Serious, life-threatening injuries to two young men, Tom and Vic, in 2012. The incident involved a third person; all three individuals were considered suspects and subsequently arrested. Tom and Vic pleaded guilty in 2012. Both were well known to agencies and had histories of periods of going missing and substance misuse. Both were regularly subjected to stop and search procedures by the police, received convictions for criminal behaviour and were placed in secure accommodation. Tom was looked after by the local authority at the time of the incident and had been absent from formal education for over a year. Issues identified include: agency focus on procedures not outcomes; insufficient direct work with young people; slow pace of service delivery; insufficient consideration of adolescents who offend in groups. Recommendations include: a holistic package of intervention and support to ensure young people involved in criminal activity access education; children's social care to prioritise improved understanding of related issues including racial harassment, gangs, possessing weapons, and anti-social behaviour.
      
Title: Redacted overview report on the serious case review relating to Tom and VicLSCB: Kingston Local Safeguarding Children Board Author: Fiona Johnson Date of publication: October 2013 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.  1   STRICTLY CONFIDENTIAL      KINGSTON LOCAL SAFEGUARDING CHILDREN BOARD   Redacted Overview Report on   The SERIOUS CASE REVIEW relating to Tom and Vic       Published October 2013  2  1 INTRODUCTION 1.1 Background to the review  1.1.1 The serious case review was held as a result of an incident in information redacted 2012 when Tom sustained potentially life-threatening injuries and Vic was also hurt. The dispute involved a third party information redacted; all three persons involved were considered as suspects and were arrested information redacted and in information redacted 2012 both Vic and Tom pleaded guilty.    1.1.2 The matter was discussed by the Kingston Safeguarding Children Board (KSCB) Serious Case Review Sub-Committee on 8th June 2012 which considered the criteria for a SCR to have been met on the grounds that one of the subjects was Looked After by Kingston Children’s Social Care at the time of the incident, the injuries sustained by both subjects were potentially life-threatening1 , and there had been intensive involvement by a number of agencies with both young men. This recommendation was confirmed by the KSCB Independent Chair on the same day.  1.2 The Terms of Reference 1.2.1 The purpose of a serious case review as set out in 8.5 of Working Together to Safeguard Children 2010 is to: • establish what lessons are to be learned from the case about the way in which local professionals and organisations worked individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons were both within and between agencies, how and within what timescales they would be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children.  1.2.2 The full terms of reference agreed for this review are attached as appendix 1.  Each IMR author was particularly asked to address the following issues: - • What was the quality of practice in relation to this case and how effective was the agency’s engagement with the young people? • Were assessments of a sufficiently good quality and did they include multi-agency involvement? • Were the interventions provided appropriate and how effective were they? • To what extent was it appropriate for the agency to take on the Key Worker role? • Was there effective communication with and from other agencies? • What was the impact on practice of issues relating to ethnicity, religion, language and diversity? • What was the impact of any language issues on the young people’s engagement with the agency and did these issues receive an appropriate response?                                                             1 P235 Working Together to Safeguard Children March 2010  3  • How effective was the support provided to new arrivals in the country, including supporting their transition into the education system?  • What was the impact or otherwise on the young people of being excluded from school and to what extent were the appropriate services provided? • Was sufficient and effective support provided to the Looked After young person by the foster placement? • To what extent were gangs and gang culture a feature in this case? • What was the quality and impact of case management and supervision in relation to this case? • Did any organisational difficulties or resource issues, e.g. vacant posts or staff on sick leave, impact on practice in this case?  1.2.3 Additionally it was agreed that authors of Individual Management Reviews, SCR Panel members and the author of the overview report should give consideration to the areas identified in W.T. 2010 Page 245 in their analysis of involvement that were not covered by the above specific issues and should bring to the attention of the SCR panel chair any other matters identified which appeared to fall within the scope of the review if they thought that there were lessons to be learnt either for an individual agency or for the KSCB.  1.2.4 It was also expected that authors of Individual Management Reviews who identified other significant issues not falling within the scope of the review should bring them to the attention of a senior manager within the agency. Finally it was expected that consideration would also be given to the findings of recent SCRs both locally and nationally  1.2.5 The time frame of the review was from January 2008 information redacted up until immediately prior to the incident that took place information redacted in 2012 and agencies were asked to provide a detailed chronology for that period. All agencies were also requested to provide a summary of any significant events and relevant family history outside the specific scope and timescale, where this would help to inform the overall analysis.  1.3 Review Process 1.3.1 Individual Management Review (IMR) reports were received from the following sources: • Royal Borough of Kingston, Children’s Social Care,  • Your Healthcare • General Practitioners, Kingston   • Kingston Hospital Trust • Epsom and St Helier University Hospitals NHS Trust • Metropolitan Police Service • Royal Borough of Kingston, Youth Offending Service • Kingston & Richmond Joint Substance Misuse Service • Royal Borough of Kingston, Learning and School Effectiveness Service,  • South West London & St George’s Mental Health Trust  1.3.2 IMR authors were provided with a briefing session and all authors were also asked to attend the serious case review panel in order that feedback could  4  be provided on the reports and the panel could ask questions in order to clarify any issues.   1.3.3 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: - • The secondary schools attended by Vic and Tom. • The Fostering Agency who managed the placement where Tom was living. • RBK Children’s Centre Family Support Service Information redacted. • RBK Legal Services. • Information redacted. • ASKK information was requested and was then incorporated into the Social Care IMR.   1.3.4 A health overview report was also produced by the Designated Nurse to enable NHS Kingston, as commissioners, to review and evaluate the practice of all involved health professionals (including GPs and providers) commissioned within the PCT area.  1.3.5 Individual Management Reviews (IMRs) and the Health Overview Report were drawn up by officers who had had no previous involvement in the case.  1.4 Family Input to the Review 1.4.1 Consideration was given to involving the parents and the young men in the review process and the independent overview author offered to meet with both young men and separately with their parents. In the event the author met with Vic and Tom’s mothers. Vic did not feel he wished to meet with the author as following discussion with his mother he felt she had provided all relevant information. An appointment was made to meet with Tom, however he went missing information redacted at the time the report was being completed.   1.5 The Review Panel 1.5.1 The review group membership was as follows: - • Paul Kerswell Independent Chair • Metropolitan Police  • Education Services, Royal Borough of Kingston  • Youth Offending Service  • NHS Kingston - Designated Nurse, Child Protection • Children’s Social Care, Royal Borough of Kingston2• School – Deputy Head teacher,    • KSCB Business Manager.                                                             2 There was no attendance at early panel meetings by Children’s Social care however after representations were made via the Chair of the LSCB there was attendance from 22nd November 2012 onwards.   5  Additionally Fiona Johnson, the Independent Overview Writer attended Review Panel Meetings.  1.5.2 Dates of review Panel meetings were as follows: - • 28/9/2012 • 12/10/2012 • 22/11/2012 • 4/1/2013 • 18/1/2013  1.5.3 The Chair of the Panel is Paul Kerswell and he has had no direct involvement with any of the professionals’ work being reviewed. He is an independent Children’s Services consultant and qualified in Social Work in 1988. He has 12 years’ experience of operational management of children’s social care services including 7 years at senior management level. Working for the past seven years as an Independent Consultant he has been involved as either Overview Author or Panel Chair in more than 20 Serious Case Reviews. He is Chair of the Pan-London SCR Chairs and Authors Group.  1.5.4 The independent overview writer is Fiona Johnson, an independent social work consultant. Head of Children’s Safeguards & Quality Assurance in East Sussex County Council between 2004 and 2010, Fiona qualified as a social worker in 1982 and has been a senior manager in children’s services since 1997 contributing to the development of strategy and operational services with a particular focus on safeguarding and child protection. She is HCPC registered and has previously written overview reports for East Sussex, Brighton & Hove, Portsmouth, Southampton, Kent, West Sussex, Wandsworth, Surrey, Slough and Bracknell Forest LSCBs.  1.5.5 The overview report was completed based on information provided in the IMRs and the additional reports. The overview author was also provided with executive summaries from previous serious case reviews held in Kingston that were considered to be relevant.   1.5.6 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible. Full publication of the findings of the review will follow on from the completion of the serious case review process.  1.6 Parallel Processes  1.6.1 NHS agencies are required to carry out reviews of “Serious Untoward Incidents” (SUIs). For the NHS agencies involved, that requirement was met by the conduct of this Review. There were criminal processes underway at the start of the review and the panel liaised with the relevant police officers to ensure that the legal process was not compromised in any way by the review.     6  2 THE FACTS 2.1 This review is complex because it concerns two young men who have different life histories but who were injured whilst together, having previously engaged, jointly, in significant levels of anti-social behaviour. In the main the services provided to the young men were separate; and, whilst some agencies were aware of the connection between them, prior to the incident there was no significant attempt at working with them together, and no linking of the two families. This report will therefore provide separate accounts of the services provided to the young men but will then identify any joint themes or systemic concerns that the review has identified.  Family Structures  Information redacted  A genogram and a full chronology covering the period are redacted.    2.2 The Family Background - Tom 2.2.1 Tom is a young man of dual heritage. Information redacted. All his older siblings moved away from the family home in their teens information redacted.     2.2.2 Tom was born in England and his first language is English information redacted. There was little reported in IMRs about the socio-economic background for the family however they are reported to have owned their own home information redacted.   2.2.3  Information redacted.   2.3 The Family Background - Vic 2.3.1 Vic is also of dual heritage information redacted. Vic is one of two children living with their mother in England.  Information redacted. Although Vic spoke English well he may have had some comprehension issues.   2.3.2 Little is recorded in the IMRs of the socio-economic background of the family information redacted. She was seen by professionals to be supportive of Vic and worked co-operatively with agencies. There was very little professional involvement with Vic and his family apart from core services until the end of 2010.  2.4 Agencies’ Involvement with Tom 2.4.1 Tom returned to England information redacted and started at a local secondary school. There were no immediate problems identified however information redacted he exhibited some behavioural problems in class which were discussed with his mother who felt that Tom’s misbehaviour was because he was not being sufficiently challenged in lessons. That school year showed a slow and steady deterioration in Tom’s behaviour resulting in a further meeting with Tom’s mother in the summer information redacted. At  7  that meeting she again advised school staff that Tom’s behavioural problems were a result of under-stimulation at school. At this point a CAF (Common Assessment Framework) was completed by the school with the aim of getting additional support for Tom however the parents refused to accept this assistance and would not sign the CAF assessment.  2.4.2 Information redacted Tom’s behaviour continued to deteriorate and the school had difficulties engaging with the parents to achieve any change.  Information redacted. The parents were very critical of the school and wanted Tom to transfer to another local secondary school however they did not make an application for a transfer. The parents also refused any other offers of support and would not agree to a referral to Children’s Social Care (CSC).  2.4.3 In information redacted Tom and his older sibling attended a local Accident and Emergency Department because they had both sustained injuries information redacted. Hospital staff considered Tom’s injury to be serious and information was shared with the school health service via the liaison health visitor. The school nurse then contacted the Kingston ‘contact centre’, ASKK to see if any other professional was working with the family and was told that no-one was involved. The nurse did not make a referral and ASKK did not pass on the information to CSC.   2.4.4 In information redacted there was an incident after school where Tom and his information redacted brother were involved in a fight with some information redacted youths. Tom and his brother sustained injuries and both attended hospital accompanied by their father. The police were also involved and information redacted the youths were arrested, the matter was investigated and papers were passed to the CPS, however no legal action was taken. After this the hospital referred the family to CSC however the police did not pass on any information. The next day the school were concerned that there could have been a connection with boys at the school and suggested that Tom and his brother remain at home while the risk was assessed. The parents refused to do this and three days later Tom’s mother made a formal complaint to the Local Authority information redacted. This led to a full investigation which fully exonerated the school.  2.4.5 Relations between the parents and the school continued to deteriorate and on information redacted Tom’s mother contacted the Local Authority asking that Tom have a ‘managed move’ to another local secondary school. A ‘managed move’ is a process that can be initiated by the school where they consider that it would be in the child’s interests to have a new start at a different school. This was explained to Tom’s mother and she was encouraged instead to submit a parental application to the school and was advised of other local schools with vacancies. The Local Authority also advised the school of Tom’s mother’s request.  2.4.6 Tom’s behaviour at home was also proving challenging and on information redacted Tom’s mother contacted the Local Authority and requested that he and an older sibling be accommodated information redacted. This request  8  was passed from the ASKK to CSC and an initial assessment was undertaken which was completed on information redacted. The outcome of this assessment was that Tom was to be referred to information redacted (a service provided by the YOT prevention service) and that the parents would be assisted via the Multisystem Therapy Team (MST). It is unclear which agencies were consulted as part of this assessment information redacted.  2.4.7 On information redacted Tom’s mother contacted CSC to say that she had not ‘…seen Tom for two weeks…. [he] has come home covered in faeces and vomit… [CSC] could take them into care’. No action was taken. On information redacted a social worker telephoned Tom’s mother who wanted him removed that day information redacted. Following this the social worker reported Tom to the police as missing. The police contacted Tom’s mother who refused them entry to her house. On information redacted Tom’s father advised the Police that he had returned the previous evening but the parents refused to allow the police access to the house to meet with Tom. They attempted to see him at school but he had been excluded. On information redacted Tom absconded again and as the parents were not willing to report him as missing the social worker again did so. On information redacted the CSC Prevention and Resource Panel determined that a core assessment should be completed before there was any decision to accommodate Tom and that the ‘missing person’s protocol’ should be followed by the social worker.  2.4.8 Tom was returned home by the police on information redacted; he absconded again that night and was reported missing by his father on information redacted. The police returned him home on information redacted but his father was not keen for him to return and the police placed him instead with an older sibling. On information redacted his mother contacted the Emergency Duty Team (EDT) saying ‘her son is out of control and keeps running away…refusing to return home.’ The EDT case note record says ‘it would appear a decision needs to be made by Day Services about an alternative placement…’ there is no evidence that any action was taken.  2.4.9 On information redacted the school contacted the social worker saying that Tom wanted to talk to a social worker because he was homeless. The social worker contacted the parents who denied that they had thrown Tom out. The social worker then told the school to send Tom home and that she would see him at the school on information redacted. When they met the social worker discussed with Tom the possibility of a respite placement however Tom’s father when telephoned refused to agree to this happening. The school were expressing concern about Tom and raised questions about whether he was ‘sleeping rough’. The social worker then visited the parents on information redacted who were not willing to agree to Tom being accommodated on a respite care basis as they felt that it would not achieve anything. Tom was absent from the family home for most of the rest of the week information redacted. On information redacted the social worker agreed with MST to defer discussing foster care until they had been able to engage with the family. On information redacted the MST undertook an initial assessment  9  with the parents; they had no contact with Tom or his older sibling. They followed this by two further visits to the family on information redacted.  2.4.10 During August Tom was often absconding although his parents did not report him missing.  Information redacted. The social worker reported Tom missing on information redacted. The social worker again reported him missing two weeks later although it is not clear why. There was no contact with Tom by social care during August although there was telephone contact with his mother.  Information redacted. YOT contacted Tom’s mother who declined their services and said that she was unhappy with Social Services and would be making a complaint about them.   2.4.11 On information redacted Tom was found by the police information redacted at 23.15 and was taken home, he refused to answer any questions and stated that he had been wandering the streets and staying with friends. The police passed this information through to Kingston CSC. On information redacted Tom was given financial support by a duty worker for CSC. On information redacted Tom was arrested in connection with an assault on a youth information redacted; Tom admitted the offence and was bailed. On information redacted there was a meeting at the family home attended by YISP/REWIND, MST and the social worker. At the meeting the parents reported that Tom wanted to be in foster-care and that was the reason for his behaviour, they also expressed concern about his school placement.  Information redacted. The professionals recommended that Tom move to foster-care and that the family work with the MST team to resolve the problems; this was rejected by the parents.  2.4.12 On information redacted Tom attended school with a bruise on his cheek said to have been caused by his father. There was a strategy discussion with the police and a legal planning meeting. The decisions reached were that there should be no criminal action but that a section 47 assessment should be undertaken on Tom’s younger siblings and he should be placed in foster care. Information redacted. Both parents were contacted and indicated that they did not want Tom to go to foster care however after discussion he was accommodated and placed in a foster home, in a neighbouring borough, with an expected return home within one month. The next day, information redacted, Tom did not return home from school and was reported missing by the foster carer he was found and returned by the police to the placement on information redacted September. At this point he was noted to be looked after but it was not recorded that he was placed out of borough. The police information on the missing person reports from this point forward are passed to a neighbouring borough CSC not Kingston. Tom was reported missing again by the foster carer information redacted and was found by the police and seen at school on information redacted when he advised them that he did not want to return to the foster home after school but preferred to remain with his friends in the local area. Tom did not return home from school on information redacted and so was reported missing again that day he was eventually found by the police on information redacted. There is no evidence that Tom was seen by a social worker in the two weeks after he was  10  accommodated. His parents have almost daily contact at this time with both the social worker and the MST worker information redacted.  2.4.13 On information redacted Tom was arrested for an offence and was also debriefed about going missing; he refused to answer any questions and was returned to the foster home the following day. Tom was then charged information redacted and placed on police bail. On information redacted Tom was seen in the foster home by his social worker. Tom’s demeanour in school deteriorated during information redacted and he was excluded for five days because of poor behaviour. The school tried to refer Tom to the Pupil Referral Unit but the parents opposed this; they also tried to arrange a managed transfer to a local school requested by Tom’s parents, but this was not successful because the school were over numbers in that year group. The parents were encouraged to appeal against this decision however took no action but insisted to the Local Authority that this was the only suitable mainstream school for Tom. Eventually on information redacted Tom was permanently excluded from school because of his ‘poor behaviour and a lack of parental support’.   2.4.14 On information redacted a new social worker took over as key worker. During October a first Looked After Child (LAC) Review was held. This involved three meetings; the first information redacted was a meeting between the Social worker and the IRO; the second information redacted included the social worker, IRO and Team manager; and the third  information redacted involved Tom, his parents, information redacted, the foster carer and her support worker, Tom’s social worker; the MST worker and the IRO. At this point there was no Personal Education Plan (PEP) in place. There was no involvement in the review by YOT, the school or the LAC nurse or doctor.   2.4.15 The social worker had arranged for Tom to attend the PRU but his mother was not happy with this temporary arrangement and refused it. Tom then walked out of the review meeting. The plan at the LAC review was that Tom should return home within four weeks providing a school placement could be found. Tom was out of school for three weeks following his exclusion and started at a new secondary school on information redacted. Tom attended the new school for three days and then went missing from the foster placement and stopped attending school. In late November there was some discussion between the school, the LAC Education Achievement Advisor and the Exclusion and Re-integration Officer about the best way to ensure Tom’s attendance at school. It was considered that Tom did not go to school because he wanted to be at home. No other action was taken for the rest of that school term.  2.4.16 During October information redacted there were five meetings between the MST worker and the family, Tom was present at only one of these meetings. Much of the focus of the meetings was on the parents reporting on Tom’s activities and the parents’ unhappiness with the social worker’s actions in placing Tom in foster-care. Information redacted.   11  2.4.17 During October information redacted Tom was reported as missing from the foster placement five times. On a number of occasions he was returned to the placement by the police but sometimes he returned alone, he also visited his parents during this time. In November information redacted Tom continued to go missing regularly and he was reported missing to the police eight times. On many occasions he returned of his own accord within twenty-four hours information redacted.   2.4.18 Tom attended court on information redacted where he pleaded guilty information redacted and was sentenced information redacted. As a result YISP, who had never been able to engage with Tom, because his mother was unwilling to give consent to their involvement, withdrew.   2.4.19 MST continued to work with the family and during November information redacted had three meetings with the parents about Tom as well as another meeting with Tom and his older sibling.  Information redacted.   2.4.20  In December information redacted Tom was stopped by British Transport Police at a London mainline station and said he had been sleeping rough with a friend, he was returned to the foster home. On information redacted December Tom was reported missing by the foster carer and the next day he failed to appear at the police station in response to his bail hearing and so he was circulated to the police as ‘wanted’. On information redacted Tom was arrested for an offence on the previous day information redacted. He was charged information redacted the following day and remanded in custody. Tom appeared in court on information redacted and was made the subject of bail conditions requiring him to live at his foster home with a curfew between 20.00 and 06.00 hours to be electronically monitored.  Information redacted. For the rest of December Tom broadly co-operated with the requirements of his bail.  2.4.21 On 10th December information redacted a second LAC review was held attended by Tom’s parents information redacted, the social worker, the year head from the school, MST and the foster carer and her supporting social worker. Tom was in police custody so could not attend. There is no evidence that YOT or the LAC nurse or doctor were involved or consulted. At this point Tom was the subject of a referral order, had started at a new school and stopped attending after three days and had not had any health assessment undertaken despite some reports of substance misuse being reported in the sessions with MST. The outcome of this review was a plan that Tom would return to his parents on information redacted. There is no record of any contact between the social worker and Tom except for seeing him at the LAC reviews.  2.4.22 During December information redacted MST continued to work with the parents seeing them at the LAC review and for further meetings on three occasions. The work of the therapist was directed towards Tom returning to his parent’s care but he was not involved directly in many meetings. On information redacted December the therapist advised Tom’s parents that MST involvement might have to end because it was intended to be time- 12  limited and she was concerned that it was not proving to be productive. A further meeting was held in January (not attended by Tom) where Tom’s parents reported that they had seen Tom on Christmas Day and Boxing Day and that he had told them that he wanted to return home. A plan was agreed with the parents of Tom spending increased time at home from mid January onwards with a view to him returning home later in the month.  2.4.23 On 10th January information redacted the social worker and YOT worker visited Tom at the foster placement and he told them he had a good Christmas visit to his parents and that he wanted to return home. Tom was advised to attend the MST meeting arranged for the next day, to go to school and to prepare for his court appearance information redacted. On information redacted Tom was arrested in connection with an offence that he admitted to having observed but denied direct involvement. He was found to have in his possession an item that was thought to be stolen and so was bailed for five weeks. Tom then attended the MST session and talked positively about the electronic tag helping him stick to curfew and said that he had been attending school.  2.4.24 On information redacted Tom attended court and pleaded guilty information redacted. He was sentenced information redacted. Tom spent the weekend at his parent’s house but this did not go well information redacted. At the MST session on information redacted Tom’s parents indicated that they did not think he could return home and confirmed this view at a follow-up meeting information redacted. Tom’s view was that when he was at home he was picked on by his siblings and his parents did not support him. MST ceased active involvement with the family from the end of January although unsuccessful attempts were made in February and April to have closing sessions with both the parents and Tom.  2.4.25 On information redacted Tom was seen by the Substance Misuse Service following a referral being made by the YOT worker. Information redacted. In February Tom was given a harassment warning in the presence of his foster carer. On information redacted January Tom was reported missing from the foster placement and was found by the police very early the next morning and returned to the foster home. Tom was reported missing again on information redacted January when he appears to have been with Vic; he returned voluntarily the next day. On information redacted January the social worker and YOT worker saw Tom together. He advised them he did not want to see his parents and was not going to attend school.   2.4.26 During February Tom attended three sessions out of four at the SMS. On two occasions he engaged well but was ‘under the influence’ at the third session. Information redacted. He saw his YOS worker on information redacted February and spoke positively about relations with his parents and said that he was aiming to ‘stay out of trouble’. The YOT worker spoke to the foster carer on information redacted February who was less positive and admitted that Tom was missing. When Tom met with his YOT worker on information redacted February he admitted that he was ‘under the influence’. On information redacted Tom was reported as missing to the police by the  13  foster carer and returned of his own accord in the late evening on the information redacted. Early in the evening on information redacted there was an attempted robbery information redacted; Tom was identified as one of the assailants and was later charged information redacted. There was no recorded contact between Tom and his social worker during February and his key worker was changed again on the 17th February. Tom did not attend school during February information redacted and there is no evidence that any professional, education or social care attempted to address this with him.  2.4.27 During March information redacted the foster carer reported Tom missing on five occasions; he is also stopped by the police on four occasions.  He attended two meetings with an SMS worker. He did not attend school and did not meet with his YOT worker and so was reported for breach of his order on information redacted. On information redacted Tom visited his family home and was verbally aggressive towards his younger brother and had to be removed from the family home. On information redacted there were two incidents involving the use of weapons. Tom was implicated and on information redacted he was arrested (with Vic) information redacted. Following this arrest Tom was charged with the offences information redacted to which he pleaded not guilty. He appeared in court the next day when he was remanded to a Secure Training Centre (STC) information redacted.  2.4.28 Tom remained at the STC until information redacted he was transferred to HM Prison and Young Offender Institution (YOI) because of his aggression towards staff and other young people. The social worker arranged for his foster placement to be kept open whilst he was in custody. A review was held at the STC on information redacted attended by his the YOT worker and Tom but not by his parents who did not visit him; it is not clear if this was a LAC review or secure review. Concern was expressed at this meeting about his parents’ attitude and a recommendation was made to consider whether there should be a legal planning meeting to consider care proceedings. There is no evidence of any action being taken with regard to this recommendation. After Tom was moved to the YOI he was deemed not to be ‘looked after’ and therefore no LAC review meetings were held. There is also no evidence that he was visited by a social worker whilst there. Information redacted.    2.4.29 Tom was discharged from the YOI in June information redacted. He returned to the foster placement where he was seen by the social worker on information redacted. Tom initially co-operated with the requirements of the rehabilitation order; he attended his induction and a behaviour group information redacted and attended a reintegration meeting at the school information redacted. He was reported as missing on information redacted returning of his own accord the following day. He failed YOT appointments information redacted however was not issued with a warning as the foster carer said she had not received the appointments.   14  2.4.30 On information redacted Tom was arrested with regard to a possible offence but no action was taken. He was not attending school and was reported as missing information redacted returning of his own accord the next day. A LAC review was held on 1st July information redacted attended by Tom, the social worker, the YOT worker and the education worker from YOT worker, the foster carer and her support worker; his parents did not attend. At this review it was noted that Tom was attending a Youth Rehabilitation Project, was not attending school and sometimes stayed out overnight without informing his carer. The decisions from this meeting were to work towards a possible return home and to reintegrate him into school.  2.4.31 During July and August information redacted Tom co-operated minimally with the YOT supervision requirements and was close to being breached in information redacted August. He also was reported as missing on a number of occasions usually returning of his own accord. He was stopped by the police on three occasions but was not arrested. In September Tom’s non-compliance with the YOT requirements increased and he was breached in court  information redacted when the order was allowed to continue with no separate penalty despite this being a third breach and a clear history of disengagement with statutory orders.  2.4.32 During September information redacted Tom was reported as missing five times; he returned of his own accord on all occasions usually only being missing for one or two days.  Information redacted. The LAC review was not attended by Tom’s parents and the professionals involved were the YOT worker and social worker and foster carer. It was clear that Tom had not been in contact with his parents and he was said to have returned to school on a part-time basis. The conclusions of the meeting were that Tom was to stay in placement until information redacted, that a PEP meeting should take place and that he should visit a local lodgings project which was considered a possible future placement. Information redacted.   2.4.33 During October, November and December information redacted there was little change. Tom continued to go missing regularly (he was reported missing by the foster carer on nine occasions) but on most occasions returned of his own accord frequently the same day or early next morning. He was stopped by the police on eight occasions; on one occasion this was because he was involved in a fight at the school with Vic and some other boys and on another occasion he was involved in another fight on a bus, Vic was not present on this occasion.   2.4.34 During this time Tom was not attending school and there were discussions between education staff, the social worker and the YOT worker about this on three occasions. Finally a meeting was held information redacted when it was agreed that alternative provision would be explored for Tom as school was not working at this point it was recorded that he had attended three sessions at the school since September information redacted. During October Tom was failing to co-operate with the YOT worker leading to the breach. Immediately after this court appearance information redacted he again failed to attend however this was then followed by a period of minimal  15  engagement until his order expired information redacted when the case was closed to the YOT. The social worker is recorded as seeing Tom once during this period information redacted however that worker ceased to be the key worker soon after this visit.  2.4.35 Tom had no contact with his family over Christmas spending it with the foster carer. His mother contacted the new social worker on information redacted to say that children’s services were ‘…failing her son…’ Tom was missing from the placement from information redacted however he was not reported missing for the rest of the month. The new social worker visited on information redacted and Tom told her that he wanted to stay at the placement and did not want to see his family. Tom was not in education at this time and was stopped by the police on three occasions in January, twice with Vic. On information redacted Tom was charged with an offence, this related to the incident on information redacted where he was involved in a fight on a bus.   2.4.36 On information redacted Tom was arrested for an offence in a neighbouring county; his co-defendant in this matter was Vic. During February Tom was missing from the placement on three occasions information redacted. He saw his social worker on information redacted when he denied involvement in the offence. He also had a health assessment on information redacted. During February and March Tom was stopped by the police on six occasions, for four of these he was accompanied by Vic. There was a LAC review on information redacted. He did not want to see his parents who had not contacted him for Christmas or his birthday. The conclusion of the review was that Tom was to stay in the foster placement for at least another twelve months so long as he regularly attended college from September  information redacted; the social worker was also attempting to arrange some educational input prior to then. Tom saw his social worker on information redacted. The next day his mother contacted the social worker information redacted. During April information redacted the LAC Education Achievement Advisor was negotiating for Tom to attend a Foundation Learning Programme and a referral had been made to an education and employment project for young people; he had been offered a place at a Further Education College from September information redacted. On information redacted the social worker completed a pathway plan assessment with Tom which concluded that he was not yet ready for semi-independence.  2.4.37 On information redacted Tom was arrested with Vic for possessing an offensive weapon. Both young men were charged and remanded to appear in court the next day. In court Tom pleaded guilty and was remanded on conditional bail information redacted. On information redacted Tom was seen at 01.06 hours by the police and escaped information redacted. On information redacted Tom was reported missing by the foster carer but returned home later that night. On information redacted Tom was arrested for breach of his bail and appeared in court the next day after which he was fitted with a tag. During the next two weeks Tom was stopped by the police on a number of occasions but was seen to be observing his curfew times and bail requirements. On information redacted Tom was arrested for breach  16  of his bail conditions as he had been seen with Vic earlier that day, he was kept in custody to appear in court the next day. On information redacted Tom appeared in court and was sentenced to a youth information redacted order information redacted. Later that day both Tom and Vic were involved in the incident with a third party where they were both injured. Information redacted.   2.5 Agencies’ Involvement with Vic 2.5.1 Information redacted Vic attended a local secondary school. He presented few problems for the school in Year 8 but his attitude deteriorated in Year 9. He was disruptive, rude and aggressive which resulted in some fixed term exclusions in October and December information redacted. In January his mother shared with the school that she was also having difficulties managing his behaviour at home. Various members of the pastoral team attempted to assist but were not successful. Vic was a talented sportsman and in information redacted he transferred to a specialist information redacted Academy information redacted. Vic had some difficulties attending the information redacted Academy as the journey was lengthy each day and there were on occasions evening training sessions in information redacted. On information redacted Vic was reported missing by his mother but in fact had fallen asleep on the train information redacted. To alleviate these pressures Vic lodged with a staff member’s family during the week and returned home to his mother at weekends. Vic attended the information redacted Academy until information redacted. The school record details that Vic ceased attending school because he had moved to another country however he did not do this until information redacted.  2.5.2 Between April and December information redacted Vic started to present some challenges to his mother. She reported him missing on four occasions and each time he was spending time with Tom or another young man known to both of them. On information redacted Vic was arrested for an offence. Information redacted. On information redacted he was seen by a community police officer to try and steal an item, this matter was resolved by him being given a warning.  2.5.3 In November Vic’s mother contacted the Substance Misuse Service (SMS) because she had concerns about her son’s drug use. Vic was offered an appointment on the same day which he attended.  Information redacted. A risk assessment was undertaken and he was offered a follow-up appointment information redacted. He failed to keep this meeting and a further appointment despite the worker attempting to contact him via letter and text. The case was closed in January.    2.5.4 On information redacted Vic was arrested for an offence; he was interviewed and bailed information redacted. On information redacted January Vic went missing with Tom. His mother reported him missing to the police and he returned of his own accord the following day.  On information redacted Vic’s mother approached CSC asking for assistance, she mentioned his contact with Tom as a factor in his difficult behaviour. A social worker was allocated to undertake an initial assessment this was concluded on 16th February and  17  the outcome was referral to another agency, YOT, and the case was closed on 21st February. On information redacted Vic appeared in court and pleaded guilty to the offence; he was sentenced information redacted. Prior to his appearance in court his mother had arranged for his father to take him to another country in an attempt to separate him from his peers. This arrangement was agreed with the YOT case manager, so long as he returned in a month and reported to YOT in accordance with the order.   2.5.5 On information redacted Vic’s mother contacted YOT and the police informed them that Vic, who was due to return to England information redacted, had run away from his father’s care. Vic’s parents had decided that he should not return to England and this was the trigger for him running. Vic was picked up by the police at St Pancras and was returned to his mother’s care. In March Vic attended his first YOT appointment and on information redacted he was arrested with Tom for a criminal offence involving use of a weapon. Both young men were charged and appeared in court information redacted. The outcome was that Vic was returned home on bail, but with curfew conditions and to have no contact with Tom, who was remanded into secure accommodation.  2.5.6 Vic was arrested for theft information redacted and breach of bail in April. He then failed to co-operate with curfew requirements and was arrested for breach of curfew arrangements on information redacted. The YOT worker referred him to MST on 12th April. On information redacted the police started an investigation of a criminal incident involving a weapon in which Vic was named as one of the suspects. As a result Vic was arrested information redacted; he appeared in court on information redacted and was remanded into care to a Secure Unit. As a result the MST work did not start as they do not work with families whilst young people are in custody.  2.5.7 Vic remained in the secure unit until June. Whilst in the unit he was involved in a fight and placed on the bullying log twice information redacted. A LAC review was held on 5th May attended by Vic, the social worker, his mother and a manager. The review identified the need information redacted for dental and optical appointments to be made. Information redacted.  On information redacted Vic pleaded guilty to possession of an offensive weapon but not guilty to the other offence. The YOT case manager discussed with Vic his reasons for carrying the weapon and was concerned about his cognitive processing in terms of attitude towards carrying weapons.  2.5.8 Vic was granted bail information redacted and returned to live with his mother. He was subject to a curfew between 1900 and 0700 hours and was electronically monitored as part of bail conditions, there was no requirement regarding contact with Tom. At this point Vic had no school place and there was no obvious activity for him in the day time. He was stopped by the police on two occasions in July. On 6th July Vic’s YOT caseworker had a joint session with him and Tom to try and develop the positive side of their relationship; she was concerned that they both lacked victim empathy. Vic’s social worker also referred the family to the Family Intervention Project on  18  the 6th July. On 14th July Vic’s mother was advised by education to make an application to school admissions for a school place for Vic and the same day contacted the YOT worker saying that she was concerned about Vic’s aggressive behaviour information redacted. This worker contacted the police who visited. Vic had become angry and had thrown property around his bedroom; he agreed to try and control his temper. The next day Vic’s mother contacted YOT repeating her concerns regarding Vic’s temper information redacted. On information redacted Vic cut his curfew tag off and went missing, with Tom. He continued to breach his bail conditions and on information redacted he was taken to court and re-remanded to a Secure Training centre.   2.5.9 Vic remained in the secure training centre until September. Initially Vic’s behaviour was challenging and there were questions as to whether he would be able to stay however this behaviour modified information redacted.  2.5.10 A LAC review meeting was held on 5th August attended by Vic’s mother, YOT, and staff from the secure unit, the social worker was not present. The meeting was attended by Vic information redacted. His mother advised professionals that information redacted she was having phone contact but not visiting. Information redacted. No date was fixed for the next review. There was no evidence that Vic was visited by a social worker prior to his release and most of the supervision records at this time relate to the need to transfer case responsibility to the LAC team. A plan dated 28th September indicated that a core assessment should be undertaken to identify supports for the family to ensure that ‘…he [Vic] does not revert to criminal activity…’ however this was not completed until January. While Vic was in the secure unit his mother applied on his behalf for a place at a community college she was also supported by the FIP Project who became involved in July.   2.5.11 Vic was acquitted of robbery on information redacted and was released from the secure unit on bail with curfew requirements. His social worker was on long term leave and so another worker had been allocated to him. On information redacted Vic was stopped by the police outside his curfew hours and ran away. On 10th October Vic’s mother contacted the YOT and CSC saying that she could not cope with him and would not be attending court with him or taking him to school; furthermore she said that he was breaching his curfew and that she thought he was staying with Tom. On information redacted Vic was arrested with Tom at a fight outside the school, his mother refused to act as a responsible adult and he was detained for court.  The next day Vic was involved in a fight information redacted. His mother took him to hospital which meant that he was breaching his curfew; she advised the police of the reasons for the breach. On 16th October Vic’s mother contacted EDT upset and crying saying that she could not cope with having Vic at home as he was beyond her control. The EDT worker recommended an assessment as the family was in crisis. The social worker attempted unsuccessfully to contact the YOT worker and was advised in supervision to undertake a core assessment but that Vic was ‘…not to be received into care…’   19  2.5.12 Although Vic’s mother had applied for a school placement for him the Individual Pupil Management Meeting in September decided that the option of an additional/alternative placement at the pupil referral unit should be considered given that Vic was in Year 11 and had been out of mainstream school for over six months. By information redacted October this had still not been arranged.   2.5.13 On information redacted Vic was in breach of his curfew; he was arrested for   three offences.  One offence resulted from Vic intervening to prevent the police from arresting Tom and a friend. On 1st November information redacted Vic and his mother were seen by a social worker. Following this there was negotiation with the YOT regarding the provision of tuition in a local library. On 1st November a referral letter was received by Kingston Family Adolescent and Child Team (FACT) from FIP asking for support because of cognitive clumsiness this referral was declined on 8th November and FIP was advised to approach a psychologist within the YOT. A whole family assessment meeting planned for 9th November was then cancelled as the social worker was unavailable.   2.5.14 On information redacted Vic was arrested for failure to appear in court information redacted. On information redacted he pleaded guilty to one of the offences and was remanded on conditional bail with curfew arrangements and electronic tagging. On information redacted Vic pleaded guilty to a second offence and was sentenced information redacted. The requirements for curfew were lifted at this court hearing. On information redacted Vic was sentenced information redacted for one of the offences. Following this court appearance there was consideration of his educational needs and on 17th November (seven weeks after his discharge from the secure unit) a package of alternative provision at the Pupil Referral unit (PRU) was arranged. A meeting with the tutors was scheduled for the 24th November however Vic and his mother failed to attend it.  2.5.15 On information redacted Vic was arrested with two others for possession of an illegal substance. Vic’s mother spoke to a social worker on 29th November and was very distressed. Vic’s mother was very concerned about the impact of Vic’s behaviour information redacted and was asking for Vic to be removed. As a result an initial assessment was undertaken with regard to his sibling on 12th December. This concluded that there was a strong bond between the sibling and Vic’s mother and that it would not be appropriate for Vic to be placed outside the family home but that ‘... the intensive package of care in place should continue…’ and that his mother should engage in the work with FIP. A planning meeting with FIP took place on 16th December. There was a change of social worker at this point as the previous worker had returned from extended leave.  2.5.16 In January information redacted Vic appeared in court on two occasions; he was stopped by the police on four occasions, on two occasions (with Tom)  information redacted and was charged with possession of drugs information redacted, this related to the incident in November when he was found with  drugs and street-bailed. On 4th January Vic was contacted by SMS and  20  offered support but he denied any drug problems and declined the service. The social worker had telephone contact with Vic’s mother but no contact with him. A network meeting was held with the FIP worker on the 18th January. On the 30th January the social worker completed a core assessment that recommended no further action on the basis that Vic was not engaging with the social worker and other agencies (YOT and FIP) were involved. At this time Vic was not attending education and on 19th January he and his mother attended a meeting with the education welfare service and YOT education worker. Their preference at this stage was that Vic should be home-educated however they were persuaded by the professionals to consider a NACRO education project. This was arranged to start on 9th February.   2.5.17 On information redacted Vic appeared in court and pleaded guilty to possession of drugs and was sentenced information redacted. The same day Vic’s mother contacted CSC saying that she was very concerned because Vic had started dealing in drugs ‘…suspicious people come to the door..’ and she was concerned about the effect on his younger sibling. The social worker asked for Vic to immediately come to the office and arranged to see his mother on 6th February; she also liaised with the YOT worker who advised her that YOT were considering making help with substance misuse a part of the order but thought it was unlikely.   2.5.18 On information redacted Vic was in custody for an offence; he had gone missing with Tom and another friend on the 4th February. Vic returned home to his mother on 7th February but remained for a short period before leaving because he was angry information redacted. Vic did however start attending the NACRO education project from 9th February and attended regularly throughout the month. Vic was stopped and searched by the police on two occasions in February but there was no contact with other professionals. There was also a meeting with FIP and possibly MST on 20th February.  2.5.19 In March Vic was stopped by the police on two occasions, on both occasions he was with Tom. By 15th March Vic’s attendance on the NACRO programme was at 50% of the sessions and on 29th March the trial placement was not extended due to lack of engagement and Vic started to be home educated for the remaining period of statutory education requirement. Vic appeared in court on information redacted March and was sentenced for three offences and committing an offence whilst a Youth Rehabilitation Order was in force. He received a further Youth Rehabilitation Order information redacted.   2.5.20 MST started work with Vic and his family on 19th March following a request in mid-February from Vic’s mother for further support.  MST attended a FIP review on 21st March. MST met with Vic on 26th March at home. There were then sessions with Vic and his mother on 3rd April, 4th April, 11th April, 12th April 16th 17th April 23rd April and 25th April. This work was aimed at developing a behaviour plan and house rules. On 17th April there was a meeting with FIP to work out how to handover case responsibility as it was not considered appropriate for both agencies to be involved. There was no  21  other agency contact during April and Vic was only stopped once by the police in April when he was with Tom. On 1st May information redacted CSC ceased to work with Vic on the basis that YOT, FIP and MST were involved with the family. MST continued to work with the family throughout May having meetings on 2nd May, 8th May (when the FIP worker ceased to be involved), 9th May, 14th May, 16th May and 22nd May. The focus of work was on understanding Vic’s motivation for criminal behaviour and in particular his use of weapons. He reported that he carried them as a defence (as did his peers) because of threats made against him.   2.5.21 On information redacted Vic was arrested with Tom for possessing an offensive weapon. Both young men were charged and remanded to appear in court the next day when Vic pleaded guilty and was remanded on bail with conditions that included a curfew to be electronically monitored, no contact with Tom and to keep all appointments with YOT. On 8th May Vic’s mother contacted the police to report that Vic had received threatening texts from another young man and that this was the reason he had been carrying the offensive weapon. The police visited on 10th May and initially Vic would not speak to the police but was persuaded by his mother. Information redacted. Unfortunately Vic was not able to name the young men who had sent the texts and had not kept the messages. He was also not willing to substantiate any of the allegations and would not disclose the name of another person whose Facebook account had been used to send similar threats. The police therefore could not take any action. On information redacted Vic’s mother called the police after she saw Vic being threatened by another boy with a knife. Vic was annoyed that his mother had called the police and would not speak to the police officer. Vic was visited by the police information redacted but he would not substantiate the allegation and so was given safety advice and was told not to take matters into his own hands. During May Vic was stopped and searched by the police on four occasions, on one occasion (twice in the same day).   2.5.22 On information redacted Vic was arrested for breach of his bail conditions as he had been seen with Tom earlier that day; he was kept in custody to appear in court the next day. On information redacted Vic appeared in court and was sentenced to a youth rehabilitation order with supervision and curfew requirements including electronic tagging. Later that day both Tom and Vic were involved in an incident with a third party where they were both injured. Information redacted.    3. VIEWS OF FAMILY MEMBERS 3.1 Contribution from Tom’s mother based on interview on 18th December 2012. 3.1.1 Tom’s mother was very unhappy with the services that had been provided to her son and family and points out that they have asked for the services to work together to help but have been refused. Tom’s mother claims they only seem to want to help each other avoid having to do anything. Information redacted. She says that ‘the family failed to get the necessary support information redacted that they asked for and instead adult services refused to  22  work with children’s services except to consider them as a problem or at risk.’ Tom’s mother is currently in legal dispute with the Local Authority information redacted and it is for that reason that she was unwilling to give the Serious Case Review Panel access to her medical notes.  3.1.2 Tom’s mother identified her difficulties as starting while Tom was at secondary school and said that when he was there he was bullied by other young men information redacted and she ascribes the incident in April information redacted to this. She also felt that the secondary school was poorly managed and that her sons were unduly punished for poor behaviour. Tom’s mother did say however that she was experiencing difficulties managing Tom information redacted.   3.1.3 Tom’s mother said she did not agree with him moving to a foster-home and described it as the Local Authority ‘snatching him from her care’ whilst he was at school. She said that she agreed reluctantly to him staying short term in the hope that the ‘supported planned re-integration’ offered would help her care for Tom but it never happened and once Tom was in foster care she felt that there were very different rules applied in the two homes despite promises this would not happen and that Tom was not expected to abide by appropriate house rules which meant that he did not want to return home as Tom felt he could do just what he wanted in foster care which he thought was great but could not cope with this ‘freedom’ and went totally overboard. 3.1.4 Tom’s mother felt that he was rewarded for poor behaviour and that this was fundamentally wrong. Tom’s mother did not find the police or social care supportive and said it was not unusual for Police to arrive in the middle of the night to wake the family and demand to search the house because Tom was missing yet again and often they were rude and difficult as well. Also MST said that they were unable to work properly because Tom was in foster-care not at home. Tom’s mother complains that the Local Authority claim Tom is on a section 20 but the family do not consent to him being held by social services who now say they can keep him because he wants to stay. She complains that the family have been totally excluded from all processes involving Tom and his welfare and have no say at all in anything. Their parental rights have been totally removed without any Court hearing or process ever taking place which is illegal. She says she had warned many times of the terrible consequences this would bring but no one would take any notice. 3.1.5 Tom’s mother was very critical about the ways in which Tom’s behaviour was and is being managed by the foster carer and the social workers feeling that it is ineffective and that he should be subject to a stricter regime with clearer consequences for poor behaviour and not given money for drugs or allowed to stay out in unknown places overnight. She says Tom himself claims he is being paid to stay where he is and that he is saving his money and has got what he considers to be a lot. He is now waiting to be housed. She is also very critical of the behaviour of the foster carer who has been given the parents number several times but did not even phone when Tom was in hospital information redacted. She also complained about his family picking Tom up to visit them.  23  3.1.6 Tom’s mother also felt that gangs and drugs use were a significant feature with regard to Tom’s behaviour. She was clear that she felt that Tom and Vic and some other young men were in a ‘gang’ together and that on a number of occasions there had been gang disputes which had resulted in them being hurt. Tom’s mother was very clear that the incident when both young men were injured information redacted was associated with a gang process.   3.1.7 Tom’s mother wanted a recommendation from the serious case review to be that there should be a truly independent body for people to complain to about the local authority with powers to hold the local authority to account and force them to abide by the law and governmental guidance. She says ‘The public must be able to complain about unfair or illegal treatment and enforce their legal rights especially those relating to parental rights in relation to their own children without having to fight to be heard. We did nothing at all to lose our children and our parental rights. Parents should be able to say they have been lied to, deceived or cheated by the Local Authority if they feel this is happening. At the current time Local Authority is pretty much free to do anything wrong they like and the only thing that can happen is that another review will take place. This will not stop abuse of power or bad practice and it will not fix the problems going on so many more disasters will keep happening. Something fundamental has to change and the Local Authority has to accept that they are supposed to provide public services to a paying public not ideological manipulation of families or money and comfortable housing to naughty children who want to take drugs party and behave badly without parental wrath or punishment.’ 3.18 Further comments were made by Tom’s mother. However, these referred to incidents and situations that were outside the agreed timeframe for this review, as set out in its terms of reference, and therefore have not been included in this report.  Tom’s mother’s contribution also raised significant concerns about some aspects of services that were provided to Tom. These matters were scrutinised as part of the review but were not considered to be substantiated. 3.2 Contribution from Vic’s mother based on interview on 19th December 2012. 3.2.1 Vic’s mother identified that her problems with Vic started at his first secondary school when he became involved with Tom and started to ‘act out’. Information redacted.  3.2.2 Vic’s mother saw the first major agency involvement stemming from January information redacted when he was arrested for an offence. She felt that at that time she felt very powerless and experienced the police intervention very negatively feeling that it was very punitive with very little scope for prevention. 3.2.3 Overall she felt that she received little help from social care or the police but that FIP and MST were helpful. FIP was particularly supportive and assisted her in caring for Vic’s sibling and ensuring that his behaviour caused as little damage as possible. The MST input was also useful and was progressing  24  well but was interrupted by information redacted Vic’s subsequent move to secure accommodation. 3.2.4 Vic’s mothers criticisms of the police were about the level of usage of stop and search and the fact that on occasions he was late home and in breach of his bail because he was stopped by the police. She felt that the over-use of stop and search meant that Vic had no faith in authority and so undermined others (YOT and MST) attempts to enable Vic to behave more positively. 3.2.5 Vic’s mother felt that YOT did not take sufficient notice of Vic’s substance misuse problems and that they should have asked the court to make him the subject of a drug treatment order that would have forced him to work with the substance misuse services. She also felt that he should have been breached sooner and that the service gave him too much leeway which was not in his best long term interests. Generally Vic’s mother felt that Vic had difficulty building relationship with and trusting in the YOT worker because of the number of changes in his key worker. More recently Vic has had one worker and has built a good rapport and this works better.  3.2.6 Vic’s mother felt that social care rarely provided support unless she was desperate and described being unaware of her key worker and not knowing how to contact them. She contrasted that with the very positive relationship she currently had with Vic’s social worker and said that she felt the service had previously been very disorganised. 3.2.7 Vic’s mother was very unhappy with the educational services provided to Vic and felt that he had been badly let down. Vic’s mother said that she received little guidance on what she should do to enable Vic to access education and felt that there was significant delay in any action being taken. She was critical that Vic had never been the subject of a statement for educational needs with regards to his ‘emotional and behavioural difficulties’ and did not feel that suitable ‘appropriate provision’ was provided for him. In particular she felt that the NACRO education should have been made available immediately after he was first released from secure accommodation, she was also clear that when it was eventually arranged it was because she organised it. Overall Vic’s mother felt that if he had been more fully occupied during the day through education and other activities it is possible that his more difficult behaviour could have been avoided.  4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS  4.1 Agency focus on procedures not outcomes 4.1.1 A significant feature of this review was that although there were high levels of input by most agencies working with these two young men there was very little evidence of any positive outcomes being achieved. This may be considered to be a facet of working with adolescents who are notoriously difficult to engage with services and often resist all interventions however the question that must be raised is the degree to which there was any review by agencies of the effectiveness of their interventions and any consideration of outcomes achieved.   25  4.1.2 It is clear from the IMRs that most professionals were acting in accordance with their local procedures and were providing services in an appropriate manner. The exception to this would be CSC where it is clear that there were considerable limitations in the social work interventions as described in the IMR. It is interesting then to consider why, if professionals were operating in accordance with procedures and protocols, so little was achieved with the young people. In order to understand this contradiction analysis must go beyond exploring whether procedures were followed to consider whether the procedures were right in the first place.   4.1.3 An example of an intervention that required significant resources but which achieved little in terms of outcomes were the ‘missing persons’ processes’. Major efforts were made by a range of professionals to ensure that these young men were reported missing to the police; which then involved the police in considerable efforts in both tracing the young men, and then undertaking follow-up interviews most of which provided minimal, useful information. As the Police IMR identifies, with the exception of reports being sent to the wrong borough, the police almost always followed procedures and the missing person investigations were completed in accordance with protocols. This however is to ignore the probable purpose of the protocols which surely must be to prevent the recurrence of the young person going missing. When judged by those standards the effectiveness of the intervention is significantly reduced. Research undertaken with young people in care who run away identified three main reasons for children running away; ‘…running somewhere simply to have fun… running to somebody you want to be with… and running away from your placement because you cannot cope with things there…’3 . Young people also said that sometimes young people were reported as missing when they had simply stayed out longer than they should or had gone somewhere without permission but intended to return. Many of Tom’s missing episodes either fit the last category or were simply ‘to have fun’ yet there was no evidence that professionals considered whether this should influence the professional responses made to his actions. Clearly when Tom and Vic were subject to curfew arrangements there was a need for more formal intervention however it is probable that this would have been better dealt with via breach protocol rather than the missing person procedures. 4.1.4 Similarly the YOT IMR also reports that in general the YOT work was in accordance with the National Standards for Youth Justice Services’ minimum requirements and thus was acceptable practice. It is clear however that in terms of reducing criminal activity committed by these two young men the YOT interventions were far from successful. The IMR does suggest that YOT could reflect on whether their interventions with ‘…regards to the balance of engaging him [Vic] compared with the enforcement of further external controls to monitor him…’ and also suggests that with regard to Tom ‘…a systemic team approach may have been beneficial within the integrated offender management system in order to review the plans and directions of the young people’s systemic support. It is relevant that at the time although there was                                                            3 Running away Young people’s views on running away from care Reported by the Children’s Rights Director for England Ofsted 2012  26  appropriate management oversight neither of these things were done. There was also very little attempt to bring together agencies (including police, CSC and education) to see if alternative interventions should be considered.   4.1.5 There were also very high levels of stop and search used by the police; all of which were deemed to be appropriate and in accordance with guidance. It is clear that these young men would generally meet the criteria accorded to the police for use of stop and search as clearly they did present on occasions a threat to the community and the safety of the public. The effectiveness of this intervention to prevent these young men from committing crimes is questionable and it is unclear what positive outcomes it achieved. It probably contributed to these young men having little confidence in the criminal justice system as a positive process that could protect them as well as controlling their actions; as witnessed by Vic’s unwillingness to co-operate when a victim. Research has shown that ‘stop and search’ may have a negative impact on some individuals. “There is no compelling ‘business case’ for the present level of stop and search … it has a deeply damaging effect on society; it impacts negatively on the law abiding population and is cause of a loss of public support for and de-legitimation of the police. It increases the frequency of adversarial encounters – some of which have the potential to trigger public disorder – and contributes to accelerating the flow of young black people disproportionately into the criminal justice system”4 . Information redacted. There was no consideration of using a multi-agency approach to address Vic’s behaviour; in particular the MST could have worked more proactively with him to enable him to manage the situation in a better way if they had been more aware of the problems.  4.1.6 There was no evidence that agencies reviewed their work with these young men in terms of its effectiveness. In fact despite there being systems in place to measure many of these interventions, the level and number of ‘stop and searches’ and ‘missing person incidents’ did not appear to be known prior to this review being undertaken. It was certainly never shared across agencies and there was no attempt to consider across all the agencies working with the young people whether there could be more effective interventions to achieve better outcomes. Despite both young people being ‘looked after’ for periods of time and a range of agencies being involved there was no evidence that there was ever a discussion between the professionals involved about whether there were other ways in which these young men could be helped. In fact there did not seem to be any expectation that this could or should happen.  4.1.7 The issue of greatest concern is that the absence of this was not examined within the IMRs and there was limited consideration within those reports as to whether the expected interventions were useful or effective. Instead these reports are focussed on whether professionals operated in accordance with the procedures. There was ‘A concern with doing things right versus a concern for doing the right thing.’5                                                           4 Race, Crime and Justice Bowling and Philips (2007: 959-60).  The challenge for Kingston LSCB is to 5 14 Peter Drucker (1909-2005), writer, management consultant, and ‘social ecologist’ quoted in The Munro Review of Child Protection Part One: A Systems Analysis Professor Eileen Munro DfE 2010  27  consider how agencies can promote and develop a multi-agency professional mind-set that enables consideration of the effectiveness of interventions and uses outcomes not outputs as measures of their success.    4.2 Insufficient direct work with young people 4.2.1 Despite these young people being of an age when they were very capable of expressing their wishes and feelings the chronology shows low levels of direct contact with the young men. Furthermore those professionals that saw them most were possibly the people who had least capacity for achieving a meaningful relationship. The professionals who had most direct contact were the police however their intervention was often in a context that could be adversarial and there was little continuity so did not provide opportunity for building relationships.   4.2.2 The other agency in regular contact with both young men was YOT and these case workers did have some opportunity for developing more meaningful contact. It must be acknowledged however that these workers are in an ambiguous position as they are also holding the young people to account for their criminal activity and are able to breach them if they fail to act in accordance with the orders to which the young people are subject. This probably places some constraints on the trust that will be accorded and for Vic was made more difficult by a lack of continuity of case worker. There was some evidence of a YOT case worker trying to build relationships information redacted when she met with both young men together to try and develop the positive side of the relationship. This was not further developed and soon after Vic was placed in secure accommodation.  4.2.3 MST also did direct work with both young men with different levels of engagement and success. The MST IMR rightly identifies that their intervention with Tom was less successful and concludes that this was because he was in foster care most of the time and did not attend appointments with the MST staff. The work with Vic was more successful but was challenged by his remands into custody. One of the significant differences between these two interventions was the level of direct contact between the MST worker and the young person; Vic attended five sessions compared with Tom attending one, but also Vic was engaged earlier in the process which probably enabled him to feel he had some control and input over the process. A significant feature of positive engagement with young people is a ‘…willingness to listen and show empathy, reliability, taking action, respecting confidences, and viewing the child or young person as a whole person…’6  It is possible that Tom considered the MST intervention was unfairly biased towards his mother as the bulk of the MST worker’s time was spent with her. It is clear that the worker made attempts to understand Tom’s perspective and the worker did meet with him alone however it is also evident that Tom did not consider that his parents were willing to accommodate his needs, which may be why, ultimately, the MST intervention failed.                                                             6 The Munro Review of Child Protection Interim Report: The Child’s Journey Professor Eileen Munro DfE 2011  28  4.2.4 An agency whose professionals should have had positive relationships with the young people was CSC; however it is noteworthy that these professionals had least contact with both young men despite them both being looked after and Tom in particular having been in foster care for almost eighteen months. In reality a lack of continuity in social workers and an absence of direct work being undertaken meant that Tom and Vic had minimal relations with their social workers. This was particularly unfortunate as they should have been the professionals who could have provided the young men with advocacy and support at points of crisis. ‘Elements of frontline practice that children and young people particularly valued were access to consistent help from the same social worker, to respectful treatment and to services which do not get withdrawn as soon as the crisis is passed.’7  The other person who did develop a positive relationship with Tom is his foster carer and it is positive that this placement was maintained which did enable this relationship to continue. The lack of continuity of social worker probably made it difficult for the foster carer to intervene purposefully on Tom’s behalf. 4.2.5 The absence of any truly effective relationship‐based practice with these young men contributed to their increasing alienation from the system of supports supposed to assist them. Whilst it is probable that much of their offending behaviour may still have occurred the chance to positively intervene was absent whilst there was no professional who had fully engaged with them. It may have also contributed to the lack of co-ordination of service delivery which is considered later in this report.    4.3 No timely response to provide services 4.3.1 Another facet of the services provided to these young men was the slow pace of service delivery which meant that often they were no longer willing or able to engage with options that had been discussed with them. It must be noted that some services did respond rapidly most notably the SMS who provided Vic with an appointment on the same day that his mother accessed the service, but also the police who generally visited in a timely manner.   4.3.2 A stark contrast was the provision of education by the Local Authority. There were delays in the provision of educational options and a failure to engage either young man in educational provision meaning that both Vic and Tom effectively did not attend formal education for almost two school years. This was particularly apparent when reviewing the arrangements for Vic’s education. He ceased attending the information redacted Academy in January information redacted and alternative educational provision was not provided for him until November information redacted. Initially his mother had some responsibility as she did not prioritise finding him a new school when he returned from abroad in March. It is unclear, however, why the Local Authority did not refer Vic to the Education Welfare Service when his mother did not identify a new school for him. Vic’s mother did apply for a school place in August information redacted when he was in secure accommodation. In early September, however, a decision was made by the Local Authority that it was unsuitable for him to be placed there. When he was discharged from secure accommodation on information redacted September it was almost six weeks                                                            7 The Munro Review of Child Protection Interim Report: The Child’s Journey Professor Eileen Munro DfE 2011  29  before alternative provision was provided. The lack of structured activity in the daytime was clearly a risk for re-offending yet despite this there was significant delay in provision of service. ‘Poor attendance or exclusion from school, or attendance at a Pupil Referral Unit, have been cited as key risk factors in the development of offending behaviour for young people’.8  This slow response was replicated when Vic failed to attend the PRU provision in November information redacted. Education welfare staff did not meet with Vic and his mother to discuss alternative options until 19th January information redacted and then he could not start at the NACRO project until 9th February information redacted. Vic did engage to some degree with this provision and it is possible if that had been provided immediately following his discharge from secure accommodation that different outcomes could have been achieved. 4.3.3 There were similar deficits with regard to Tom’s access to education. Despite having a school placement, he rarely attended school throughout 2011 and little was done successfully to address this. An example being that a meeting in December information redacted agreed that alternative provision should be explored for him, the options being foundation learning course and Princes Trust. Funding for this was not agreed until 21st February information redacted  and the application was made on 21st March information redacted but was delayed initially by the Easter holidays and then by Tom being remanded. In the event an appointment was not made until May by which time his foster carer had referred him to the education and employment programme for young people starting in September information redacted.  4.3.4 The delay in provision of education was most extreme but other agencies were also slow to provide services. After Vic left secure accommodation in September there was no contact with his mother by the social worker for ten days and that contact was only because she contacted them to say that she would no longer be responsible for him. It was only after his mother had contacted EDT on two occasions in October saying that she could no longer look after Vic that the social worker made contact.   4.3.5 Speedy and responsive service provision is essential to intervening positively with families when they are in crisis. This is particularly true of work with adolescents where there are often very limited windows of opportunity for intervention which need an immediate response.  4.4 Working with adolescents who offend in groups 4.4.1 A significant facet of this review was the extent to which Tom and Vic were offending together. It is clear that they were influenced and affected by each other’s actions as well as being involved consistently with at least one other young person. The extent to which this constituted ‘gang’ activity is open to debate. The definition of ‘gang’ activity in the London Safeguarding Children Board procedures is ‘…a relatively durable, predominantly street-based group of children who see themselves (and are seen by others) as a discernible group for whom crime and violence is integral to the group’s identity.’9                                                           8 (Farrington, 1995; Young et al, 2007) quoted in Teenagers at risk The safeguarding needs of young people in gangs and violent peer groups Kate Fitch NSPCC March 2009   9 Safeguarding children affected by gang activity and / or serious youth violence, London Safeguarding Children Board 2009   30   4.4.2 It is possible that the young men were developing a group identity and certainly they refer to other gangs and appear to be in conflict with young people who may be in gangs. Information redacted. Tom’s mother also referred to Tom and his brother being attacked by gangs. Both young men had also been attacked and suffered significant injuries and this is often evidence of gang involvement as young people involved in gangs are more likely to be victims as well as perpetrators of violence. Whether they were directly involved in a ‘gang’ or not it is clear that Tom and Vic were involved in co-offending behaviour that involved ‘serious youth violence’10 .  This accelerated during the period of the review and it was significant that both young men were alleged to have undertaken criminal activities using weapons and had been convicted of having offensive weapons on their person. Fear and a need for self-protection is the key motivation for carrying weapons – it affords a young person a feeling of power. Where a young person is involved with a gang or serious youth violence, the risk or potential risk of harm to the young person may be as a victim, a perpetrator or both. 4.4.3 It is clear from all the IMRs that professionals did not consider the issue of ‘gang’ violence prior to the review and none of them had considered using the London Safeguarding Protocol with regard to responding to the particular challenges of working with young people in gangs. They also did not identify the escalation in the levels of violence; a pattern of behaviour which is most common with serious youth violence that leads to serious injury or death. ‘By far the majority of children do not become violent overnight. Their behaviour represents many years of [increasingly] anti-social and aggressive acts, with aggressive habits learned early in life often the foundation for later behaviour. Where a child succeeds at low-level anti-social acts, such as verbal abuse and bullying, violating rules and being disruptive, s/he may feel emboldened to perpetrate increased violence.’11  This description certainly matches the profile of both young men whose activities became increasingly anti-social and involved increasing levels of violence and aggression. 4.4.4 Research into how best to respond to the needs of young people involved in serious offending behaviour identifies that it should ‘… be planned on a multi-agency basis and include provision from schools, youth offending teams, social care, police and youth and leisure services.’12                                                           10 The definition of ‘serious youth violence’ currently in use by the Metropolitan Police Service is ‘any offence of most serious violence or weapon enabled crime, where the victim is aged 1-19…’  This is confirmed by the London Safeguarding Procedures which advise calling a multi-agency meeting informed by advice from the local professional with specialist knowledge about gangs. This review has identified that whilst many professionals were working very hard with these young men much of their work was in isolation and without a clear perspective about how it fitted with other agencies. There was a sense that professionals found the problems presented by the young men’s behaviour too challenging and looked to another agency, usually YOT to resolve the difficulties. In reality no one 11 Safeguarding children affected by gang activity and / or serious youth violence, London Safeguarding Children Board 12 Teenagers at risk The safeguarding needs of young people in gangs and violent peer groups Kate Fitch NSPCC March 2009   31  professional could achieve the change necessary and what was required was a well-resourced timely package of support that would divert the young people and assist them in addressing their problematic offending. The risk of failing to provide that input is that the young people continue to take increasing risks that lead to potentially more dangerous outcomes. ‘The deaths or serious injury of older young people regularly make up a quarter of all serious case reviews. … The tendency for vulnerable “hard to help” adolescents to be neglected by agencies, who give up on these challenging young people because their needs have become too overwhelming, was first identified in the 2003-2005 study’.13  ANALYSIS  5.1 What was the quality of practice in relation to this case and how effective was the agency’s engagement with the young people? 5.1.1 Quality of practice was variable with some agencies delivering good services and others, notably CSC, failing to meet minimum standards. MST provided good quality interventions but these were limited in achieving positive outcomes because of the problems associated with maintaining engagement with young people who were living away from home. The SMS also provided good services but had limited positive outcomes because of the young people’s unwillingness to accept their intervention. FIP was also seen as very supportive by Vic’s mother who described it as providing her much support and also assisted his sibling even if it did not achieve a change in Vic’s offending behaviour.  5.1.2 The police generally provided services in accordance with their procedures and protocols. The YOT also met most of the minimum standards although their use of breach could have been more proactive. The education service practice was in accordance with legal minimum requirements but was slow and cumbersome and it was partly because of this that they failed to engage with the young people. The school health team practice was sound however there was poor quality of practice by the LAC doctor which has already been addressed by that agency.  5.1.3 The quality of practice within CSC was almost universally poor and there was minimal engagement with the young people. The one positive for Tom was that he was provided with a very competent foster carer who maintained links with him and was enabled by CSC to remain his carer even when he was placed in secure accommodation. This good practice is to be commended.   5.2 Were assessments of a sufficiently good quality and did they include multi-agency involvement? 5.2.1 Assessments provided were generally adequate with the exception of the CSC initial and core assessments and the LAC doctor assessment. The latter                                                            13 serious case reviews: A two-year analysis of child protection database notifications 2007-2009 Brandon et al DfE 2011  32  has already been addressed by that agency. The quality of the CSC assessments was extremely poor in that they were undertaken late, did not include appropriate consultation with other agencies, notably health and adult services, and lacked a sound analytical basis. This work seems to be representative of general practice as the recent Ofsted inspection described; ‘The analysis in the majority of assessments seen, including those in Section 47 enquiries, is poor. Assessments are usually descriptive and lack focus on identifying robustly whether a child has suffered significant harm or is likely to in the future.’ 14  It is therefore being addressed as part of the improvement plan in response to that inspection. 5.3 Were the interventions provided appropriate and how effective were they? 5.3.1  As has already been identified in the ‘themes’ many of the interventions were in accordance with procedures but lacked efficacy. This was particularly true of the missing children procedures which were in the main adhered to by the police and foster carer but which achieved little as the motivations and reasons for Tom going missing were not being addressed.   5.3.2 A missed opportunity for earlier involvement was the incident information redacted when both Tom and his brother attended Accident and Emergency with significant injuries information redacted. The school nurse made contact with ASKK but did not make a referral and the ASKK staff failed to identify that these injuries warranted a referral regardless of the actions of the nurse.   5.3.3 The MST interventions were appropriate but did not achieve the goals and one consideration that could be made is whether it is helpful to cease such involvement when young people go into secure accommodation. It is noteworthy that FIP who also became involved whilst Vic was in secure accommodation continued to provide support which was experienced extremely positively by Vic’s mother.  5.3.4 One aspect of all interventions with Tom and Vic was that most of the community based services ceased when they were imprisoned and there were often delays in re-starting services on their return to the community. Given that the young men may have been most accepting of support immediately after discharge from secure accommodation it is unfortunate that the relationships with community based professionals could not be maintained. Most important however was that these young men would have had to be involved in education and activities whilst in the secure environment and so this should have been maintained on their discharge. In reality there was often significant delay before these arrangements were made.   5.4 To what extent was it appropriate for the agency to take on the Key Worker role? 5.4.1 A significant weakness in the inter-agency working was the absence of a single key worker rather there were a number of key workers with different                                                            14 Inspection of safeguarding and looked after children services – Kingston-upon-Thames Ofsted July 2012  33  responsibilities. Thus both Vic and Tom had social workers but also YOT case workers and it was clear that on occasions time was spent between these professionals working out who was responsible for co-ordinating services. There was an absence of a single planning meeting process that all agencies joined and instead there were LAC reviews, FIP reviews, Education reviews and YOT reviews all of which involved some agencies but none of which involved all agencies. This led to some overlap in decisions and delay in sharing information it also added to the confusion for carers who often had to repeat the same information to a number of professionals. There were also some key agencies that were left out of the process particularly the GP who had least knowledge despite being the one agency that would continue to be involved and whose records would follow the young person wherever they went.    5.5 Was there effective communication with and from other agencies? 5.5.1 There were high levels of communication between YOT, CSC, FIP and MST. It is questionable as to its efficacy as there was little evidence of positive outcomes for Vic and Tom as a result of these discussions. There was minimal involvement of health agencies particularly GP and school nurse in these communications and this was particularly notable around LAC reviews and general health assessments. Much of the communication was necessary because there was an absence of a clear case planning process with a key worker co-ordinating services. There was little evidence of the Local Authority education service contributing to the planning process although the YOT education worker did attend some meetings.  5.6 What was the impact on practice of issues relating to ethnicity, religion, language and diversity? 5.6.1 Both young men were of dual heritage and this was generally identified as part of routine recording by agencies. None of the IMRs identified that they considered that issues of ethnicity, religion, language or diversity impacted on the practice of professionals working in their agencies. It is clear that for the young people their ethnic identity and life experience information redacted was a key factor in their relationship with each other and this was acknowledged by the YOT and MST workers. There is little evidence however of this being taken into account in their work with the young men and little consideration of how a better understanding of the young men’s feelings about their ethnic and cultural identity might assist in working with them and influencing their behaviour.   5.6.2 No agency recorded the young men as following any formal religion so it is probable that this was not significant in their lives. There was very little information provided in any IMRs that gave information about either boy’s social economic background and little about their cultural identity except where it related to their racial and ethnic background.    5.7 What was the impact of any language issues on the young people’s engagement with the agency and did these issues receive an appropriate response?  34  5.7.1 Vic was by birth a European language speaker and his mother raised his need for additional language support at a number of meetings and both his schools identified that he needed some additional support for complex work. It was interesting therefore that the LSES IMR reported that there was no language issue that would impact on the young people’s engagement with the agency. It was clear that this aspect of his educational need had not been highlighted within the educational assessment. 5.7.2 Tom was an English speaker from birth and had no specific language needs.  5.8 How effective was the support provided to new arrivals in the country, including supporting their transition into the education system? 5.8.1 Both young men started school in Year 8 having arrived from abroad and presumably having previously experienced very different educational provision. The LSES IMR reported that there was no specific support programme in place for new arrivals in the country and suggested that schools would provide support to pupils based on their individual need. This did appear to be the case in that Vic was provided with additional English support for some lessons. Whilst this will have addressed learning needs it is questionable as to whether it would address any social or identity issues.   5.8.2 Adolescence is a time when young people are extremely egocentric and when they are developing a concept of self which is very linked to ethnic and cultural identity. Where young people experience shifts in culture or migrate from one culture to another there may be challenges which need resolution. These conflicts and challenges may have been relevant in understanding the conflictual behaviour of these young men and possibly some additional support earlier about identity could have been a preventive factor.   5.9 What was the impact or otherwise on the young people of being excluded from school and to what extent were the appropriate services provided? 5.9.1 Tom was formally excluded from school in October information redacted and was rapidly placed at a new school which was the school that his mother wished him to attend. This process was managed effectively and therefore the exclusion did not have a detrimental effect on him. Vic was never formally excluded from school as his mother withdrew him from school and there is no evidence that he was likely to be asked to leave.  5.9.2 In reality however neither Tom nor Vic attended school for most of the last two years of their formal education and the delays in identifying alternative provision that was suitable for their needs was in effect an exclusion from learning.   5.10 Was sufficient and effective support provided to the Looked After young person by the foster placement? 5.10.1 It is clear from all the IMRs that one of the few consistent supports that have been provided to Tom was his foster placement and his foster carer is to be commended for remaining committed to him throughout a difficult period. It was good practice for this placement to be kept open whilst Tom was in secure accommodation.   35   5.11 To what extent were gangs and gang culture a feature in this case? 5.11.1 The issue of gangs has been addressed earlier in the report under section 4.4. It is not clear whether these young men were in a ‘gang’ however they were co-offending and committing serious youth violence and therefore consideration should have been given to using the ‘Safeguarding children affected by gang activity and / or serious youth violence’ protocols developed by the London Safeguarding Children Board. The absence of any agency considering this issue prior to this review being undertaken does suggest that there may be a need for the LSCB to implement some of the recommendations contained within that protocol.   5.12 What was the quality and impact of case management and supervision in relation to this case? 5.12.1 Case management and supervision was generally sound in all agencies except CSC. The quality of supervision described in the CSC IMR was not positive with staff reporting cancelled sessions. The records of supervision were also poor with records being perfunctory and formulaic with little evidence of reflective discussion and challenge to workers. There were ten formal records of supervision in relation to Tom over a period of two years.    5.12.2 There was limited evidence of middle and senior management oversight of casework despite the complex challenges that both young men presented to social workers. The IMR author rightly suggests that the nature of the problems presented by these young men should have involved middle managers escalating concerns to senior staff however there was no evidence of this being considered. Tom was discussed on five occasions by the Prevention and Resource Panel however the records seen do not show clearly what decisions were made.  5.13 Did any organisational difficulties or resource issues, e.g. vacant posts or staff on sick leave, impact on practice in this case? 5.13.1 The police IMR reported that Kingston PPD had some staffing difficulties which affected the distribution of ‘merlins’ to Kingston however they are now fully staffed and a recommendation was made to audit the performance regarding information sharing via ‘merlins’.   5.13.2 The CSC was re-organised in January 2011 when ASKK moved to early Intervention and four safeguarding teams were created that undertook all social work with children from initial assessment through to long term work with looked after children. There were interim management arrangements between 2010 and 2012 and after January 2011 many staff were under new management arrangements. In June 2011 plans to merge Richmond and Kingston services and provide them via a ‘not for profit’ company with reduced costs from reducing management and administrative expenses were announced. Many staff interviewed for the IMR felt that the changes in management and the uncertainty around future structures destabilised the service. The Ofsted inspection in May and June 2012 highlighted problematic practice and since then there have been significant changes in senior and  36  middle management. There is a comprehensive improvement plan in place to address the shortfalls identified by the Ofsted inspection.   5.13.3 The YOT IMR identified that both young men had changes of worker. This resulted from a combination of factors; student placements, maternity leave and the team needing to be supported for a time by an agency worker.   5.14 Relevant Information from previous serious case reviews 5.14.1 The overview author was provided access to a previous serious case review undertaken in 2010. This was concerned with a family of six children who received services over a significant period of time and who experienced sexual abuse within the family. The author also had an oversight of themes identified by the LSCB from other file audits and multiagency reviews. Whilst there were no exact similarities between these previous reviews and the issues raised by this review a relevant similarity was that many of the reviews had highlighted issues regarding joint working between agencies which is also a factor in the work with Tom and Vic.    6 ASSESSMENT OF IMRs and the SCR process This serious case review was commissioned at a time of significant change within Kingston. An Ofsted inspection had just taken place which had deemed the authority inadequate for safeguarding and the DCS had resigned; the LSCB chair also stood down during the period of the review. These events had an inevitable effect on the process which took longer than planned partly because a number of IMRs had to be re-commissioned and some agencies struggled to prioritise the SCR process when there were other more significant competing demands on their time.   6.1.1 Children’s Social Care, Royal Borough of Kingston 6.1.1 This report addresses the key terms of reference and provides an overview of the involvement by CSC. The report author had considerable difficulty accessing the records to undertake this report as the ICS system was complex and many records were incomplete. There were delays in the report being presented to the SCR panel because of health and holiday commitments which meant that the final version was only approved by the panel in January 2013 after the first draft of the overview report had been completed.  6.1.2 The report highlights some significant failings in the services provided to both Vic and Tom particularly with regard to missing children protocols, the quality of assessments, the arrangements around LAC reviews, the development of care plans and the quality of risk assessments both with regard to the two young men but also with regard to younger siblings in both families.   6.1.3 This IMR was reviewed twice by the panel and after some additional work it was considered to fully address the terms of reference. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  37   6.2 Your Healthcare 6.2.1 This IMR reported on the involvement of the school nurse and LAC nurse with Tom, there was no involvement with Vic. The report identifies the limited involvement of the agency and highlights two areas for improvement; firstly with regard to health assessments of young people starting late at secondary schools; and secondly the need for better involvement of health professionals with looked after children, particularly in attending LAC reviews.   6.2.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.3 General Practitioners, Kingston   6.3.1 This IMR was limited in part because Tom’s parents refused consent for their records to be accessed which limited the IMR content. The report covers the minimal involvement of the GP with both Tom and Vic. It identifies the lack of information sharing between agencies and the GP service which meant that little was known by that service of the particular difficulties being presented by the young men. It identifies particular limitations in the first LAC medical undertaken on Tom and some weaknesses in health recording.    6.3.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.        6.4 Kingston Hospital Trust 6.4.1 This IMR details the limited involvement of this hospital with Vic who attended on three occasions. The main learning identified was that all of the presentations were because he has been involved in fights and the author noted that within the last two years procedure have been amended to ensure that this information is shared with relevant health professionals. 6.4.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.5 Epsom and St Helier University Hospitals NHS Trust 6.5.1 This report details the limited involvement that this hospital had with regard to Tom and his sibling when they presented as a result of being attacked. The IMR identifies that key safeguarding processes were followed and that relevant agencies informed.   6.5.2 This IMR was reviewed by the panel which considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  38   6.6 Metropolitan Police Service 6.6.1 This IMR provided an analysis of police involvement with the family and their interventions with the young men. It identified that generally practice was in accordance with established procedures and highlighted that information on Tom’s missing episodes had been sent to the wrong Local Authority because the police were unaware that he was a Kingston child placed out of borough. The report also concludes there was limited understanding of the boys patterns of offending behaviour but is dubious as to whether greater analysis would have achieved more positive outcomes.    6.6.2 This IMR was reviewed by the panel who did not feel any changes were needed and considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.7 Youth Offending Service 6.7.1 The first IMR presented by this service was deemed inadequate by the SCR panel and the agency identified another author to produce a second report. This report provided an overview of the YOT casework including some information about the FIP service provision. There were delays in the provision of the full chronology for the YOS and the overview author asked for additional information about the FIP input which was provided speedily.  6.7.2 The final report gave a robust analysis of the inputs to the family and identified two areas where the service could be more robust in ensuring compliance with breach protocols and in the agreed responses with regard to missing persons. The report also identified the need for better understanding within the YOS of issues concerning gang activity and / or serious/ youth violence.   6.7.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.8 Kingston & Richmond Joint Substance Misuse Service 6.8.1 This report details the limited contact between this service and the two young men. The report identifies that the major issue raised by the review process was the understanding and awareness within the service of gangs and gang culture which is then reflected in the recommendations.  6.8.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.   6.9 Learning and School Effectiveness Service, Royal Borough of Kingston  39  6.9.1 This report provides a comprehensive overview of the services provided by the local authority education services clearly stating that all statutory duties were fulfilled. The report suggests that the major reason that the planned outcomes were not achieved was because of the ‘defiant and uncooperative’ nature of the young people. The report does acknowledge that some information was not known by education services but does not comment on the time taken to provide alternative provision for the young men.  6.9.2 This IMR was reviewed by the panel and some amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.     6.10 South West London & St George’s Mental Health Trust (MST) 6.10.1 This IMR provided a comprehensive and insightful analysis of the work undertaken by the service with both young men. It highlights the difficulties of working with Tom when he was in foster care and rightly suggests that CSC should have taken the key worker role in managing the interventions between Tom’s parents and the foster home. It also reports on the more positive work with Vic and his family and draws attention to the need for greater inter-agency working particularly around police stop and search.  6.10.2  This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.     6.11 Health Overview Report  This very comprehensive and detailed report appropriately reviewed the key themes from the health IMRs and identified any relevant matters of concern for commissioners. The key recommendations relate to the need for greater health input to multi-agency working with looked after children and for the MST processes to be better integrated with LAC processes where a young person is in foster care and the care plan is for them to return home.  7 LESSONS LEARNED FROM THE REVIEW 7.1 This review has identified significant limitations in the services being provided by Children’s Social Care. This mirrors the findings of the Inspection of Safeguarding and Looked after Children undertaken by Ofsted between May 2012 and June 2012. This reported “significant failings in the contribution made by the council and partner agencies to child protection” and that “The quality of assessments and subsequent plans are generally of poor quality.” The IMR provided by Children’s Social Care acknowledges the problems and also reported on changes put in place since the Ofsted inspection. There is an Improvement Board in place which is ensuring that the changes recommended by Ofsted are implemented and this is being monitored at every LSCB meeting. For this reason the recommendations from this report focus on multi-agency learning rather than on the significant changes that are required and being implemented in Children’s Social Care.  40   7.2 The key learning across all agencies was about the difficulties of working with adolescents who are involved in criminal behaviour and serious youth violence perpetrated by their peers in gangs, with increasing anti-social behaviour. It was clear that, although Kingston LSCB has adopted the London Safeguarding Children Board protocol ‘Safeguarding children affected by gang activity and / or serious youth violence’, the understanding and knowledge of these issues by all agencies was very limited.  7.3 A significant weakness identified was multi-agency working to ensure that these young men attended educational provision, during the period of this review. The assessments of need and services provided were slow to be implemented and thus there were missed opportunities to improve educational outcomes for them. In particular it was unacceptable that both young men did not attend formal education for over a year.  8 CONCLUSIONS 8.1 It is not clear whether it was possible to prevent these young men from sustaining potentially life-threatening injuries as they were both involved in risky anti-social behaviour and criminal activities and might not have ceased these activities. The review has identified, however, that professionals were insufficiently aware of the implications of this behaviour and specifically did not identify that the escalation of their criminal activities could mean that they were at greater risk of significant harm. The review has also shown there could have been better co-ordination and speedier delivery of services which might have improved outcomes for these two young men. 9 RECOMMENDATIONS   Kingston Local Safeguarding Children Board 1.1 Kingston LSCB to require all agencies to work in partnership with Learning and Children’s Services to develop a system of multi-agency risk assessment and management for adolescents who are at risk of involvement in: • Emergent criminality, serious youth violence perpetrated by their peers in gangs, or increasing anti-social behaviour; and • Serious youth violence perpetrated by children acting on their own.  1.2 Kingston LSCB to ensure all agencies address the issues highlighted in this report around the provision of education for adolescents involved in criminal behaviour and to report on how the services have been improved. The expected outcomes to include: • A holistic package of support to ensure; • Immediate access to education for young people on discharge from secure accommodation; • More rapid intervention to provide alternative provision for young people not accessing formal education; • Improved monitoring and intervention regarding young people who are not attending education for long periods.  41  The Director of Children’s Services to report to the LSCB on progress within one year.  1.3 Kingston LSCB to commission a workshop for middle and senior managers from across the partnership to look at the difficulties of working with hard to reach young people. The outcome of the workshop to be: • Greater understanding by all managers of the particular needs of adolescents who may be at risk because of their own behaviour; • Commitment by all managers to implementing changes required to implement the agreed system of multi-agency risk assessment and management; • The development of a clear implementation plan to achieve the required changes.  RBK Children’s Social Care 2.1 Children’s Social Care to ensure that assessments address the risks to all children in the family. Risks to younger siblings need to be rigorously examined and be part of the assessment.    2.2 Children’s Social Care in conjunction with CAIT and partner agencies to undertake a review of the current practice in RBK relating to strategy meetings and discussions, including a review of the extent to which these are inter-agency forums.  2.3 Children’s Social Care to ensure that there is a clear supervision policy and protocols in place which will include 3 monthly summaries where families receive on-going work from Learning and Children’s services.  2.4 Children’s Social Care to ensure that training is available for social workers to develop their skills in relation to direct work with children in order to enable social workers to develop relationships with the young people and families they are involved with.   2.5 Children’s Social Care to work with Adult Services to improve communication and the sharing of information, including establishing clear protocols for working with families where there is learning difficulty, physical disability or mental illness.   2.6    Children’s Social Care to review the role of the virtual head teacher in RBK.   2.7 Children’s Social Care to prioritise improved understanding and working about the related issues of racial harassment, gangs and postcode areas, drug use and supply, antisocial behaviour, possession of weapons, children out of secondary education as part of their on-going training plan.   2.8 Children’s Social Care to ensure that there are clear transition protocols in place including manager to manager, face to face meetings to reduce the impact of the transfer process.  RBK Youth Offending Service  42  3.1 Youth Offending Service to implement a consistent compliance panel and protocol in regards to the breach process.  3.2 Youth Offending Service to complete a Service Level Agreement with the Police and Children Service’s regarding the agreed response/interventions around safety awareness in relation to Missing children.  3.3 Youth Offending Service to embed gang identification and interventions via the Pan London Safeguarding children affected by gang activity and / or serious / youth violence and Serious Youth Crime protocol, in order to identify those vulnerable to gang /serious youth crime violence and agree the appropriate level of intervention to address the issues i.e. links with SNT wards to target areas for further surveillance.    3.4 Youth Offending Service to provide refresher training on risk management for staff with specific emphasis on external controls.   3.5 Youth Offending Service to explore the use of volunteers within Kingston and develop a volunteering strategy to embed additional resources from the third sector and volunteering opportunities. Examples of these could be compliance mentors and transitional support for LAC.  3.6 Youth Offending Service to address the lack of Education to Employment resources within the borough (this is not a direct recommendation purely for the YOS).     Metropolitan Police Service 4.1 Operation Compass to include in their current review of the Standard Operating Procedures in relation to missing children who are in care homes or foster care the need for the initial investigating officer to record which local authority has responsibility for the Looked after Child.  4.2 The Senior Leadership Team at Kingston Borough Operational Command Unit to carry out an audit of MERLIN missing person reports involving children to ensure that the Public Protection Desk have sent the information to the Royal Borough of Kingston Children’s Services.  4.3 The Senior Leadership Team at Kingston Borough Operational Command Unit to ensure that all staff are reminded that after carrying out a debrief of a missing child a MERLIN/PAC is created detailing information gleaned from that interview.  4.4 The Senior Leadership Team at Kingston Borough Operational Command Unit to ensure that all frontline staff are reminded of the requirement to comply with the completion of a MERLIN/PAC in accordance with Standard Operation Procedures (SOPs).  4.5 The Senior Leadership Team at Kingston Borough Operational Command Unit to review the frequency that checks are carried out by the Kingston Public  43  Protection Desk for non-compliance by staff of not completing MERLIN/PAC reports and ensure that the unit is adequately staffed to carry out their duties.  Substance Misuse Service, RBK 5.1 The Substance Misuse Service should ensure that a standardised assessment form is used with all young people accessing the service. It should be adapted or developed to include an exploratory question about gang culture, with a view to exploring the potential impact of gang related activity on young people using substances further.  5.2 The Substance Misuse Service should agree a working definition of the term ‘Gang’ for use by the organisation. Guidance is available on the Home Office website www.homeoffice.gov.uk.  5.3 The Substance Misuse Service should identify and participate in specific training based on the guidance ‘Safeguarding young people who may be affected by Gang Activity’ so that a better understanding is developed of what the local problem is and the team is better able to identify and appropriately support young people at risk. This could be provided by the YOT or through Kingston LSCB.  Learning and School Effectiveness 6.1 The Director of Children’s Services to ensure that there is sufficient communication about individual children and young people across the statutory bodies within the Local Authority.  South West London and St George’s Mental Health Trust 7.1 When a referral is made to the Multi Systemic Therapy Team and the young person is subsequently accommodated, MST with the health service for LAC should support a multi-agency plan for the steps and milestones for the young person to return to the family home within the LAC review process. This should include a collaborative consistent approach to maximise success.  7.2 Multi Systemic Therapy Service in collaboration with the Local Authority to review the referral criteria for cases where the family foster carer is involved in the care of the young person. This should include shared approaches to boundaries and limit setting and limitations of the service.   7.3 The Multi-Systemic Therapy Team to ensure that when presenting at multi agency meetings the MST plans are reviewed in conjunction with the plans of other agencies.  7.4 The Serious Case Review recommendations and their implementation as it affects MST to be considered and monitored by the MST Multi-Agency Strategic Board as part of annual review of the service.  Your Healthcare 8.1 Your Healthcare Board Lead for Universal services to discuss with NHS Kingston Commissioners, service redesign to extend the role of the School  44  Health Team to offer health reviews of all children transferring into a Kingston school.  8.2 Your Healthcare to develop a school health transfer in policy in line with commissioning arrangements.  8.3 Your Healthcare to ensure that the LAC Specialist Nurse is aware of all LAC health reviews. Appropriate health professional to be invited to LAC reviews and receive minutes.    Epsom and St Helier University Hospitals Trust 9.1 The Hospital Trust should ensure that, as part of the information sharing audit which is currently recorded on the Safeguarding Children Audit Plan 2012/13, an information sharing audit tool should be designed to incorporate a question in relation to whether the ED record and safeguarding documents are filed in a main record when concerns are identified about the safety and welfare of children who attend the ED.  9.2 The Hospital Trust should ensure that the information sharing audit incorporates a question in relation to whether a record of the GP letter is filed electronically and whether the information recorded on the GP letter is relevant and appropriate to the safeguarding concern identified.  9.3 The Hospital Trust should ensure that a further re-audit of the Paediatric DNA Policy is added to the Safeguarding Children Audit Plan 2013/14 and the notes audit must include children who have not attended Outpatient Fracture Clinic appointments.   Kingston General Practitioners 10.1 GP practices to review systems in place for ensuring sharing of information with the school health team when requested.  10.2 GP practices to review their system for reading and acting on children’s A+E discharge summaries.  10.3 GP practices to consider sending out a letter to the carers of looked after children to offer the child a medical review.  10.4 GP practices to consider whether in cases where risk factors for child abuse have been identified, there should be a way of cross referencing information between different family member’s notes.  10.5 GP practices to review their system for identifying and documenting ethnicity of patients.  NHS Kingston/CCG – Health Overview 11.1 The Designated Nurse, NHS Kingston, to ensure that the Joint Strategic Needs Assessment for LAC includes a recommendation that health practitioners are  45  invited to attend LAC reviews, send a full health report, and receive timely minutes of the meeting.  11.2 NHS Kingston to ensure that the commissioned RIO electronic record system is installed into Moor Lane where the LAC medical team are based. This should be the primary health record for LAC including those children with disabilities who are in respite care. The health assessments can be uploaded onto the RBK electronic system by the LAC coordinator.   11.3 The Designated Nurse, NHS Kingston, to ensure that the Joint Strategic Needs Assessment includes a clear outline of the referral process to the LAC health professionals. This is to include accurate information for all LAC, foster carers, current GP and any other health information to improve the service provision.    11.4 The Designated Doctor for Safeguarding and the Designated Doctor for LAC to ensure that all Paediatric clinicians receive and actively participate in regular supervision and support in relation to specific safeguarding and child protection issues within the context of their role and specific caseload.    11.5 The named nurses for Kingston and Epsom & St Helier hospitals to ensure that A&E documentation is improved to ensure there is detailed information about the history given about the injuries sustained, any child protection concerns or any referral into safeguarding services.    Fiona Johnson 46  Appendix 1 TERMS OF REFERENCE 1. Rationale for SCR The Royal Borough of Kingston upon Thames (LSCB) is conducting a new Serious Case Review in respect of V and T because the circumstances associated with the physical injuries they sustained during an incident in information redacted 2012 meet the criteria for conducting such reviews, as set out in “Working Together to Safeguard Children 2010”. Ofsted were notified of the incident under the notification of serious childcare incident procedures information redacted in 2012.  The decision to carry out the Serious Case Review was taken by the LSCB SCR Sub-Committee on 8th June 2012. The Sub-Committee considered the criteria for a SCR to have been met on the grounds that one of the subjects was Looked After by Kingston Children’s Social Care at the time of the incident and the injuries sustained by both subjects were potentially life-threatening.  2. Scope of the Review The overall purpose of the SCR will be to: • Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; • Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; and • As a consequence, improve inter-agency working and better safeguard and promote the welfare of children.  The SCR will commence from January 2008, information redacted, up until immediately prior to the incident that took place information redacted in 2012. The review will examine: • the quality of practice, including multi-agency practice; • the effectiveness of agencies’ engagement with the subjects and the interventions provided; • the quality of assessment, including multi-agency involvement in assessments; • the effectiveness of communication between and across agencies; • the extent to which the appropriate agencies take on the Key Worker role; • the lessons to be learnt to improve safeguarding arrangements and practice within and across agencies.   47  3. SCR Process The Kingston LSCB SCR Sub-Committee has agreed the scope and Terms of Reference for the SCR. The Terms of Reference have been approved by the Independent Chair of the LSCB. Paul Kerswell works as an independent consultant and has been appointed as SCR Panel Chair. Paul has completed a number of Serious Case Reviews, including three for which he has been the SCR Panel Chair. Paul also has considerable experience in the operational management of Children Social Care Services, including at senior management level. The Panel Chair is responsible for ensuring that the SCR is completed in accordance with relevant guidance, as set out in Working Together to Safeguard Children 2010, and the requirements of Kingston LSCB. The SCR Panel will comprise the following members:  • Metropolitan Police – DCI, West Region CAIT • Education Services, RBK – Strategic Manager Education Welfare Service,  School Safeguarding & LADO  • Youth Offending Service - Service Manager Youth Offending Service & Young People’s Substance Misuse Service   • NHS Kingston - Designated Nurse, Child Protection • Children’s Social Care, RBK – Independent IMR Author / Service Manager, Professional Standards & Development • School – Deputy Head teacher, Pastoral Care and Guidance  In addition Legal Services, RBK will be invited to contribute to the Panel as necessary and neighbouring LSCBs will be formally contacted about this SCR. SCR Panel members have had no direct involvement in the practice or line management of the case and are considered to possess the required knowledge, skills and experience to fulfil this role. To facilitate and support the SCR process, and links with operational staff, the SCR Panel will be supported by: • LSCB Business Manager  • CP & LSCB Administrator The SCR Panel has identified the following agencies that will be required to submit Individual Management Reviews as part of the SCR: • Children’s Social Care, RBK • Your Healthcare  48  • General Practitioners, Kingston   • Kingston Hospital Trust • Epsom and St Helier University Hospitals NHS Trust • Metropolitan Police Service • Youth Offending Service • Kingston & Richmond Joint Substance Misuse Service • Learning and School Effectiveness Service, RBK  •  South West London & St George’s Mental Health Trust In addition, information reports will be requested from: • the two secondary schools Tom and Vic attended • the specialist academy Vic attended • CAFCASS • United Kingdom Border Agency. Other agencies may be identified as the review progresses and asked to provide information / reports: • Independent Fostering Agency • Children’s Centres Family Support Service • Information redacted. All agencies formally contributing to the SCR will identify an appropriate officer, who will have had no direct involvement with the family, or the immediate line management of any practitioner(s) involved, to undertake an Individual Management Review / prepare an information report.   All identified agencies contributing to the review will complete:    • An Individual Management Review.  • A tabular chronology of their involvement with the family.  • The chronology must be completed on the WORD template attached to these Terms of Reference. They should not be anonymised.    49  All agreed timescales for completion of reports and attendance at meetings must be adhered to and any indication that an agency is unable to meet its commitment must be referred to the independent SCR Panel Chair, Paul Kerswell immediately.  Fiona Johnson has been appointed as Independent Overview Author. Fiona works as a consultant and has extensive experience of contributing to SCRs, in particular as Overview Author. The Overview Author will produce the Overview Report and Executive Summary and present these to the SCR Panel and Kingston LSCB. These will be based upon collation and critical analysis of the IMRs, SCR panel discussion and any supplementary interviews with key stakeholders determined to be required.   Upon completion, anonymised IMRs, the overview report, integrated chronology and agencies’ respective actions plans will be submitted to the Department for Education.    4. Outputs Key outputs from the SCR will be as follows: • An integrated anonymised chronology • The Overview Report for publication • An Executive Summary for publication • An Action plan.  5. Parallel Review Processes This case is not expected to give rise to other parallel investigations of practice. However, the review process will need to take account of criminal enquiries. The Legal team have been invited to participate in the SCR Panel to liaise with the Police and Crown Prosecution Service as necessary. 6. Production of Individual Management Reviews All agencies’ reports and chronologies should commence from January 2008 until information redacted 2012.  All agencies are required to review all records and materials including: • Electronic records • Paper records and files  50   and provide any information that may be relevant outside the agreed timeframe for the SCR. Agencies that identify significant background history pre-dating January 2008 should provide a brief summary account of the significant history. This will be for the SCR Panel in reviewing the agreed scope of the SCR. Where individual staff are interviewed copies of the interview notes should be retained and referenced within the Individual Management Review (IMR). Appropriate agency support should be identified for all staff involved in the IMR process.  All agencies should complete their Individual Management Reviews and chronologies in line with the requirements of Working Together to Safeguard Children 2010, and the London Child Protection Procedures 4th Edition 2011.  The Individual Management Review should follow the Kingston template and guidance (derived from the pan-London SCR toolkit published by the London Safeguarding Children Board). The aim of the IMRs is to look openly and critically at individual and organisational practice to determine whether the case indicates that changes could and should be made and, if so, to identify how those changes will be brought about.    The SCR Sub-Committee at its meeting on 23rd July 2012 identified the following issues to be considered by the SCR:  • What was the quality of practice in relation to this case and how effective was the agency’s engagement with the young people? • Were assessments of a sufficiently good quality and did they include multi-agency involvement? • Were the interventions provided appropriate and how effective were they? • To what extent was it appropriate for the agency to take on the Key Worker role? • Was there effective communication with and from other agencies? • What was the impact on practice of issues relating to ethnicity, religion, language and diversity? • What was the impact of any language issues on the young people’s engagement with the agency and did these issues receive an appropriate response? • How effective was the support provided to new arrivals in the country, including supporting their transition into the education system? • What was the impact or otherwise on the young people of being excluded from school and to what extent were the appropriate services provided? • Was sufficient and effective support provided to the Looked After young person by the foster placement? • To what extent were gangs and gang culture a feature in this case? • What was the quality and impact of case management and supervision in relation to this case? • Did any organisational difficulties or resource issues, e.g. vacant posts or staff on sick leave, impact on practice in this case?  Each IMR should also consider the relevant issues outlined in Chapter 8 of Working Together to Safeguard Children 2010. Where an issue is not judged relevant to the involvement of an agency, the IMR must clearly indicate that this is the case.  51   Internal Management Reviews should be quality assured and signed off by the most senior officer of the reviewing agency.  7. Involvement of Family Members Contact will be made with the subjects of the SCR and their parents by the Independent Chair of the SCR Panel to invite their participation in the review.   8. Media Enquiries It is possible that this case may attract some media interest. There should be no contact with the media under any circumstances. All media contacts and enquiries should be directed to the LSCB, who will be advised and supported by Kingston Council’s Press Office.  9. Timescales The SCR process is to be concluded by 28th February 2012. Refer to SCR timeline for key milestone dates  During the course of the SCR new information may emerge which necessitates amendment or addition to the Terms of Reference. These Terms of Reference may therefore be revised with the agreement of the SCR Panel. The changes will be approved by the Independent Chair of the LSCB.     Appendix 2 Genogram – information redacted        