day’s training for new DSLs allowing greater content to be covered.  A 7-minute briefing on forced marriage has been developed by education safeguarding leads. This will be shared with DSLs this academic year and they will be encouraged to use this for staff training and induction days, share with safeguarding governors and in other staff meetings. Staffordshire’s education safeguarding leads are recommending that training is completed on a regular basis ensuring that, even if cases are infrequent, knowledge and confidence is not diminished and the message remains clear that “it could happen here”. This was communicated in the Autumn DSL briefings and reiterated in the Level 4 DSL training. All DSLs are being encouraged to consider using the FMU slides in staff meetings and staff training days so that all staff are confident and remain vigilant.     16 It is worth noting that the content on the Learning Net was expanded after the completion deadline for the questionnaire sent out as part of this review to ensure that this did not influence results on existing knowledge 27  9.4.2 School The high school the children attended already had strong safeguarding practice. The forced marriage element in their training has been strengthened in response to this case and they are using case studies to help make the learning real to staff.  The school operates a robust ‘if in doubt act’ policy. They proactively monitor all students with an emphasis on those from cultural backgrounds who are vulnerable or whose families are vulnerable / have had past issues during the primary stage. They have a dedicated Friday morning meeting where the three Designated Safeguarding Leads consider all cases in depth: where there is even a minor doubt the school consults with outside agencies.  The school also has a ‘no fear’ approach in their interactions with parents. Since the lifting of Covid-19 pandemic restrictions, there has been a large increase in the number of Asian families traveling to visit family overseas (half of all pupils are Asian). The school routinely talks to parents and carers to establish the reason for these visits. School staff ask for proof of tickets, return flight bookings etc. Staff have to be a little fearless about this but parents are usually very cooperative.  9.5 Health  This review found that the GP and associates require additional training and increased understanding of forced marriage and FMPOs. To identify the level of need, this area of safeguarding has been added as a question to the annual safeguarding audit issued to primary care across Staffordshire. The Integrated Care Board (ICB) safeguarding team will soon have a reference area on the GP365 system, the intranet for all primary care practices across Staffordshire.  This will be a ‘go to’ reference area, accessible from every computer in primary care.  Forced marriage information will be included along with the contact details of ICB safeguarding staff for advice and guidance.   Once fully developed and adopted the integrated care record (known locally as One Health and Care) should also allow practitioners involved with individuals at risk to have some visibility of the involvement of social care or other healthcare providers. 9.6 Intensive Prevention Service  The Intensive Prevention Service have disseminated national guidance on forced marriage to all practitioners and have also taken steps to raise the profile of the national Forced Marriage Unit with these staff. This includes ensuring staff have the Unit’s public helpline number to access advice and guidance. All staff have been asked to book on the Forced Marriage Unit’s training for Social Care Staff. Attendance will be reviewed as part of team meetings and tracked through supervisions. A Reflective Session will be organised to offer a space to discuss the training and to help build on the team’s learning.  10. Conclusion This review has identified important learning regarding both practitioners’ confidence and skills in recognising the warning signs for forced marriage and the way they then respond to these warning signs.  28  There is particular learning for the Staffordshire system around Forced Marriage Protection Orders (FMPOs), including the need to understand how these can and should be used and which agency should take the lead in making an application. (It has been established that for children this should normally be the local authority children’s social care service). Whilst there is much good practice in terms of viewing events through the child’s eyes (particularly in relation to physical abuse and emotional harm), it is recognised that there is always more that could be done. In relation to forced marriage, there could be significant benefit in proactively raising awareness of both the issue and the warning signs with young people in a school environment.  Advice, Guidance and Training is an integral part to all of the above: this includes appropriately raising awareness of the support that is available from the national Forced Marriage Unit. This will, however, only be effective if practitioners have the time to undertake training, the capacity to reflect on their practice, and the opportunity to seek advice and guidance through supervision and peer conversations. Perhaps most important of all is the need to ensure there is consistent and widespread understanding of the ‘One Chance Rule’ – that practitioners working with victims of forced marriage and honour-based violence may only have one chance to speak to a potential victim and thus they may only have one chance to safeguard the child. In the case of J and K, practitioners had more than one chance but these were lost. This has resulted in two British children being potentially at risk in a foreign country and UK agencies having no powers to return them to the UK. 10.1 Developing the Recommendations This report summarises the learning from this review. This learning will be developed into formal recommendations which should be read alongside this report.  The recommendations will be developed by staff within Staffordshire to ensure that they fit within the context of wider operational and strategic developments in the county. This will ensure that recommendations make a real difference to the way children are safeguarded in Staffordshire.  Recommendations will be focused on outcomes and will be clear what is required of relevant agencies and others, both collectively and individually, and by when. The formal recommendations will be endorsed by the three statutory Safeguarding Partners. As members of the Review Team, the Forced Marriage Unit are aware of the learning related to the understanding of their role. This national learning will also be shared with the independent Child Safeguarding Practice Review Panel who have a remit for national learning. 