The sexual abuse of an 11-year-old girl, and grooming of her 8-year-old sister, by their mother and her boyfriend over a 12 month period prior to April 2020. Learning is embedded in the recommendations. Recommendations include: schools should consider how they monitor and review the concerns logged on their child protection online management system, there should be an automatic review built in when a certain number of concerns are logged within a specific period; safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time; health services need to ensure that all transfers in families where children are at risk are accompanied by appropriate documentation, management review and a visit; when a concern is raised with health services by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier; children and young people services should ensure that at the point of referral, any extensive history is carefully considered within the multi-agency safeguarding hub as part of effective decision making on what action to take; and children and young people services should set any retracted compliance regarding a common assessment framework within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn.
      
 Title:  Local children’s safeguarding practice review: Young People F: overview report. LSCB: Suffolk Safeguarding Partnership Author: Chris Burton Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            This report is the property of Suffolk Safeguarding Partnership and is confidential. Its contents may only be shared with appropriate representatives of the relevant agencies for the purposes of completing the Local Children’s Safeguarding Practice Review Process.  Local Children’s Safeguarding Practice Review Young people F Overview Report DATE 26/04/2021 Author: Chris Burton – County Safeguarding Manager  Page 3 of 14 Contents 1. Introduction ..................................................................................................................................... 5 2. Scope of Review ............................................................................................................................. 5 3. Organisational Context ................................................................................................................... 6 4. Key Findings ................................................................................................................................... 7 5. Recommendations Emerging from this Review ............................................................................. 9 6. Action Plan .................................................................................................................................... 11 7. Glossary of Terms......................................................................................................................... 13 8. Appendices ................................................................................................................................... 13 Appendix 1: Terms of Reference .................................................................................................. 13 Appendix 2: Attendees at Information Gathering Event............................................................... 13   Page 5 of 14 1. Introduction 1.1 It is always shocking when long term sexual abuse of children emerges in the absence of any obvious indicators – nothing said by the child and no apparent distress or even unease, no alarm bells heard by school, health or CYP. Professionals have to acknowledge the unpalatable reality that in some instances the shocking abuse such as in this case may not be experienced by the child as terrifying and that there may paradoxically be some positive and affectionate feelings for the abuser. 1.2 That is the context within which the abuse of these girls occurred, only emerging when the wife of the abuser found explicit images of the girls on his phone in April 2020 and immediately called the police. These and other videos, indicated that her husband was conducting an affair with the mother of the two girls in question, abusing the older girl and preparing to do the same with the younger child. It became clear during the police investigation that the children’s mother was instrumental in preparing the girls to be abused by her lover and complicit in the physical and sexual harm experienced by them both. 1.3 The abuse continued for a period of at least 12 months prior to April 2020. During this time, F1 the eldest girl now aged 11 had been sexually assaulted on several occasions, so seriously that the perpetrator was convicted of rape. Her sister F2, now 8 was in the process of being physically and emotionally prepared by her mother for a similar pattern of sexual abuse. The perpetrator was known to the two girls as a friend of their mother who was kind and affectionate to them with a daughter in the same class as F1. Aspects of the preparation that the mother had put them through were not without discomfort and both physical and emotional pain – both adults received a 22 year prison sentence, the maximum permitted by law. 2. Scope of Review.  2.1. During the Care Proceedings in respect of these girls, the family court judge requested information as to what steps the local authority had taken [if any] to investigate and identify why the abuse suffered by these children was not picked up sooner either by them or by any other agencies involved with the children and what changes if any might be made to any procedures/process to help prevent serious abuse in respect of children in the future being missed. The response by the Chair of the Suffolk Safeguarding Partnership effectively set the scope of this review, namely:  2.2. To determine whether or not there were any indicators that were missed during the 18 months to 2 years prior to April 2020 2.3. To question what links were made between individual concerns that arose, mother’s history and the broader context of what became known during the 10 years since the family moved to Suffolk  2.4. To highlight the ‘lived experience’ of these children and determine what might have been done for this to have become apparent to professionals in the months and years before the abuse was discovered 2.5. To evaluate the role of agencies both before the abuse was discovered and afterwards  2.6. To consider whether a lack of professional curiosity was a factor in dealings with this family during their time in Suffolk  2.7. To understand whether there is any further learning and development needed to distinguish the identification of neglect and the implications for children 2.8. Interviews were conducted with relevant staff: - Investigating police officer and Inspector from the Child Protection Unit - Headteacher and Safeguarding lead from the school  Page 6 of 14 - Healthy Child Programme Lead  - Allocated social worker  - Current foster carer 2.9. Chronologies from Health and Education, Police interview transcripts with the girls and detailed records from CYP were examined as well as the details of the concerns logged on the school’s CPOMS (Child Protection Online Management System) since the girls first attended.  3. Organisational Context 3.1. The answer to the understandable question about how this could have been missed is simply that there were no obvious indicators to suggest the nature and extent of the abuse they suffered. However, there were factors in the history of this family which might have elicited a greater degree of professional curiosity, with a subsequent linking of apparently disconnected events and a willingness to at least consider the unthinkable. These links were not made. No single agency, other than the school, had any consistent overview of these children.  3.2. There are three main phases to organisational and professional links with this family – firstly 2010 to 2016 – CYP and some Health involvement. When the family first moved to Suffolk, a period of CP Planning for F1 in another county had recently ceased. There was no Health handover visit when the family arrived, something that would happen now.  3.3. However, F1 was once again made the subject of a CP Plan in Suffolk from June to November 2011, category of neglect. There was significant involvement and assessment during 2011 and `the case was closed immediately after F1 was removed from a plan  3.4. CYP received several referrals in the following years: - Oct 2013: Concern from mother’s half-sister that stepfather was coming to stay for a week in the household and was a Schedule 1 offender; - May 2014: Concerned neighbour reporting smelly children and various men coming and going. HV reported that when she had visited in February house and children were ‘clean and tidy’; - November 2015: Allocated for SW assessment due to concerns about domestic violence and physical chastisement.  None of the above resulted in any clarity about what had been done and whether the home had been visited or the children seen.  A further unspecified MASH referral was made in April 2016 with an information and advice outcome. 3.5   A second phase from 2016 – 2020 when the local primary school recorded a range of concerns and incidents with some involvement from Early Help in 2019 when a CAF had to be abandoned after mother withdrew her agreement. There were some referrals for specialist health appointments but with no specific outcome. It was in the latter stages of this phase that the girls were being abused – school staff who knew them well are horrified and distraught that they did not consider the possibility of harm as they saw no sign. On one occasion, F1 missed the first part of the school day for a visit to the dentist, returning for lunch after suffering penetrative sexual abuse by the male perpetrator. No one talked to her about the ‘dental appointment’, as there was nothing about her presentation on that  Page 7 of 14 day to cause worry and yet…. she had been the subject of a catalogue of queries and concerns about personal hygiene, cleanliness, poor clothing and her mother had refused a CAF after initially agreeing. 3.6  A third phase from April 2020 ‘till the present, when the abuse was uncovered and the children removed. It is this period that has shown exemplary multiagency work starting with the Police/CYP joint investigation and characterised by an unwavering focus on the children’s view of their world and how it has been impacted by the abuse they suffered  4. Key Findings 4.1. Main observations as follows: • Although there was no single indicator that would have suggested these children were being abused, agencies had information that was not systematically evaluated – multiple single occurrences or concerns were not linked over time, nor did frequently recurring doubts trigger any more formal review of each individual concern. An example of this is an excess of 30 concerns being logged by the primary school over a three-year period without an evaluation of what this might mean for the lived experiences of the girls; • When the police and social worker visited the girls’ family home, the physical standards were poor – dirty bedding, few clothes, an older father who simply sat continually downstairs, unable and/or unwilling to do anything to meet their needs. No professional had entered the house for some months; • Staff within the school were available to the girls should they have wished to speak about what was happening at home, but did not consider that there might be a need to engage them carefully and pro-actively to get an understanding of their world and their experience of it; • An absence of professional curiosity, information being fitted within the pre-conceptions of professionals and an overly optimistic view of what might be happening for these girls; • Both health and CYP had historic information from before the family moved to Suffolk that indicated: -  The mother of the girls had suffered sexual abuse and physical harm from her own parents and been a looked after child in the latter years of her childhood - She had low cognitive functioning and identified herself as having a degree of learning disability - She had married a man 41 years her senior after initially having a relationship with his son - Her eldest daughter F1 had been on a CP Plan for neglect as a baby in another county All of these elements were never fully pulled together, even though there was a further CP in Suffolk during 2011.  • No one agency made the link between this history and what were seen simply as sporadic low-level indicators of neglect at various points from 2011 to April 2020. Yet there were other concerns - a CP referral in 2013, two reports of domestic incidents, and an allegation that mother hit F1 in 2015, concern expressed by a neighbour about different men being seen entering the house • Referral to MASH might have been the mechanism that prompted this scrutiny of individual concerns with the historic context but this was not the outcome of the referrals that were made   Page 8 of 14 • Neglect is an overused term especially the phrase ‘low level neglect’. A classification of low may conceal a high adverse impact for a child. The classification  is sometimes used as a justification for professional inaction and more seriously can blunt the impetus for exercising appropriate and proportionate professional curiosity. The assumption was made by the school that when the at times poor hygiene and grubby presentation of the girls improved, this was  a positive indicator. In fact, it was the result of the girls being cleaned and physically ‘groomed’ before the abuse began. • These girls were not able to verbalise their lived experience during the time that the abuse occurred, at least not to those professionals who they saw most often. However, no one considered that it might be helpful to encourage them to say more about life at home • It was only after the abuse had been discovered that these girls have been able to talk about what their life was like.  • No one agency had the complete picture about this family. When they first moved from Herts in 2011, F1 had only recently been removed from a CP plan – this information informed the CYP response and there was a short further period of Child Protection and  the case was shortly thereafter closed.  • There was no formal review of the health records as they were transferred (which would happen now).   • It was only the police investigation that revealed the extent of the abuse suffered by  these children. However they have only begun to be able to express the nature of their experience over the period of months since they have been placed elsewhere. This is not unusual as many children can only disclose once they feel safe enough to do so.  4.2. The only aspect of this case that is positive is the response of agencies after details of the abuse emerged in April 2020. 4.3. From the point of the at which the girls were supported when their mother was arrested and they were removed to a safe environment, excellent work has been done in trying to help uncover the extent of what happened and then supporting them and their carers.  4.4. The transcripts of the initial joint interviews show a sensitivity, a responsiveness and a willingness to suspend disbelief and enter into the world of these children. The commitment to the girls from both the investigating police officers and their social worker has been unwavering. 4.5. The social worker who is working with the girls has demonstrated both a thorough knowledge of the family history and how this can better inform responses to their present trauma.  5. The ‘lived experience’ of the girls  5.1. The children are now placed together – F1 is struggling in a range of ways e.g. soiling. Only at points when she appears content will she speak a little about the abuse. Her carer believes that she loves and misses her mother as well as the perpetrator to some extent. She also describes their concern and worry for their father. F1’s younger sister doesn’t talk about what happened. The foster carer describes a ‘turbulent period’ in the months since they arrived in November of last year, ‘if one is on track then the other is not’. 5.2.  The impact on both girls is incalculable – specialist support is available both to them and the foster carers whose insights are invaluable in helping these girls to process what has happened. The female carer describes how F1’s smearing and urinary incontinence somehow makes her feel closer to the perpetrators – in a sense she welcomes the discomfort (the abuse was accompanied by incontinence) and her current soiling becomes self- harm.  Page 9 of 14 5.3. The girls have expressed a wish to remain where they are and have taken the name of the family. As the carer described it……..’they are part of our family and this is their forever home. There is no one else for them – we are it!’   6. Recommendations Emerging from this Review  6.1. It is clear from the body of this report that there were no specific instances when a clear indication of abuse was missed. However, there is learning which all agencies can take from the pattern of events after the children moved to Suffolk:  - Forty years ago Tony Morrison coined the phrase ‘professional dangerousness’ (Dangerous Families – Tavistock 1981) to highlight the way in which professionals can behave in a way which ‘colludes with or increases the dangerous dynamics of the abusing family. Sadly, this is still a feature of professional thinking as is demonstrated in this case. The SSP should consider delivering a Partnership learning event which builds on the need to:-  o Talk with the child o Exercise professional curiosity o Understand the experience of the child not simply the adults’ point of view o Beware of the parent who habitually visits school, clinic or office as a possible strategy to discourage professionals visiting the home o Access or develop a comprehensive chronology and learn from what is known. This is an important counter to professional optimism and also the ‘start again’ syndrome when a family moves to another area or service o Assess if in any doubt – do not assume it is simply how this family lives  o Deep dive into reasons for variable/disguised compliance   o Clarify all routes for expressing concerns – not simply MASH – contacting the relevant service manager and safeguarding manager o Avoid assuming that another agency or professional will have an overview of risk o Challenge decisions by agencies that do not follow on from the evidence-base in  a referral o Understand the implications of professional uncertainty for how cases are managed and workers supported o Embed authoritative practice which can effectively challenge parents when needed o Understand the dangers of silo thinking   6.2.   Schools should consider how they monitor and review the concerns logged on their CPOMs system. There should be an automatic review built in when a certain number of concerns are logged within a specific period. 6.3. Safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time. Any perceived failure in responsiveness should be escalated within the school and the Headteacher can then contact a senior manager within the receiving agency   Page 10 of 14 6.4. Health need to ensure that all transfers in of families where children are at risk are accompanied by appropriate documentation, management review and a visit. 6.5. When a concern is raised with Health by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier 6.6. CYP should ensure that at the point of referral, any extensive history is carefully considered within the MASH as part of effective decision making on what action to take 6.7. CYP should set any retracted compliance regarding a CAF within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn.    Page 11 of 14 7. Action Plan The following Action plan has been developed by the review group to implement the recommendations made in this report. Theme Action No.  Action Lead Responsible  Progress / notes Voice of the Child 1.     Family Engagement 2.     3.     4.     Identifying Neglect 5.     6.     7.     8.     Professional Curiosity 9.     10.     11.     12.     13.     14.       Page 13 of 14 8. Glossary of Terms CCG NHS Clinical Commissioning Group GP General Practitioner JPUH James Paget University Hospital LH Lound Hall Nursing Home MASH Suffolk County Council Safeguarding Multi-Agency Safeguarding Hub – central point through which all safeguarding referrals are made SCC Suffolk County Council SSP Suffolk Safeguarding Partnership Pt acronym often used in clinical records for ‘patient’ ‘SystmOne’ NHS clinical notes recording system used by GP practices 9. Appendices Appendix 1: Terms of Reference Appendix 2: Attendees at Information Gathering Event                Endeavour House Ipswich Suffolk, IP1 2BX 01473 26 55 00 ‖  www.suffolksp.org.uk  