Death of a 16-year-old girl in 2018, assumed to be suicide. Child C had experienced adverse childhood experiences, including sexual abuse, and was believed to be at risk of exploitation. History of self-harm and had spoken about ending her life from time-to-time since 8-years-old. Child C was known to the universal services, Police, Children's Social Care, Child and Adolescent Mental Health Service (CAMHS) and local voluntary agencies. In July 2016, she was made subject to a child protection plan under the category of sexual abuse which includes sexual exploitation, until March 2017. In 2018, she stayed in a specialist facility for young people with mental health problems. Diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) at 15-years-old. Ethnicity or nationality not stated. Learning includes: it's essential that practitioners understand parental capacity, strengths and attitudes to increase the effectiveness of interventions and avoid placing additional stress on children and their families; child sexual exploitation (CSE) requires a different focus from other forms of child abuse; adolescents can be exposed to a wider range of risks than younger children and concentrating on a single issue may lead to an over optimistic assessment of risk; assessments should include listening and responding to children's views. Recommendations include: develop a research-based risk management strategy designed to address the specific features of adolescent risk taking and suicidal ideation; promote the concept of contextual safeguarding and ensure that it is adopted by practitioners and managers working within the child protection process.
      
 Title:  Child safeguarding practice review: Child C. LSCB: Cornwall and Isles of Scilly Safeguarding Children Partnership Author: Karen Tudor Date of publication: 2020  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.                                           Our Safeguarding Children Partnership              for Cornwall and the Isles of Scilly  CHILD SAFEGUARDING PRACTICE REVIEW CHILD C     Independent Reviewer Karen Tudor October 2019   1 | P a g e   Contents  INTRODUCTION .............................................................................................................................................................. 3 Summary of events leading to this Practice Review .................................................................................................. 3 Anonymisation ............................................................................................................................................................ 3 Methodology .............................................................................................................................................................. 4 Family Participation in the Review ............................................................................................................................. 5 SUMMARY OF EVENTS .................................................................................................................................................... 5 2015 – Child C is living in Cornwall ............................................................................................................................. 5 2016       - .................................................................................................................................................................... 6 Early Help .................................................................................................................................................................... 6 Referral about Sexual Exploitation ............................................................................................................................. 6 Child Protection Plan .................................................................................................................................................. 7 2017      - ..................................................................................................................................................................... 8 Case Stepped Down to Early Help .............................................................................................................................. 8 Child C is living in County B ......................................................................................................................................... 9 In-Patient Treatment ................................................................................................................................................ 10 2018         - ................................................................................................................................................................. 11 Police Investigate Alleged Assault ............................................................................................................................ 11 Children’s Social Care Assessment ........................................................................................................................... 11 Rape Allegation ......................................................................................................................................................... 11 Child C Returns to Cornwall ...................................................................................................................................... 12 Police Welfare Check ................................................................................................................................................ 12 FINDINGS AND LEARNING ............................................................................................................................................ 13 UNDERSTANDING “PARENTAL CAPACITY” ................................................................................................................... 14 Expectations of Child C’s Parents ............................................................................................................................. 14 Parental Capacity ...................................................................................................................................................... 14 Discharge from in-patient care ................................................................................................................................. 15 CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS ....................................................................... 16 Frameworks for multi-agency intervention:............................................................................................................. 16 Early Help .................................................................................................................................................................. 16 Child in Need ............................................................................................................................................................ 16 Child Protection Procedures and Managing Risk in Adolescents ............................................................................. 17  2 | P a g e   The Focus of the Conference/Assessment ............................................................................................................... 17 Protection and Therapy ............................................................................................................................................ 18 Poly-victimisation ..................................................................................................................................................... 18 The Impact of the CP Process on Child C and her Family ......................................................................................... 19 Step-down to Early Help ........................................................................................................................................... 19 Response to CSE ....................................................................................................................................................... 19 MANAGING TRANSITIONS – SHARING INFORMATION ................................................................................................ 20 Child C moved to County B ....................................................................................................................................... 20 Lost Opportunities for Information Sharing ............................................................................................................. 21 Sharing information when Child C moved back to Cornwall .................................................................................... 22 RESPONDING TO THE “VOICE” OF THE CHILD .............................................................................................................. 23 SUMMARY OF LEARNING ............................................................................................................................................. 24 UNDERSTANDING PARENTAL CAPACITY ................................................................................................................... 24 CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS ................................................................... 24 MANAGING TRANSITIONS –SHARING INFORMATION ............................................................................................. 25 RESPONDING TO THE “VOICE” OF THE CHILD .......................................................................................................... 26 CONSIDERATIONS FOR THE SAFEGUARDING PARTNERSHIPS ...................................................................................... 26     3 | P a g e   INTRODUCTION Summary of events leading to this Practice Review 1. In the autumn of 2018 a sixteen year old girl died; to protect her identity she is known as Child C.   2. During her childhood Child C had experienced sexual abuse, alleged physical abuse, witnessed domestic abuse, the break-up of her parents’ relationship, been the victim of sexual assault and was believed to be at risk of exploitation. Child C had also been warned about her own anti-social behaviour. These events impacted on her relationships, led to her having attachment difficulties, low self-esteem and feelings of despair.   3. Child C had a history of self-harming and, from the age of 8, had spoken from time-to-time about ending her own life. Child C was known to the universal services, Health and Education and to the Police, Children’s Social Care, the Child and Adolescent Mental Health Service (CAMHS) and some local voluntary agencies. In 2018 she spent a few weeks in hospital, in a specialist facility for young people with mental health problems. At the age of 15 she was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD.)  4. Despite her adverse experiences, Child C was an intelligent, engaging child with an exceptional talent for music and singing; she felt things deeply and had a strong sense of justice. During the period of this Review Child C lived at first with her mother, in Cornwall and then moved to be with her father (and older sibling) in County B, where she lived for 15 months. She returned to live with her mother a few weeks before her death.  5. The records indicate that Child C’s parents had troubled childhoods; little is recorded about her father, information about Child C’s mother included a family history of suicide. Child C’s parents separated when she was about 4 years old.   6. At the time of writing the Coroner’s Inquest had yet to take place; prior to her death Child C had made her intentions explicit, it is therefore assumed Child C took her own life.  Anonymisation 7. For the purposes of anonymisation the family members are referred to as follows:  • Child C – Subject of this Review • Ms CM – Child C’s mother  • Mr CF – Child C’s father   4 | P a g e   Methodology    8. Following a Rapid Review1 and consultation with the National Panel2, the local Safeguarding Partnership concluded that the case met the criteria for a Local Child Safeguarding Practice Review. An Independent Reviewer was commissioned and a methodology agreed, which is consistent with the principles set out in Working Together 2018.   9. The period under Review is three years from September 2015, just before Child Protection Procedures were initiated, to September 2018 when Child C died.  10. A multi-agency Review Panel3 was established and agreed that the Review should consider the following:  • Were there issues within the management of the case by the children’s social care and education services of two local authorities, two police constabularies and several health organisations? • Were there difficulties that arose from Child C moving between different areas in the country?  In particular, the review was asked to consider information sharing. • Whether there are any concerns around the response of the services and how information was evaluated and acted upon. • Any vulnerabilities of the young person to sexual abuse and exploitation. • Whether there was an over-reliance on parents managing risk. 11. Chronologies and practice analysis were requested from: • CAMHS, Cornwall and County B including the residential care provider • GPs • Police, Cornwall and County B • Children’s Social Care, Cornwall and County B • Education providers, Cornwall and County B  1 Safeguarding Boards/ Partnerships are required to undertake a Rapid Review into all serious child safeguarding  cases within fifteen working days of becoming aware of the incident. The information collated leads  to a recommendation about whether the criteria are met for Serious Case Review/Child Safeguarding Practice review.  2 The National Safeguarding Practice Review Panel decides if a Serious Case Review (WT 2015)/Local Child Safeguarding Practice Review (WT2018) is required and informs the local LSCB/Partnership of their decision.                                            3 See Appendix for list of members.   5 | P a g e   12. Meetings were held in both Local Authority Areas with chronology authors and the practitioners who had worked with the family. The process was overseen by the Review Panel.  Family Participation in the Review 13. Child C’s family were invited to participate in this Review. The Reviewer is grateful to Mr CF, Ms CM and Child C’s maternal grandmother who met with the Reviewer and spoke about Child C her character and talents; despite their grief, her family shared their views about the services they received in the hope of raising awareness about the tragedy of teenage suicide.   SUMMARY OF EVENTS  14. Child C was born in December 2001 and died in September 2018, aged 16 years and 9 months.   15. Prior to the period of the Review Child C’s mother and her school had expressed concerns about Child C including reference to self-harming and anti-social behaviour. Child C had previously been referred to CAMHS in 2014.   16. During the three year period of this review a number of practitioners from different organisations and disciplines spent hundreds of hours working with Child C and her family; the summary describes the key events in Child C’s life and focuses on opportunities for learning. 2015 – Child C is living in Cornwall 17. In 2015 Child C’s school made a referral to CAMHS who carried out an assessment. Child C was described by CAMHS as “vulnerable” “needing to be in control” “on edge the majority of the time” and unable to control her emotions or behaviour; her mood was described as “dysregulated.”  Child C reported that she had stopped self-harming and the risk of harm was assessed by CAMHS as low; they did report their view that Child C was at risk of sexual exploitation based on her previous sexual abuse and some sexualised behaviour.   18. A month after the assessment Child C took an overdose which led to a hospital admission, further assessment from CAMHS led to an offer of family therapy and Child C being offered one-to-one work.  19. In November 2015 referrals were made by the school and by CAMHS for Early Help with a view to enlisting the support of a youth worker to help Child C address her increasing  6 | P a g e   social isolation and help her form relationships in the community. Three weeks later Child C was seen by Children’s Social Care as part of an Early Help assessment; the case was closed. There was no further involvement on the basis that a youth worker from the voluntary sector commissioned by the police had already begun to meet with Child C.   20. In December 2015 the school made a second referral for Early Help which led to a Team around the Child meeting in 2016.  2016       -                         Early Help 21. In January 2016 when Child C was 14, a Team around the Child (TAC) meeting4 was convened and described as “well attended” by CAMHS, the school, police and the commissioned youth worker. The Lead Professional was from Child C’s school.5 Ms CM attended but Child C was not present. Teachers had reported that Child C’s school attendance had dropped to 71% and that she appeared to be disengaging from education.   22. Child C’s “complex needs” were identified and her mood changes and behaviour discussed. The plan arising from the meeting was to continue to provide therapeutic services from CAMHS for Child C and Ms CM.  Referral about Sexual Exploitation 23. In February 2016 the police made a referral to Children’s Social Care about possible Child Sexual Exploitation; (CSE) Child C was observed to be very vulnerable and reporting unwanted sexual advances by a 17 year old male.   24.  An Achieving Best Evidence6 (ABE) interview took place and a Section 17 Child in Need Social Work assessment was completed. The assessment recognised Child C’s “poor mental health” and “vulnerability to CSE,” Ms CM and her mother (Child C’s  4 Team around the Child meeting, known as a TAC: this is a multi-agency meeting of professionals who are working with a family or may be able to provide a service. The meeting is part of the Early Help approach and its purpose is to devise a plan detailing who will do what and when. It is aimed at those families who would benefit from early help but who do not meet the threshold for intervention from Children’s Social Care.  5 It is the job of the Lead Professional to convene meetings, facilitate planning and make sure notes are taken.  6 ABE, Achieving Best Evidence, is the guidance drawn up for police about the interviewing of children where allegations of abuse are being investigated. The interviews are video recorded and can be used as evidence in criminal and care proceedings. The guidance is intended to ensure that children’s evidence is contemporaneous and interviewers are specially trained in order that children are not influenced by the way questions are asked.    7 | P a g e   grandmother) were viewed as “supportive.” The outcome was for help to continue to be provided within the Child in Need Framework.7   25. Coincidentally, at the time of the assessment, Mr CF contacted CAMHS expressing concerns about Ms CM’s parenting. He was advised to seek legal advice and contact Children’s Social Care, although he didn’t progress this further. Mr CF was not included in Children’s Social Care assessment.   26. In March 2016, CAMHS met with Ms CM who discussed some of her family history and reported that a close family friend had recently committed suicide. The chronology author reflected that suicide was “a feature” in Child C’s family history.   27. CAMHS continued to work with Child C and undertook some work with Ms CM. A youth worker from a voluntary agency specialising in sexual exploitation also started to see Child C.   28. In May 2016 Child C was admitted to hospital “hearing voices.” Her school attendance had dropped to 67% and a Section 47 Strategy Discussion8 was held because of further concerns of the risk of sexual exploitation. A Child Protection assessment took place and the possibility of another ABE interview was discussed. Child C was unwilling to engage with the police and reported to CAMHS that she was still having suicidal thoughts “now and again.”  29. The records suggest that during this time Child C was visiting and staying with Mr CF; he was in touch with CAMHS expressing his concern about the pace of safeguarding practice and “wanting to get things moving.”   30. In June 2016 CAMHS were seeing the family every three to four weeks. A professionals’ meeting was held at Child C’s school, the purpose of the meeting was to consider sexual exploitation and the risk to which Child C was exposed. Child Protection Plan 31. In July a further Strategy Meeting was held, and subsequent Section 47 enquiries resulted in a Child Protection Conference taking place. Child C was made subject to a  7 Child in Need, Section 17 of the Children Act 1989 states that it is the general duty of every local authority to safeguard and promote the welfare of children within their area who are in need; and so far as it is consistent with that duty, to promote the upbringing of such children by their families.  8 Where there are child protection concerns (reasonable cause to suspect a child is suffering or likely to suffer significant harm) Section 47 of the Children Act 1989 sets out the responsibility of local authority social care services to make enquiries and decide if any action must be taken. A multi-agency Strategy Discussion is the first step.  8 | P a g e   child protection plan.  The category of risk was noted as Sexual Abuse which includes sexual exploitation. The Child Protection Plan was in place for nine months, from July 2016 until March 2017.   32. In August 2016 Child C was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). The diagnosis provided an opportunity for the prescription of medication to help Child C with her mood and take advantage of the therapy she was receiving.   33. In September 2016 Child C made further disclosures of sexual assault and reported being threatened with a knife.  34. Child C spent Christmas with Mr CF which she described as a positive experience, and “having fun.” 2017      -              35. At the beginning of the year Child C was described by CAMHS as “settled, brighter and working hard at making changes in her life.” The improvement was considered by the professional team as being partly due to the medication Child C had been prescribed.  36. In February 2017, following difficulties at school, Child C took an overdose of co-codamol and was admitted to hospital. She also reported feeling “pressure from lots of different services.” The overdose was assessed as premeditated with a view to ending life and the risk assessed as “high.” There were a number of professionals involved with the family and one worker spoke about the challenge of managing a “difficult multi-agency team” and the risk of Child C’s voice being lost.   37. In February 2017 when Child C was 15, Children’s Social Care carried out a statutory child protection visit and noted that Child C was not attending school and her “mental health appeared to be deteriorating.” Ms CM contacted Children’s Social Care to say she was struggling and did not feel able to keep Child C safe, CAMHS had difficulty engaging with Child C. Case Stepped Down to Early Help 38. In March 2017 a Review Child Protection Conference was held and the Child Protection Plan was discontinued. The reasons were as follows: • Child C reported that the Child Protection process had increased her stress and isolation;  • There was no evidence of the continuation of the risk of sexual exploitation;  9 | P a g e   • Child C’s mental health was the primary concern and this was to be supported outside of the Child Protection Process. 39. The Conference recommended that the plan be stepped down to Child in Need status and a date was set for a meeting of the relevant practitioners; however, the record states that following discussion with the Independent Chair, this was not considered necessary as the appropriate services were already in place and could be coordinated through support from Early Help Services.   40. Not all conference participants agreed with the decision to bring the Child Protection Plan to an end but no-one felt strongly enough to escalate their concerns. Early Help intervention was not followed up and there were no further planning or multi-agency meetings. Conference participants did not become aware of this until after Child C had moved to County B.   41. In the summer of 2017 Child C took another overdose, left Cornwall and moved in with her father in County B. The conference stepping-down process and lack of follow-up meant that Child C moved without a plan in place and the case having been closed to Children’s Social Care.  Child C is living in County B  42. August 2017, living in County B, Child C had a new CAMHS worker and new assessment and was diagnosed with anxiety and depression. Mr CF had strong feelings that Child C’s ADHD medication was having a negative impact on her and she stopped taking it.   43. In September Child C was described as being Electively Home Educated (EHE) which enabled funding to be secured for her to attend a pre-sixteen course at a local college.9    A month later she reported a sexual assault by a pupil at the same college and stopped attending.  44. The sexual assault was reported by Mr CF to CAMHS who advised him to contact the police. The police investigated and decided there was insufficient evidence to pursue the matter. The police, the college or CAMHS did not consider referring the matter to the  9 Elective home education is a term used to describe a choice by parents to provide education for their children at home or in some other way they choose instead of sending them to school. Individual families do not receive any of the money which is otherwise paid to schools for each registered pupil but in some circumstances funding can be made available to education providers to meet individual need.    10 | P a g e   Multi Agency Safeguarding Hub (MASH10) of County B with a view to a Strategy Discussion.   45. In the Autumn of 2017 Child C reported feeling worse and had thoughts of self-harm; reports describe her as “constantly thinking about ending her life” and she asked to be placed somewhere safe.   46. Soon after this, Child C cut herself and was taken to hospital. After liaising with CAMHS, Child C was admitted as a voluntary patient to a hospital which provides acute psychiatric assessment, diagnosis and care for adolescents.  In-Patient Treatment  47. In October 2017, for four weeks, Child C was an inpatient on the specialist ward. Almost from the outset, Child C did not want to be there, allegedly rebelling against what she saw as unnecessary restrictions. The staff had difficulties in managing Child C’s behaviour which escalated and included self-harming and tying ligatures, she was also reported to be placing other patients at risk of harm.   48. A series of planning meetings decided that Child C was at less risk in the community than in hospital and she was to be discharged to the care of Mr CF.   49. Although Mr CF agreed Child C couldn’t remain in hospital, he strongly expressed the view that he couldn’t keep her safe or provide the care she needed. The hospital, with CAMHS, made a referral to Children’s Social Care seeking support in the community for Mr CF; Children’s Social Care responded by stating they did not consider there was a role for them and that it was Mr CF’s “responsibility” to care for Child C.   50. Child C was discharged from hospital and returned to her father’s care. A doctor’s report from the hospital stated that “there are no major mental health issues” and no legal grounds (under the Mental Health Act) to keep Child C in hospital.   51. This led to Mr CF’s family withdrawing their support, as their understanding from the hospital was that Child C’s behaviour was not a symptom of mental ill-health but was “attention seeking.”   10 Multi-Agency Safeguarding Hub (MASH): The MASH is the central resource for the county receiving all safeguarding and child protection enquiries. It is staffed with professionals from a range of agencies including police, probation, health, education and social care. These professionals share information to ensure early identification of potential significant harm, and trigger interventions to prevent further harm.  11 | P a g e   52. After Child C’s discharge, County B CAMHS provided prompt and sustained support for the family and the college place was kept open for Child C ready for when she felt able to attend. Towards the end of the year Child C’s mood appeared to have improved although she was also reported to have said that “life is a joke and not worth living.”  2018         -                           53. In January 2018 aged 16 years, Child C took another overdose and Mr CF reported being out his depth; Child C had not returned to college (she was still classified as being electively home educated) and Mr CF could not work because he had to watch her all the time; as a result the family were experiencing serious financial problems.  Police Investigate Alleged Assault 54. In February 2018 Child C reported her father punched her on the leg and CAMHS made a referral to the MASH. Referral information included some of the background, Child C’s “mental health, vulnerability to CSE and the family’s enormous financial and emotional strain.”   55. Following the referral the police contacted Children’s Social Care with a view to a joint investigation. After repeated attempts without success to get a response, the police made a single-agency visit to Child C and Mr CF; Mr CF was asked to attend the police station to make a statement. As there was no evidence of an assault and Child C withdrew the allegation, the police closed the case.  Children’s Social Care Assessment 56. Following up the report of assault, Children’s Social Care made two visits to the family to undertake an assessment. Child C and her father were seen and information was sought from CAMHS. The focus of the assessment was the allegation from Child C that her father had hit her. It was reported in the assessment that Child C was unable to remember the incident. The assessment reports that Child C’s mental health is “stable,” she is engaged with CAMHS and “intends to return to live with her mother.” No role was identified for Children’s Social Care and the case was closed.  Rape Allegation  57.  In July 2018 Mr CF reported to the police that Child C had disclosed rape by a “much older man” which had occurred in Cornwall, when Child C was on holiday with her mother. The local police investigated the complaint and liaised closely with police in Cornwall, where the reported offence had taken place.   58. Cornwall police undertook a single agency investigation and concluded that Child C, who was over 16, had initially given consent which she then withdrew and due to lack of  12 | P a g e   evidence, the case was closed. Child C was referred to an Independent Sexual Violence Adviser (ISVA11)  59. Children’s Social Care in County B (where Child C was still living with her father) were informed of the allegation but, as no “welfare concerns” were identified, concluded there was no role for them.   60. Child C was seen at a local sexual health clinic who offered a vaccination for Hepatitis B and full screening.  Child C Returns to Cornwall 61. In August 2018 Child C told CAMHS in County B that she intended to take her own life at her mother’s home in Cornwall and described in detail how she would do this. Child C then went to visit her mother, CAMHS understood this to be for a short holiday.   62. In September 2018, when Child C decided to remain in Cornwall, Mr CF informed his local CAMHS team in County B. The team advised Mr CF to discuss Child C’s comments about ending her life with her mother; they planned to refer Child C back to Cornwall CAMHS but Child C died before this happened.  Police Welfare Check 63. On her return to Cornwall Child C was enrolled in college near her mothers’ home. During an introductory visit Child C expressed her anxiety to a friend who was concerned about Child C’s mental state. The conversation was overheard by a member of college staff who called the police.   64. The police then carried out a “welfare check.”12 Child C was seen to be safe and the officer who visited judged Child C to be anxious about starting a new course; they ensured Child C’s mother was with her before they left. The information was passed on to Children’s Social Care who concluded there was no role for them at that point; Child C’s mother was given information about how to seek help through the Early Help Hub.   65. Child C started at college the next day; two days later she told a member of staff about the previous rape allegation expressing her frustration that the police investigation had not led to any arrest and that the alleged offender was still trying to contact her. The  11 ISVAs tailor support to the individual needs of the victim or survivor. They provide accurate and impartial information to victims and survivors of sexual violence and emotional and practical support to meet the needs of the victim or survivor. 12 The police make a visit to see the child to ensure they are not in any immediate danger. Depending on the circumstances, a referral may be made to an appropriate agency.   13 | P a g e   staff arranged for Child C to see a police officer who happened to be visiting the college to talk to the students, with a view to seeing if anything further could be done about the investigation.   66. A week later Child C reported unwanted sexual contact with a student from the college and was observed to be withdrawn in class; a staff member offered to talk and asked her what was wrong, Child C was reluctant to say anything but suggested “something had happened” but she didn’t want it “reported.”   67. The following day Child C did not attend college. A staff member telephoned her, spoke to her and Child C said she would probably not attend that day or the following day. Child C was reported to be reluctant to talk any further but agreed to the suggestion of a meeting to consider how best to support her. The staff member asked Child C if she was alone to which she replied she was, but a relative was close by if she needed someone.   68. Later that day Child C took her own life.   FINDINGS AND LEARNING  69. Within the three year period of this review (and in the years before) hundreds of hours of professional time were spent with Child C and her family to explore the impact of Child C’s experiences and to plan interventions which could help address her distress and emotional turmoil.   70. Despite some periods of stability and relative well-being, the improvements were not sustained; Child C described herself feeling “trapped and exhausted” and expressed her frustration at the “lack of change.”   71. The learning comes from examination of the multi-agency work done with Child C and her family, identified learning themes are:  • Understanding Parental Capacity • Child Sexual Exploitation and the Child Protection Process • Managing Transitions – Sharing Information • Responding to the “voice” of the Child   14 | P a g e   UNDERSTANDING “PARENTAL CAPACITY” Expectations of Child C’s Parents 72. During the period under review, two local authority areas worked with Child C and her family, Cornwall and County B.   73.  In Cornwall practitioners worked well together and multi-agency meetings were held within the Early Help, Child in Need and Child Protection frameworks. Plans were put in place, which included work with Child C and Ms CM and there was an explicit expectation that Ms CM would care for and protect Child C.   74. Ms CM was expected to play a part in the safety-planning; she attended most of the meetings, at times restricted Child C’s social activities and managed her challenging and self-harming behaviour. Towards the end of Child C’s life, when she returned to Cornwall, Ms CM was made aware of Child C’s suicidal thinking and expected to keep her safe although, at that time, without any professional support or guidance.    75. In County B Mr CF faced similar challenges, yet without the support of a multi-agency team. (see paragraph Transition Arrangements) The “safety plan” developed by CAMHS relied on Mr CF and included reducing the risk of harm at home, for example moving furniture to block off access to a first floor balcony, constantly watching Child C and reducing her social activities.   76. The willingness of her parents to do everything they could for Child C was never in question and it is likely that this distracted practitioners from any detailed exploration of parental strengths or needs. At all times, Child C was the focus of attention, she was consistently described by those who knew her as a very engaging young person, she was bright and bold and made a big impact on people she met.  Parental Capacity 77. For both parents their own childhood experiences, their knowledge, skills, attitudes and the factors which influenced their parenting of Child C were not fully known or incorporated into the interventions offered to the family.. Assumptions were made based on their education and own professional backgrounds.   78. The lack of understanding meant that the different ways each parent responded to Child C sometimes led to disagreement with the professionals with a risk of conflict or disengaging with services.     15 | P a g e   79.  Mr CF had clear views about prescription drugs and having shared this with Child C, she stopped taking her prescribed ADHD medication; this was in contrast to the view of the CAMHS team in Cornwall who had observed a marked improvement in Child C’s mood when she was taking the medication. Mr CF considered vaccinations unnecessary and Child C turned down the offer of a hepatitis B vaccination against the advice of the sexual health practitioners.   80. The lack of understanding of the parents’ view is particularly evident in County B when Child C was discharged from the inpatient care on the grounds she would be safer in the community. Although Mr CF agreed with the discharge and a number of meetings were held to try and plan the move, he made it very clear that he could not keep Child C safe without help.   81. Although CAMHS were pro-active and referred the family to Children’s Social Care for additional support, Children’s Social Care’s response was that there was no role for them. Discharge from in-patient care 82. The discharge of Child C had a significant impact on Mr CF who was already struggling and had to give up work in order to care for her. The hospital discharge summary included the comment that Child C had no “major mental health issues.” Whilst this may be meaningful to the practitioners (who for example may be thinking of conditions such as psychosis or bi-polar disorder), Mr CF’s family interpreted it as meaning there was no medical reason for Child C’s behaviour, that it was her fault, and they withdrew their practical and emotional support. A more detailed explanation would have avoided the misunderstanding. This highlights the need to be thoughtful about language and to understand the impact, not only of decisions but of the way they are communicated to families.   83. Reflection on the discharge process has identified a missed opportunity to bring this case to the Multi-Agency Resources Panel (MARP) in County B which exists to consider multi-agency planning and resources for young people discharged from adolescent mental health hospital provision. The Panel is currently considering introducing a standing item on their agenda to ensure no young people are overlooked.     16 | P a g e   CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS  Frameworks for multi-agency intervention:  • Early Help     January 2016 – April 2016 • Child in Need    April 2016 – July 2016    • Child Protection    July 2016 – May 2017   Early Help 84. In 2015 Child C’s school and CAMHS made a referral to Children’s Social Care requesting a meeting within the Early Help framework. Children’s Social Care looked at the case and declined the request on the basis that the appropriate services for Child C, (CAMHS and a commissioned Youth Worker) were already in place.   85. In early 2016 a second referral led to a TAC meeting within the Early Help framework.   86. Although the Early Help process brought practitioners together, the complexity of Child’s C’s presentation meant it had little impact; therapeutic work with Child C was ongoing, her school attendance was declining, she took an overdose and was talking about her thoughts of self-harming. The police were investigating possible violence at school and there were concerns about the risk of sexual exploitation.  Child in Need 87. In February 2016 the concerns about the risk of sexual exploitation led to a Section 47 Strategy Discussion; the outcome of the discussion was that an ABE interview would be arranged with Child C and a Section 17 Child in Need  assessment carried out by Children’s Social Care.   88. The assessment records that Child C and her mother were seen three times and information was sought from Child C’s school, the police and a youth worker. The assessment is child focussed and concluded that there were concerns about Child C’s vulnerability to CSE. Her maternal family were viewed as “supportive” and services were to be offered within the Child in Need framework. Mr CF was not involved in the assessment and there is no evidence his views were sought.   89. In the spring of 2016 Child C took another overdose and spent a night in hospital describing an experience of “hearing voices.” In July 2016 the risk of CSE to Child C was reported as increasing and a further assessment took place within the Child Protection Framework. Mr CF participated in this assessment. A Child Protection Conference was convened which led to a Child Protection Plan.   17 | P a g e   Child Protection Procedures and Managing Risk in Adolescents 90. In 2016/17, for nine months, Child C was the subject of a Child Protection Plan. The category of risk identified was Child Sexual Abuse. (there is no category specifically for CSE)   91. The Child Protection system generally works well for younger children for whom risk is located within the family system and a robust parenting assessment and plan of intervention with measurable outcomes is effective. However, the process is not designed with adolescents in mind.  92. At this time, Child C was 15½ years old and the assessed risks came from environmental or external sources (non-family) which does not sit well within a system which was devised in response to risk, generally from parents or carers, to babies and young children.13  The Focus of the Conference/Assessment  93. The focus of the Child Protection (CP) Plan was the risk of CSE, the actual and ongoing risk of self-harm and suicidal ideation was left to be managed outside of the CP process.   94. There is no evidence that the CP process considered the context of adolescent risk taking, (Contextual Safeguarding14) impulsive behaviour or that research about effective strategies was discussed. There is no evidence that the emerging diagnosis of ADHD and Child C’s emotional and mental health difficulties and the implications of this to the likely success of the plan were considered.  95. The plan focussed on Ms CM providing “stronger boundaries” for Child C and for services to provide the help and support she needed to achieve this. Although there is some comment about Ms CM that she “may not have sufficient parenting skills to keep Child C safe,” there was no further evidence of assessment or exploration of this and the complexity of parenting an adolescent presenting with challenging behaviours.   96. The record indicates that, despite her reservations, Ms CM accepted the Child Protection Plan as “the only way forward”.   13 Bilston 2006, cited in That Difficult Age: Developing a more effective response to risks in adolescence, Research in Practice, 2014 14 See for example Contextual safeguarding, An Overview of the operational, strategic and conceptual framework, Carlene Frimin, University of Bedfordshire, November 2017    14 That Difficult Age: Developing a more effective response to risks in adolescence, ibid   18 | P a g e   Protection and Therapy  97. The notes from the initial conference draw attention to the different perspectives of Child C’s family and some of the practitioners; reports indicate there was  professional difference about the best approach to help and protect Child C. Some of the practitioners also commented on the number of staff who were working with Child C (seven at one time) which compounded the potential for disagreements in responsibility and approach.  98. Ms CM, and reportedly Child C, warmed towards the therapeutic approaches and found the protective measures heavy handed and restrictive which meant that the family, in effect, disengaged with the CP process. The lack of understanding of the family’s view and where it came from, created potential for conflict between the family and practitioners; at times Child C’s parents say they felt powerless, unsupported, misunderstood, marginalised and angry.   99. Research in Practice in their paper “That Difficult Age: Developing a More Effective Response to Risks in Adolescence,15 discuss alternative approaches to managing risk and highlight that adolescent development impacts on thinking and behaviour. The research points out that experimentation and impulsive behaviour are part of the normal teenage experience and states that “while demands on services are growing, resources are subject to increasing pressures”: the paper states:  100.  “It is now widely acknowledged that, as a nation, we do not adequately understand, identify, prevent or effectively reduce the significant risks that some adolescents experience ...this is despite some excellent practice at local level.” Poly-victimisation 101. The paper also highlights that:  “Adolescents are exposed to a wider range of risks than younger children. At age 14 they are most at risk of entering the realm of ‘poly-victimisation’ – i.e. being the victim of many different types of maltreatment. Ten per cent of 11 to 17-year-olds in the UK have experienced 12 or more forms of maltreatment during their lifetime.”15  102. The (local) South West Child Protection Procedures16 state that ...  15 That Difficult Age: Developing a more effective response to risks in adolescence, ibid  16Cornwall & Isles of Scilly Safeguarding Children Partnership Procedures Manual  https://www.proceduresonline.com/swcpp/cornwall_scilly/p_respond_abuse_neg.html#def_ch_abuse  19 | P a g e   “If a decision is taken that the child has suffered, or is likely to suffer Significant Harm and hence in need of a Child Protection Plan, the Chair should determine which category of abuse or neglect the child has suffered or is likely to suffer. The category used (that is physical, emotional, sexual abuse or neglect) will indicate to those consulting the child's social care record the primary presenting concerns at the time the child became the subject of a Child Protection Plan.”  103. It is understandable that case auditing, information collection, statutory reporting and management systems require specific data. However, when working with a child with complex multi-dimensional needs who does not fit neatly into specific categories, this approach risks minimising the complexity and creating a false picture. The model used in Cornwall to reach a decision about whether a Plan is necessary involves participants using Signs of Safety to rate their perception of risk using a score from 1-10, however this still does not reflect the complexity of risks which may be involved for adolescents. The Impact of the CP Process on Child C and her Family 104. As part of this Review Ms CM shared her strong views about the negative impact of the Child Protection process on both her and Child C. Ms CM described feeling blamed, persecuted and unsupported, Mr CF described feeling that he was marginalised.  Step-down to Early Help 105. In July 2017 the Conference decided to discontinue the Child Protection Plan, the risk of CSE was said to have been reduced and Child C was reported to be very unhappy at the restrictions imposed on her by the plan. There was an acknowledgment that Child C had ongoing mental health problems, the Conference considered this could be managed outside of the Child Protection framework in line with Child C and her mother’s wishes.  106. The decision of the Conference was that the plan would be stepped down to Child in Need and a meeting was agreed. However, outside the Conference and after discussion with the Independent Chair, this was felt to be unnecessary and because services were already in place the decision was that intervention could be managed within the Early Help framework. Early Help planning never progressed and multi-agency work came to an abrupt end.  Response to CSE 107. This Review indicates that it took over six months before agencies within Cornwall viewed information and referrals in the context of risk of CSE. Given what was known about Child C’s history and the emerging concerns, the first Strategy Discussion could have resulted in the implementation of the Child Protection Procedures.  20 | P a g e    108. The initial response to allegations of CSE was inadequate; at the time awareness and understanding of CSE was in its infancy, there has since been a drive within the Partnership to improve multi-agency understanding and response to CSE.   109. The South West Child Protection procedures state that... “When a child protection plan is discontinued, the social worker must discuss with the parents and child/ren what services might be needed and required, based on the re-assessment of the needs of the child and family. A Child in Need Plan or an Early Help Assessment should be developed for any continuing support.” 110. It is not usual practice for involvement with a family to step-down from Child Protection to Early Help without a plan and a systemic failure to progress as agreed meant that multi-agency work ceased altogether. It appears that Child C moved away before the implications of this became clear to those working with Child C and no-one questioned the lack of action. Practitioner discussion during the Review highlighted the risk of removing support too quickly when intervention is seen to be working.   MANAGING TRANSITIONS – SHARING INFORMATION  111. Three months after the Child Protection Plan ended, Child C took another overdose, Ms CM described herself as being “completely exhausted” and Child C moved to County B to live with her father.  Child C moved to County B  112. By the time Child C moved to County B Children’s Services had closed the case; this meant that there was no system in place for sharing information as there would have been if they were still involved.  113. Child C’s move took place during the summer holidays and although she hadn’t been attending school, information was shared with the college in County B at the start of the new term. CAMHS contacted their counterparts and information was passed on to the new team who carried out an assessment.  114. This meant that within a few weeks Child C and her family went from being supported by a large and active multi-agency team, albeit one Child C and her mother had found to be oppressive, and overwhelming, to help from a single agency (CAMHS) with no ongoing multi-agency risk assessment or plan.    21 | P a g e   115. CAMHS in County B assessed Child C as “depressed and anxious” this was a slightly different description from Cornwall and did not include the ADHD diagnosis. Mr CF appreciated this diagnosis, partly because he felt strongly that Child C should not be taking the medication prescribed to help her emotional regulation after the ADHD diagnosis.  Lost Opportunities for Information Sharing 116. Having had what was described by practitioners as a relatively stable period in Cornwall, within a few weeks of moving to County B, Child C was described as struggling emotionally and had reported another sexual assault.   117. At this point an opportunity to share information was lost because although CAMHS, the college and the police knew about the allegation of the sexual assault (Child C was 15½ years old) no-one requested a Section 47 Strategy Discussion which would have led to sharing of information including the Child Protection history. On reflection, practitioners are unclear about why the reported assault was not referred.   118. The police in County B investigated the assault allegation as a single agency without a strategy discussion and decided there was insufficient evidence to proceed.   119. A few weeks after this incident Child C again had thoughts of self-harm and asked to be placed somewhere safe. She cut herself and was admitted to hospital, from where arrangements were made for transfer to a psychiatric facility. Child C remained in hospital for about 4 weeks.  120. In March 2018 Child C reported her father had “punched her leg and shouted in her ear.” CAMHS made a referral to Children’s Social Care which, after a delay of two months, led to an assessment.   121. The Assessment was based on one visit, the report is superficial and no further information was requested from the local CAMHS team, Cornwall Children’s Social Care or the hospital.   122. The assessment recognised that Child C was “suffering with her mental health” makes a passing reference to “incidents of self-harm” and that Child C was not receiving education and was feeling isolated. The report makes no reference to Child C’s recent hospital admission, suicide attempts or history of being at risk of CSE.    22 | P a g e   123. During the assessment Child C described her relationship with her mother as “unsupportive” with “a lack of rules and boundaries” and which had “broken down prior to her move to County B”, yet Child C’s plan to return to Cornwall was not questioned.   124. The assessment appears to have focussed on the single incident of the alleged physical abuse which was quickly discounted. Child C was spoken to alone and reportedly said she “may have imagined it.”   125. In May 2018 the assessment was signed off by a manager and closed on the basis that CAMHS were involved with the family, there was no role for Children’s Social Care and Child C was intending to move back to Cornwall in the near future.   126. In July 2018 Child C reported that she had been raped and sexually abused by an older man whilst on holiday in Cornwall. The police in County B communicated well with the police in Cornwall who investigated the allegation as a single agency without a strategy discussion, but lack of evidence meant they were unable to progress the matter.   127. County B police also passed the information to County B Children’ Social Care however they had already completed their assessment and the case was closed.  128.  Two months later Child C moved back to Cornwall.  Sharing information when Child C moved back to Cornwall 129. CAMHS in County B were aware that Child C had expressed suicidal thoughts in the days leading up to her move. Although the move was intended, it happened more quickly than expected when Child C decided to stay on after what was planned to be a short holiday.   130. County B CAMHS advised Mr CF to share Child C’s comments about her suicidal intentions with Ms CM; they had intended to share the information with Cornwall CAMHS but were not aware the move was permanent until about a week after it had taken place, the information was not shared before Child C took her own life.   131. CAMHS practitioners advise that referrals containing suicidal ideation are common and therefore do not necessarily prompt an immediate response.    23 | P a g e   RESPONDING TO THE “VOICE” OF THE CHILD  132. In the published Serious Case Review “CH” (Haringey 2015) 17 the author promotes the concept of “Thinking Differently about Capturing Children's Experiences” describing the importance of understanding and responding to the child's perspective.   133. Child C had no difficulty in expressing herself; she frequently said she felt suicidal, distressed and frustrated at the lack of change; she said she felt “invisible until she made a mistake”, and felt “trapped, exhausted and unsafe.” When Child C was discharged from the in-patient unit in County B, she was reported to express the view she was “beyond help” and could not be “healed.” Towards the end of her life she clearly put into words her intention to end her life, how, where and when she would do this.   134. The challenge of thinking beyond “hearing the voice of the child” and how to respond to the “voice” is described in detail in the work of Research in Practice “That Difficult Age: Developing a more effective response to risks in adolescence.”18 The paper explains that within safeguarding practice, responses to adolescents are constrained by systems which apply...  “traditional definitions of risk and approaches to protection that do not necessarily fit with young people’s lived experience or research.”   135. Although most of the practitioners “heard” Child C and there is no doubt that some were able to build a trusting relationship with her, continuity was difficult to achieve because of:  • the number of practitioners working with the family  • the marked difference in their approaches (during the CP process)  • significant disruption in relationships when she left Cornwall. • staff changes (particularly significant just as Child C was establishing a relationship with County B CAMHS)   136. The response to Child C was informed by established risk assessment models and the need for practitioners to adhere to child protection policy and procedure. Harder to recognise and to respond to effectively was the repeating pattern of Child C’s behaviour. Reviewing the chronology of events, the pattern becomes evident in the number of  17 Child ‘CH’ Serious Case Review, Haringey Safeguarding Children Board, 2015,Alyson Leslie - Independent Overview Author 18 Research in Practice “That Difficult Age: Developing a more effective response to risks in adolescence. Ibid  24 | P a g e   times Child C self-harmed, reported a sexual assault, would not comply with a police investigation and then walked away from school or college.   137. Thinking more creatively and responding not just to events and allegations, but understanding patterns is very challenging for practitioners, particularly those working within prescribed child protection processes.  SUMMARY OF LEARNING 138. Throughout the process of this Review individual agencies in Cornwall and County B have reflected on learning and made recommendations for practice improvement. For all agencies the learning is as follows: UNDERSTANDING PARENTAL CAPACITY A. Parents play a vital part in safety planning and are expected to work closely with professionals. In order to avoid misunderstandings and conflict it is essential that practitioners understand parental capacity, strengths and attitudes. This will increase the effectiveness of interventions and avoid placing additional stress on children and their families.    B. All agencies must be aware of the practical and emotional stress on parents and carers of suicidal and self-harming adolescents. Agencies must ensure parents’ own support needs are considered if necessary in a separate carers’ assessment.  CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS  C. When there are multiple practitioners directly involved with the family there can be confusing inter-agency communication and the risk of assumptions being made.  In this situation, the number of practitioners involved with the family and the tensions in different approaches undermined the effectiveness of the work.   D. Working with adolescents on risk management and safety planning is more likely to be effective if the child has a good and trusting relationship with one worker.  E. Considering and making explicit the therapeutic and protective interventions with young people in child protection planning and agreeing priorities, increases the chance of positive outcomes.  F. If children are to be subject to Child Protection Planning it is essential to understand any  health diagnosis they may have , for example ADHD or emotional dysregulation. Without this explicit knowledge, it is difficult to develop and assess the potential effectiveness of any plans or the ability of the child to engage with the planned interventions.   25 | P a g e    G. When a Child Protection Plan comes to an end, an up-to-date risk assessment is required to avoid over optimism based on a single incident or short term improvement.  H. The ending of any process (CP or CIN) must include a clear statement about what will follow. If involvement is to be stepped-down, a plan with child-focussed outcomes should be in place and all conference participants should ensure they are clear about their role in any ongoing work. If any conference participants disagree with the conference decision, a discussion with their line manager about whether or not to escalate their concerns will help clarify thinking and contribute to effective decision making.   I. CSE requires a different focus from other forms of child abuse. Consideration must be given to the context in which the abuse is taking place and Child Protection or alternative planning should include roles and responsibilities of all relevant agencies or individuals. This needs to be in the context of Working Together 2018, which would have ensured information sharing at least in strategy discussions when allegations of sexual abuse had been made.  J. Adolescents can be exposed to a wider range of risks than younger children; concentrating on a single issue may lead to an over optimistic assessment of risk.  MANAGING TRANSITIONS –SHARING INFORMATION  K. Assessments which are based on a single incident and which fail to consider a child and family’s history are unlikely to provide an adequate assessment of risk. All assessments should include a chronology of events and, where appropriate, information from the area from which a child has moved.   L. Reflective supervision and robust management oversight in high risk cases mitigates against the risk of confirmation bias in an assessment and helps ensure a proactive approach is taken to seeking and sharing information with other agencies.  M. There is a risk that the involvement of CAMHS with a young person can be seen as a reason for other agencies not to intervene with a family. If CAMHS are working with a child and Children’s Social Care receive a safeguarding referral, it is important that all aspects of the child’s life are considered with a view to a holistic risk assessment.   N. Current regulations related to Elective Home Education require an annual visit to be made by a local authority to ensure that the education of a child is satisfactory; there is no requirement to see the child. This means that a child can be “invisible” to education services for up to a year and education are unable to contribute to multi-agency assessment and planning.      26 | P a g e   RESPONDING TO THE “VOICE” OF THE CHILD  O. When a child requires safeguarding, all assessments should include listening and responding to their views. It is important to find a balance which prioritises safeguarding the child and which also recognises their agency. Considering each child’s individual capacity to understand and participate in their own safeguarding is vital.  P. Recognising a child’s pattern of behaviour around reporting and withdrawing disclosures of abuse will enable practitioners to consider the meaning of the behaviour and avoid the risk of responding to individual incidents. Recognising a pattern will enable practitioners to take an overview and think beyond the necessary processes towards more effective interventions.  . CONSIDERATIONS FOR THE SAFEGUARDING PARTNERSHIPS 139. The lines of enquiry raised at the beginning of the review process address specific practice issues associated with vulnerability, response to risk and information sharing when a child moves between different areas in the country. Invariably, from such a detailed review, shortfalls in practice will be identified. There is also, within Child C’s story, evidence of commitment, reflection and skilled work from practitioners; Child C clearly made an impression on those who knew her.   140. Recommendations are: • The Review is shared with County B; • The development of an action plan based on the learning;  • That consideration is given to the development of a research-based risk management strategy designed to address the specific features of adolescent risk taking and suicidal ideation;  • The Partnership promotes the concept of “contextual safeguarding” and satisfies itself that is understood and adopted by practitioners and managers working within the Child Protection Process;  • Existing relevant policies and procedures are reviewed to ensure learning from this Review is reflected in guidance. • The Partnership gains an understanding of the work force’s knowledge and skills in practice with vulnerable adolescents, and develops evidence-based learning to meet any gaps. 