Murder of a 17-year-old boy from multiple stab wounds believed to have been inflicted by a several other young people. Leo had special educational needs (SEN) as a result of his severe difficulties with speech and language. Learning and recommendations are combined and include: ensure that professionals have access to good training on the signs, symptoms and impact of speech, language and communication disorders, prioritising staff working with children at risk of offending; ask that agencies take all reasonable steps to identify and engage the fathers of children and young people with whom they are having contact; the Youth Offending Service should ensure that being charged with a violent offence triggers a multi-disciplinary assessment of need and risk.
      
 Title:  Learning review ‘Leo’: overview summary. LSCB: Bromley Safeguarding Children Partnership Author: Bromley Safeguarding Children Partnership 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.                            Learning Review ‘Leo’: Overview Summary   Background Shortly after reaching the age of 17, Leo died from multiple stab wounds. He is believed to have been killed by a number of other young people and his death has been the subject of a protracted police investigation.  Leo was a black child, of Caribbean heritage. His parents separated when he was in primary school and he lived with his mother and his younger sibling, who has had no involvement with any specialist or safeguarding services. Leo had always lived in Bromley where he was well known to local services. From an early age he had special educational needs (SEN) as a result of his severe difficulties with speech and language. Although he attended a mainstream secondary academy, after a year his parents agreed that he should be educated in a specialist setting (which is part of the same academy) where he would receive a higher level of individual support. Professionals questioned whether he had a disorder on the autism spectrum and a number of unsuccessful attempts were made to engage Leo and his mother in assessments with health professionals. Aged 16, Leo was convicted of wounding and theft.  These offences had taken place two years prior to the trial. He admitted to professionals that he used and was involved in the supply of drugs, though he said he was not a gang member and no evidence has been found to contradict this.  Relationships with family members had broken down and at the time of his death he was living in supported accommodation for young people, arranged for him by Bromley Council’s housing service. He had an allocated social worker and had begun to work with a member of staff in Bromley’s Youth Offending Service. Prior to his murder he showed signs of possible depression, resulting in a referral to the mental health service (CAMHS).   Findings and Recommendations The review has recommended that the Bromley Safeguarding Children Partnership (BSCP) should:   • Seek assurance from the Local Authority (LA) that current decisions on secondary school placements for children with SEN linked to speech and language disorders take full account of those needs and are made in accordance with statutory guidance. • Seek assurance that the SEN service is fulfilling its statutory duty to ensure the provision made for children and young people with SEN, for whom they are responsible, is kept under review. • Seek confirmation that speech and language therapy (SALT) provision for children and young people at secondary school level is adequate to meet identified needs, taking account of the significance of this issue as a risk factor in serious youth crime. • Satisfy itself that Bromley’s network of preventative services is making effective provision for young people who have risk factors that have an association with violent offending. • Seek evidence from all service providers that professionals have access to good training on the signs, symptoms and impact of speech, language and communication disorders, prioritising staff working with children at risk of offending. • Seek assurance from the LA that improvements in the quality of child and family assessment are being made and sustained. • Communicate a strong expectation that agencies take all reasonable steps to identify and engage the fathers of children and young people with whom they are having contact.  Recommendations for specific agencies are that: • Single and multi-agency procedures should allow for the convening of regular face to face meetings to discuss complex cases where there are multiple risk factors. • The Early Intervention and Family Support Service (EIFS) should establish how effectively its staff are working with health professionals to identify and meet the health (including mental health) needs of children. Particular attention should be paid to increasing the involvement of GPs in early intervention services, Common Assessment Framework (CAF) and Team Around the Child (TAC) arrangements. • Commissioners of Autistic Spectrum Disorder (ASD) and SALT services should ensure that specialists are available to offer advice and consultation to develop intervention strategies. • The Youth Offending Service should ensure that being charged with a violent offence triggers a multi-disciplinary assessment of need and risk, particularly if the young person concerned has other factors indicating risk or vulnerability. Consideration should also be given to the process for identifying circumstances in which a bail package of support is requested. • The local authority SEN service should ensure that reviews of SEN receive and record meaningful information about pupils’ attendance. • Health providers should explore the possibility of developing closer links with other professionals working with families (especially those in EIFS) as a means of encouraging greater attendance at specialist clinics e.g. CAMHS.  In addition to these recommendations, the single-agency management reviews include actions in the following areas: • Better collaborative working between housing and children’s social care (CSC) services in assessing and meeting the needs of vulnerable adolescents. • Better understanding of the specific needs of young people, including those linked to their racial, ethnic or religious identity. • Support for pupils and students who have been victim of or alleged perpetrator of a serious criminal offence so that their problems are not compounded by the impact of involvement in the criminal justice system. • Better identification and support of students with special needs or involvement in criminal justice system when attending colleges. • Greater engagement of GPs in safeguarding work and with the strategy to combat serious youth violence. • Closer working between Youth Offending Service and other agencies (including at points of transition and case closure). • Reiteration of standards and practices in relation to recording, supervision, information sharing and involvement of young people.  Improvement Plans CSC were judged to be inadequate by Ofsted inspection in June 2016. Many of the shortcomings in this case were identified during this inspection and have therefore been addressed as part of an overall CSC improvement plan in partnership with other agencies. The Ofsted inspection in November 2018 and the published report in January 2019 judged Bromley CSC to be good in all areas with outstanding leadership.  This is a direct reflection on the many improvements made since 2016. All agencies involved in this Learning Review have submitted an action plan to address recommendations and these are being monitored by the BSCP.  