Death of a 15-year-old-boy in July 2021. Child E was fatally stabbed by another 15-year-old-boy. Learning considers: the involvement of young people in exploitation and knife crime and the potential for rapid escalation of violence; the heightened risk that children who have special educational needs, or who experience a disrupted education, may become involved in serious youth violence or may be exploited; helping children involved in criminal activity or at risk of exploitation who have suffered severe adverse experiences in early childhood; responding to the needs and circumstances of Black children and their families; and the role of social media in exploitation and the response of professionals. Recommendations include: local safeguarding children partnerships (LSCPs) test whether there is effective response to the rapid escalation in violence that can occur when there is child exploitation or serious youth violence; LSCPs test the effectiveness of arrangements to promote better school attendance, and reduce rates of exclusion, among young people at risk of exploitation; LSCPs review the effectiveness of responses to families from Black and minority ethnic communities to consider how best to understand and discuss their experiences, values and perspectives; the Child Safeguarding Practice Review Panel should promote learning from the review of services provided to suspected perpetrators of serious youth violence and criminal exploitation, both through guidance issued by the panel and by seeking changes to the statutory guidance 'Working Together to Safeguard Children 2018'; consideration should be given to wording in the draft 'Police, Crime, Sentencing and Courts Act 2022' guidance on the review of offensive weapons homicides.
      
    Serious Case Review No: 2023/C9910  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.           Child Safeguarding Practice Review: Death of Child E   Independent Lead Reviewer  Keith Ibbetson         Child Safeguarding Practice Review   1 INTRODUCTION 1 2 THE YOUNG PEOPLE – Table 1 4 3 EVENTS LEADING TO THE DEATH OF CHILD E 6 4 ADDITIONAL INFORMATION ABOUT THE YOUNG PEOPLE TO SUPPORT THE FINDINGS OF THE REVIEW – Table 2 8 5 EXPLOITATION AND SERIOUS YOUTH VIOLENCE – ESTABLISHED AND NEW LEARNING 13 5.1 Introduction  13 5.2 The potential for very rapid escalation of violent events 13 5.3 Additional risks to children who have special educational needs or experience a disrupted education 16 5.4 Responding to the needs of young people who have had severe adverse experiences and become persistent offenders 19 5.5 Responding to the needs and circumstances of black children and their families 20 5.6 The role of social media and the professional response 23 6 LOCAL LEARNING, ACTIONS PROPOSED AND TAKEN 25 7 THE ABILITY OF PARTNERSHIPS TO REVIEW THE SERVICES PROVIDED TO SUSPECTED PERPETRATORS OF SERIOUS YOUTH VIOLENCE – NEED FOR REVIEW OF STATUTORY GUIDANCE 27 8 OVERVIEW RECOMMENDATIONS 31   1 | P a g e   1. INTRODUCTION 1.1. In July 2021 a 15 year old boy (subsequently referred to as Child E) was fatally stabbed by another 15 year old.  1.2. The local authority in which Child E was living notified the Child Safeguarding Practice Review Panel of this as a serious child safeguarding case.1 The local safeguarding children partnership (LSCP) carried out a rapid review of the circumstances, in line with the statutory guidance.2  Information provided at the rapid review meeting  1.3. The rapid review meeting considered information about Child E and his family and identified no concerns about the way in which Child E or his younger siblings had been looked after by their mother.  1.4. Child E had attended a mainstream academy school in his local community. The school knew him very well, describing him as a successful student who attended well and was punctual. Child E was conscientious in lessons though he had occasionally been in conflict with other pupils, or their friends. As a result, on a small number of occasions, the school had suspended him for short periods. The school had also been concerned that Child E might be vulnerable to the influence of young people involved in crime and it had sought to maintain very open communications with him in the hope that, if such concerns did arise, he would be able to turn to the school for support. Child E had attended workshops on topics such as awareness of knife crime which form part of the school’s curriculum. 1.5. Two months before his death, Child E had attended an alternative local educational setting for just over two weeks. This placement was made after incidents in which Child E came into conflict with another pupil, the school fearing that this might escalate and lead to violence at the school. This placement had gone well and had confirmed that Child E should return without delay to his school. This happened a month before his death and no further incidents of concern were noted during that period. The school remained concerned about potential violence in the local area and referred Child E to the local authority in order that the preventive services could be considered. Child E had had no involvement with the Youth Offending Service. Some years previously he had been in contact with the police as a victim of crime, but there are no other reports of contact with the police that are significant in  1 HM Government (2018 and 2020), Working Together to Safeguarding Children, Part 4, Sections 4.11 – 4.14 set out the criteria for determining whether an incident meets this definition and the procedures for making a notification. The local authority and the LSCP treated the death as falling within the definition of ‘abuse or neglect’ as it was linked to serious youth violence or exploitation. 2 Working Together to Safeguarding Children, Part 4, Sections 4.20 and 4.21 outline the responsibilities of the rapid review meeting. Gathering of information began immediately the notification was  made and the review meeting took place 10 days after the death.  2 | P a g e   relation to his death. He had no confirmed history of carrying or using a knife or other weapons.  1.6. The police officers leading the criminal investigation gave the rapid review meeting an account of the conflict between two groups of young people in which Child E had been killed. Child E was not carrying a weapon and it was not clear why he had been present. A second young person (referred to subsequently as Child V) had also been stabbed, suffering minor injuries. Five young people (four boys and an adult of 19) who were suspected of having been involved in the fatal attack had been charged with murder and other offences linked to the incident. Limited information was available about these young people. All five were believed to live or attend school in another local authority area which was easily accessible to the location of the stabbing. Some of these young people were reported to be well known to the police and local authority services. 1.7. By the time of the rapid review the police were also aware that there had been a large fight involving some of the same young people a week before the death of Child E. Child V and some of the other young people had been present on both occasions, though Child E had not. It seemed likely that the incidents, which took place in different local authority areas, were linked in the minds of some of those involved. This was later confirmed. Rapid review meeting decisions 1.8. The responsibility of the rapid review meeting is to consider whether a local safeguarding practice review is likely to lead to significant local learning for services to safeguard children. It is accepted practice (endorsed by the Child Safeguarding Practice Review Panel) that a review will not usually be required when either 1) the child who has suffered serious harm has had little or no contact with safeguarding services or when 2) the learning from any review will replicate the findings of other local reviews or national reviews carried out by the Child Safeguarding Practice Review Panel. 1.9. In line with this approach, the rapid review meeting determined that a full review focused exclusively on the services provided to Child E would not be justified. He had had relatively little contact with services. There was also considerable overlap between the learning from a recent local child safeguarding practice review undertaken by the partnership and the issues that appeared to be relevant to the death of Child E. The meeting agreed however that, if it could be successfully undertaken, a review which looked at the services provided to all seven of the young people principally involved (including the suspected perpetrators) offered the potential for considerable learning.  1.10. It was recognised that this was an ambitious aim, going beyond the normal interpretation of the statutory guidance which is designed to enable the review of the circumstances of an individual victim, normally a child who has been harmed by someone within his or her own family network.   3 | P a g e   Scope of the review subsequently possible 1.11. The initial terms of reference were drawn up in line with these wider objectives. As the work of the review progressed, it became apparent that it would not be possible to complete a comprehensive review of the services that had been provided to all seven young people, involving four local authorities and LSCPs.  1.12. Given that the review was seeking to set its scope beyond the parameters of statutory guidance, three of the local authorities and partnerships wished to proceed on the basis that the young people and families involved should be asked to provide written consent for information to be shared and evaluated by the independent reviewer. All the families and young people were approached by professionals who knew them in order to explain the reasons for holding the review and with a view to gaining their consent and cooperation. Although all the families indicated that they appreciated why the review was necessary, only one (the family of Child E) actively participated in the review. None of the other families was willing to provide the proposed written consent. 1.13. During contacts with the families, and professionals who knew them well, a number of factors became clear. It is very likely that all the young people and their families were influenced by the fact that they faced trial for serious charges and therefore may have felt (or indeed been advised) that it was unwise to discuss matters that might touch on evidence that would be relevant to the criminal proceedings. By the time of the criminal trial, two of the young people had become adults, who would need to provide consent in their own right, regardless of the views of their family. Two young people were judged not to have the capacity to provide informed consent, a view which the independent reviewer accepts. 1.14. Given these factors, it was not possible to undertake a comprehensive child safeguarding practice review along the lines originally envisaged. Instead, the participating partnerships compiled anonymised summaries of findings and learning, based on records and discussions in their local area. These are useful accounts, but they do not provide a full overview of the type that would normally be expected making it impossible for the review to explore every issue in the detail required by a full review. There is however useful learning, which has led to local recommendations to improve practice and services. These are set out in sections 5 and 8 of this report.  1.15. Given the lack of background information the report describes the events that led to Child E’s death in more detail than is normal in a review of this nature. This has the additional value of allowing professionals to understand how such an event could come about.  4 | P a g e   1.16. The rest of this report is organised as follows: • Section 2 provides brief details of the young people considered by the review • Section 3 gives details of the incidents that led to the death of Child E and the incident in which he died. • Section 4 provides additional information about the young people that is relevant to the review findings • Sections 5 and 6 set out the findings of local reviews and the overview. Section 6 summarises action that has been taken since the death of Child E by the LSCPs involved and their member agencies. 1.17. The views of Child E’s family are included where relevant throughout the report. The views of other family members could not be obtained for the reasons set out above. Reviews that can learn from the services provided to alleged perpetrators as well as victims of serious youth violence and other forms of exploitation 1.18. The safeguarding partnerships involved maintain the view that there is considerable value in learning from the experiences of both victims and alleged perpetrators of serious youth violence and other forms of exploitation. There is a strong case that the statutory guidance, and the advice and guidance given by the Child Safeguarding Practice Review Panel should be revised to enable this to happen. This is discussed further in Section 7, and a recommendation is made. Why this report has been published nationally and without reference to the localities in which events occurred 1.19. This document sets out the review findings without reference to either the identity of those involved, to the areas in which the young people lived or were educated, or to the agencies involved. The LSCPs involved decided that the publication of any report that identified the location of events or the statutory services and partnerships involved would be very likely to lead to the identification of the incident in which Child E was killed and therefore to the identification of one or more of the young people involved, and their families. The same is likely to apply if the report (however heavily anonymised) were to be published by one or more of the safeguarding partnerships.  1.20. Whilst it is correct and proper that all those responsible for Child E’s death are held accountable, they are all in different ways vulnerable individuals, some extremely so, who should not be placed at additional risk of harm by the publication of a report which might lead them to be identified. 2. THE YOUNG PEOPLE  2.1. Table 1 sets out brief details of the young people who were involved in the events that led to the death of Child E.   5 | P a g e  Table 1 Age at time of incidents Local authority in which resident Local authority of educational setting  Current or previous level of social care involvement Criminal justice or youth offending service involvement Child E 15 Local Authority 1 Local Authority 1 Previous family support to mother. No social care involvement at the time of his death None Child V 15 Local Authority 1 Local Authority 1 Previous contact over parental mental health and reported domestic abuse. No social care involvement at the time of his death None   Child 1 14 Local Authority 2 Local Authority 2  Substantial history of social care involvement with family  Substantial history of YOS involvement Child 2 17 Local Authority 2 Local Authority 2  Substantial history of social care involvement with family None Young adult 1 19 Local Authority 2 (supported placement made by Local Authority 4) Local Authority 2  Substantial history of social care involvement on child protection plan, as a looked after child and care leaver Extensive history of YOS involvement and was being supervised by National Probation Service at the time of the incident Child 3 15 Local Authority 2 Local Authority 2  Previous contact with another local authority over unproven allegations of harm (by parents) and school difficulties. Not in contact with social care at the time of the incidents None  Child 4 15 Local Authority 3 Local Authority 2  Referred to social care in his home authority shortly before the incidents None   6 | P a g e  3. EVENTS LEADING TO THE DEATH OF CHILD E  3.1. Events leading to the death of Child E Incident 1 3.1.1. Nine days before the death of Child E, there was an altercation involving two groups of young people. Neither group is believed to have been an established criminal group or gang.  3.1.2. This incident (subsequently referred to here as Incident 1) took place in a town centre that is easily accessible from the place where Child E was later fatally stabbed, being approximately 20 minutes away by public transport. 3.1.3. Child V was a protagonist in Incident 1, in which he stabbed a young person. The injuries were not life-threatening and the victim of this stabbing was not present when Child E was stabbed. Child V was later convicted of a serious violent offence in relation to this incident. The police notified the local authority in which the incident took place soon after it occurred and a strategy meeting was held, focused on the victim. Child V was not at that time identified as being responsible, so it would not have been possible to share information or discuss the risk to him. His school remained unaware that he had stabbed another child. 3.1.4. Child E was not involved in Incident 1. He is not believed to have known Child V and they did not attend the same school. 3.1.5. In the lead up to Incident 1, threats and disparaging comments had been made on social media platforms between young people in the two localities. There is only a limited overlap between the young people involved in these incidents and this social media conflict which drew in larger groups of children. The role of social media in such incidents is discussed in Section 5.6 of the report. 3.2. The death of Child E Incident 2 3.2.1. The incident in which Child E was killed (referred to as Incident 2) occurred as a response to Incident 1.  3.2.2. One group involved in Incident 2 consisted of three boys, all of whom lived in Local Authority Area 1: Child E and Child V (who were unarmed) and a third young person (who was carrying a knife but ran away from the confrontation). This boy had also not been involved in Incident 1.  3.2.3. It is not clear why Child E was present at Incident 2, nor is it clear what he had been told was likely to occur. At the time of his death Child E was with one boy who was carrying a knife, though he may not have known that. Information provided to the review states that in 2020, another pupil at his school told staff that he thought Child E had a knife, though he never  7 | P a g e  claimed to have seen it and no knife was found. Child E had no history of carrying or using any weapon.  3.2.4. The second group consisted of 4 boys and a young adult, aged 19. They lived in three different local authority areas but all went to school in Local Authority Area 2. The five had travelled a short distance by train to the scene of Incident 2. Three of this group were prepared for violence, with one boy carrying a knife and at least two others with weapons. Three of the five (including the young adult) knew each other because they attended the same school for children with special educational needs. The other two boys attended a different (mainstream) school. Friendship between two boys linked them. The details of their planning are not known but were sufficient for three young people to be convicted of conspiracy to commit a violent disorder. 3.2.5. Incident 2 was very brief. Child V was wounded and Child E was fatally stabbed within seconds of the groups approaching one another. Bystanders intervened and the group, including the boy who had stabbed Child E and Child V ran off. The boys involved were later identified through CCTV footage and information from the public, enabling the police to make the connection between the two incidents.  3.2.6. One boy was subsequently convicted of Child E’s manslaughter, other violent offences, and conspiracy to commit violent disorder. Two boys were convicted of conspiracy and other violent offences. Two defendants were found not guilty of all charges in relation to Incident 2.   8 | P a g e  4. ADDITIONAL INFORMATION ABOUT THE YOUNG PEOPLE TO SUPPORT THE FINDINGS OF THE REVIEW Table 2 provides additional background information about the young people involved which is relevant to the review findings Boys living in Local Authority 1 Child E Child E was a black boy of African heritage who was born and always lived in the UK. He was aged 15 when he was fatally stabbed. At school he had been involved in conflicts with other pupils or their friends on a small number of occasions, leading to a number of short fixed-term exclusions. His mother cooperated in the steps taken by the school to address these concerns.  8 weeks before his death Child E was moved to a short-term education placement because of conflict with other pupils that the school believed was at risk of escalating into more serious violence. His mother says that she wasn’t told of the reasons for the placement and does not accept that the move was necessary. This arrangement was very effective, confirming that Child E was not in need of education outside of mainstream school and he returned to his school very quickly.  In the weeks before his death, Child E’s school had been concerned about tensions between groups of young people in the local community and had held meetings with the local authority community safety partnership. These have no connection to Child E’s death. On the advice of community safety workers, the school referred Child E to the local authority social care service so that any risks arising from his contacts with other young people could be assessed. The referral was made a week before his death. The school says that Child E’s mother was told of the referral.  The referral was passed to a panel that arranged preventative support for young people. At the time of Child E’s death there had been brief discussions with the school, but no direct work had been started on this referral and there had been no contact with Child E or his mother.   9 | P a g e  Child V Child V is a black boy of Caribbean heritage. He was born and has always lived in the UK. He was aged 15 when Child E was fatally stabbed. When Child V was 12 his father attended the hospital emergency department complaining of low mood and suicidal thoughts. He reported that he had been the victim of domestic abuse by Child V’s mother, and had moved out of the family home. He decided to return to the family. These contacts were judged not to meet the threshold for social care intervention and there was no further follow up. Four months before the death of Child E, Child V was excluded from school for five days because he had been in a fight with another boy after school. A week before the incidents Child V was identified as being part of a group of young people, mostly wearing masks which was dispersed by the police. He was searched on suspicion of carrying a weapon, but nothing was found.  It is not clear what led Child V to take such a prominent role in the violent incidents surrounding Child E’s death. In the weeks that followed the death of Child E, the police became concerned that Child V might now be associating with members of a gang and might be at risk. His mother cooperated in plans suggested to keep him safe, including collecting him from school.   10 | P a g e  Young people living in other local authority areas Child 1 Child 1 is white and was born in the UK. He was aged 14 when Child E was fatally stabbed. Child 1 was well-known to social care services in his local area. His mother has a conviction for a serious offence and his family is believed to have contacts with adults involved in crime. He is suspected to have been involved in street group criminal activity. He was known to the Youth Offending Service and was well known to local authority social care services. The review has not been able to obtain more detailed information on this. He had some learning difficulties, attended specialist educational provision and had been reported missing on a small number of occasions. Child 2 Child 2 is white and was born in the UK. He was aged 17 when Child E was fatally stabbed. He was known to social care services in his local area and had a degree of learning disability. He had not been known to the Youth Offending Service. He attended a specialist educational provision. Young Adult 1 Young adult 1 is white and was born in the UK. He was aged 19 when Child E was fatally stabbed. There had been substantial social care involvement with his family from his early years due to parental abuse and neglect. He had been diagnosed with ADHD and had learning difficulties; he also suffered from depression which sometimes included having delusional thoughts.  As a child, Young Adult 1 had been subject to child in need and child protection plans and became looked after. He was living in supported accommodation and receiving support as a care leaver, and attending a school educational placement at the time of the incident. He had been arrested on many occasions (once for possession of a bladed article) and had been supervised by the YOS. He served a short custodial sentence for breaching community sentences. At the time of the incident, he was subject to supervision by the National Probation Service, though he was not cooperating fully with the supervision requirements.  11 | P a g e  Child 3 Child 3 is a black boy of African heritage who was born in the UK. He was aged 15 when Child E was fatally stabbed. He played a prominent role in both the incidents described above. While she was pregnant Child 3’s mother was referred to the local authority for assessment because of concerns about depression. His mother refused the assessment. As a young child there were allegations of physical abuse, which were investigated by social care, but unsubstantiated.  At age 8 Child 3 was referred to social care because of concerns about his reported aggressive behaviour at school. This led to a discussion at the local authority schools Fair Access Panel which provides advice about children at risk of exclusion or negotiates alternative school placements for children who have been excluded. His parents had not accepted referrals for assessment, advice and support, believing that Child 3 was being singled out and treated differently to other children.  The record of the final social work contact stated that at this point it appeared that the parents would take up an educational psychology referral. This did not happen and Child 3 lost contact with services.  It is now known that Child 3 was subsequently sent to live with extended family members overseas, where he attended a boarding school. He now says that this was a very negative experience. It is not known how long he lived overseas. On his return Child 3 was enrolled at an academy school in a different local authority area where his father then lived. His parents had now separated. The disruption to his education and his relocation may have made it more difficult for Child 3 to form and maintain ordinary friendships. His older siblings began to come to the attention of the police. There was no contact between the family and local services other than the school.  In early 2021 the academy had concerns about potential grooming and exploitation by gangs in the area, with Child 3 identified as a possible target. This concern had not been referred to the local authority prior to the death of Child E, though the school had made a referral (to another local authority) about Child 4.   12 | P a g e  Child 4 Child 4 is a black boy of African heritage who was born in the UK. He was aged 15 when Child E was fatally stabbed. He lived with his mother and sister in (Local Authority 3). He attended an academy school in (Local Authority 2) which was also attended by his brother, who lived with his father near to the school. Child 4 also had a long train journey to school. There was no concern about his education during the first three years of secondary education. There is no record of contact between the family and any statutory agency until 2021 when Child 4 went missing instead of going to school and did not return home on a number of occasions. These incidents were notified to the police and the school also notified social care in the borough where Child 4 was living. The local authority began an early help service assessment, but in parallel with this, further incidents occurred, heightening concerns about possible exploitation. A brief assessment indicated that both Child 4 and his younger brother were likely to be at risk of gang involvement and exploitation and the family were re-referred for a more comprehensive social work assessment. This had just begun when the incident in which Child E was fatally stabbed occurred. Child 4 was remanded in custody, but his younger brother (who was not involved in the death of Child E) has continued to be at risk of criminal exploitation. 5. EXPLOITATION AND SERIOUS YOUTH VIOLENCE – ESTABLISHED AND NEW LEARNING  5.1. Introduction 5.1.1. This section considers learning arising from the information available to the review: • The involvement of young people in exploitation and knife crime and the potential for very rapid escalation of violence • The heightened risk that children who have special educational needs or experience a disrupted education may become involved in serious youth violence or be exploited • Helping children involved in criminal activity or at risk of exploitation who have suffered severe adverse experiences in early childhood  • Responding to the needs and circumstances of black children and their families • The role of social media in exploitation and the response of professionals Each section summarises the information provided to the review, highlights potential learning and makes recommendations where appropriate. Some of the findings reflect those of previous reviews on this topic.  13 | P a g e  Section 6 describes actions taken or planned in the participating partnership areas. 5.2. The potential for very rapid escalation of violence when children are being exploited or are involved in criminal activity 5.2.1. This section of the report seeks to understand the very rapid escalation in violence that occurred between two groups of young people, none of whom had been identified as being a risk of committing a serious violent offence. This presents a significant challenge to the families of young people, and to professionals working with young people.  Information provided to the review 5.2.2. Based on the information provided to the review, only one of the young people who were involved in the incidents described above had a previous conviction for violence. It is possible that others had been involved in violent incidents before the death of Child E because it is common for such incidents not to be reported to the police, or for the lack of useable evidence to prevent a prosecution. There were limited indications of risk prior to the incident in which Child E was stabbed. 5.2.3. Although Child E’s death was preceded by an earlier incident, the police had not been able to identify most of the young people involved, so the response was limited to the boy injured who had been stabbed. The perpetrator (Child V) was not identified until after Incident 2, when he himself was the victim of a stabbing. A strategy meeting focused on the victim had been held, but because Child V had not been identified the school he attended could not be alerted.  5.2.4. Young Adult 1 had been convicted for carrying a bladed article, resulting in a period of supervision by the Youth Offending Service in the area where he lived. He had a large number of youth convictions for non-violent offences. He was not carrying a knife during Incident 2 and is not believed to have been involved in Incident 1. He is unlikely to have had the capacity to lead or encourage others. 5.2.5. Child E had never been arrested or charged with any criminal offence. He had been in fights at school but these incidents have no connection to his death. It remains unclear why he was present at Incident 2. There is no indication that he had ever been involved in violence on the street so he is very unlikely to have known how incidents such as this can escalate and was therefore extremely vulnerable.   14 | P a g e  5.2.6. Child E had been referred for preventive support services in the days before his death, mainly as a result of a discussion between the school and the local community safety partnership about concerns in the school locality, though they did not involve Child E. The local authority where he lived has a ‘Risk Adolescent Safeguarding and Prevention Panel’ which looks at an early point at all referrals about possible child exploitation. However, the panel had not been able to discuss Child E before his death. Even if it had, there is no indication that any action that could have been taken in the short time between the referral and Incident 2 would have prevented his death. 5.2.7. Child V stabbed a child in Incident 1 and was subsequently convicted for this offence. Otherwise he has no criminal convictions and no history of violence, other than aggression to others at school.  5.2.8. In the weeks before Incident 1, Child 3 and Child 4 had been identified by their school as being at possible risk of exploitation, because they had missed school and because Child 3 was believed to be associating with young people who the school believed had connections to criminals. Child 4 had been referred to the local authority where he lived, which began an assessment. The assessment began in the local authority early help service, which was a reasonable approach based on the information that was available. As more information emerged, responsibility was transferred to the social care service to continue the assessment. This decision was in line with the approach expected by the local authority, but in the circumstances contributed to delays in professionals seeing Child 4. The assessments were focused on Child 4 and his family, and would not immediately have taken full account of the wider context in which he was being targeted by criminals. Such an approach is more difficult to achieve when a child attends a school some distance from his home and outside the local authority area. 5.2.9. Child 1 and Child 2 were both well-known to the local authority social care service in the authority where they lived. Child 1 had been known to the YOS. Child 2 had not. There were concerns that they had been associating with young people in a street group. Mapping of this group and its activities had begun shortly before the death of Child E. Learning on these issues 5.2.10. The schools attended by the majority of the pupils were sensitive to signs of potential exploitation (such as missing episodes, behavioural difficulties and exclusions) and sought advice, offered additional support or made referrals for services. The review has not been able to establish whether Child V’s school took any further action following his fixed-term exclusion for fighting with another child. None of the boys concerned had been involved in the type of serious incident that would have met the threshold for an earlier or more concerted intervention.  5.2.11. The nature of child exploitation (particularly criminal exploitation) means that warning signs can be hard to detect, although there is always a likelihood of rapid escalation in the risk to a young person. This poses a  15 | P a g e  challenge for professionals who need to be skilled and confident in responding to possible signs of emerging harm for young people. It is too simple to say that professionals should always act quickly. This is not easy to achieve, and may have negative effects. Too rapid a response may lead to an over-reaction to minor incidents and the unhelpful labelling of children. When this occurs, trust and cooperation from young people and parents may be reduced. Systems that are already busy become stretched further when too many inappropriate referrals are made. 5.2.12. It would be useful for each local authority to consider whether their systems are able to move more quickly in response to suspicion of concerns and referrals, and to avoid administrative delays once assessments have started.   5.2.13. For some of these young people, assessment was focused on the individual child and had not begun to take account of their wider associations and environment. Service responses that are sensitive to the child’s wider context may address this. 5.2.14. A particular challenge arises when young people are travelling long distances from home to school, particularly across local authority boundaries. Patterns of the movement of children between local authority areas to attend schools were not known or explored. The response to concerns about a group of young people may need to be based on sharing of information across a number of authorities. By its very nature this is less likely to happen until there has been a serious incident. Recommendations 5.2.15. The LSCP in each local authority area should test whether local arrangements for the referral and assessment of adolescents who are at  16 | P a g e  risk are able to respond effectively to the rapid escalation in risk that can sometimes occur. This should include the following: • General awareness of signs and symptoms of child exploitation • The need for information gathering about context and peer groups in responding to referrals • Delay or additional complexity that can be caused when young people live or go to school in different local authority areas. 5.3. Additional risks to children who have special educational needs or experience a disrupted education  5.3.1. This section considers the response of services to children with special educational needs and the impact of disruptions in education, including suspensions and school exclusion. 5.3.2. For the reasons set out in Section 1 above, information about the education of young people other than Child E and Child V is limited. Information provided to the review 5.3.3. Child E had experienced a managed move between two mainstream secondary schools. It took place some years before his death and had no bearing on it. His attendance at his next secondary school was very good and overall his behaviour and engagement in education should be counted as a success. He was suspended for short periods because of conflicts with other pupils, but after each suspension he was able to reintegrate quickly into the school with the involvement of his mother who cooperated with the steps recommended by the school.  5.3.4. Shortly before his death Child E attended a temporary education placement for two weeks, again because his school believed that there was a risk of escalating conflict with other pupils. This placement confirmed that he should remain in a mainstream school and he was again reintegrated on his return. There is no evidence that the conflicts in school had any connection with his later victimisation. Child E’s mother told the review that she did not think that this temporary placement was justified, and that the reasons for it were not fully explained.  5.3.5. Child V was excluded from school for five days in the weeks before Incident 1. It is not clear whether this led to additional support being offered. From this point he began to have contacts with other young people involved in crime, so it is possible that these associations began or were strengthened while he was out of school. 5.3.6. Child 1, Child 2 and Young Adult 1 had special educational needs and were educated in the same specialist school. No further details of this are available, but given his very damaging childhood it is reasonable to assume that Young Adult 1 had experienced periods of disrupted education. The attendance level of a second child was very poor, making it impossible for  17 | P a g e  the school to know who he was spending time with when out of school and the nature of any exploitation that he might have experienced. 5.3.7. In this local authority area, schools, academies, pupil referral units and the local authority are signatories to a protocol designed to reduce permanent school exclusion to a minimum. Schools have agreed to retain accountability for the education of excluded pupils attending alternative educational provision such as the pupil referral unit. However there also needs to be a robust response to poor school attendance. 5.3.8. Between the ages of 5 and 8, Child 3 was suspended from his school for periods of one or two days. There were 8 recorded exclusions, all following incidents in which he was aggressive to staff or other pupils. The school referred him to the local authority Fair Access Panel and to social care. His parents were not willing to take up suggested offers of support and a referral to an educational psychologist for assessment. They appear to have moved him to another school, but then decided that he should move to live overseas with other family members. When he returned to the UK Child 3 entered an academy school in a different local authority area. The school appears to have had no detailed knowledge of his previous education. There is no record of exclusions from the secondary school, though the school became concerned about him in the weeks before the death of Child E.  5.3.9. Child 4 also travelled some distance by train to attend an academy school in another local authority area, travelling through the area in which Child E was killed. Prior to the period beginning six weeks before the death of Child E there were no concerns reported about him. At that point he missed school on a small number of occasions. His school referred him to the local authority where he lived and an assessment had begun.  Learning and recommendations 5.3.10. The information submitted to the review confirms the findings of previous reviews in relation to exploitation and serious youth violence.  5.3.11. Good school attendance is recognised as being a protective factor, reducing the likelihood that young people will become involved in crime.3 A large-scale Home Office review of research on knife crime and serious youth violence shows that poor school attendance is the educational factor that correlates most strongly with adolescents carrying and using knives, and with self-reported involvement with gangs.4  5.3.12. Leaving mainstream education, even if only for a brief period, can have a significant negative impact on young people. The permanent exclusion of  3 HM Government (May 2019) CP92, Timpson Review of School Exclusion 4 Victoria Smith and Edward Wynne-McHardy (2019) An analysis of indicators of serious violence: Findings from the Millennium Cohort Study and the Environmental Risk (E-Risk) Longitudinal Twin Study, Home Office Research Report 110. This study systematically reviews ‘factors linked to more serious types of violence like weapons carrying or use and gang conflict’, following a large cohort of young people over a number of years. Findings are summarised on pages 1-16 of the report.  18 | P a g e  children has attracted most attention and discussion. Permanent exclusion will almost always severely limit the young person’s future educational options, making entry to another mainstream school more difficult to secure and therefore much less likely. There is a case that temporary placements and managed moves can also be disruptive.  5.3.13. The differences between managed moves, respite placement, suspensions and permanent exclusion are not always well understood by young people and their families. In other reviews families have described how these episodes are often experienced as a decisive point in the child’s journey out of full-time education, a blow to the family and the child’s self-esteem which exposes the young person to greater levels of risk.5 The Timpson review considered in detail the role of school exclusion. Timpson found ‘evidence to suggest that children who have a history of either fixed period or permanent exclusion from school are more likely to be both victims and perpetrators of crime’. At the same time there was ‘no evidence’ that it is ‘a direct cause’.6  5.3.14. It is notable that Child 3 had severe problems in primary school, including very aggressive behaviour, that led to severe disruption of his education. Professional made many attempts to work with the family, but could not gain trust from the parents for the interventions proposed. There is anecdotal evidence from other reviews that experiencing problems of this type this level of difficulty in primary school may be a marker for serious later difficulties. Failure to engage parents in services such as behaviour support, CAMHS and speech and language therapy should be considered another warning sign which should inform later assessments. 5.3.15. The wider issue of families sending children overseas to be cared for by relatives and educated is considered in Section 5.5. Recommendations 5.3.16. The local children’s safeguarding partnership in each of the areas involved in this review should test the effectiveness of arrangements made by the local authority and schools to 1) promote better school attendance among young people who may be at risk of exploitation and 2) to reduce rates of exclusion among young people who may be at risk of exploitation. Service responses should be in place so that there is a rapid response if a child who is at risk of exploitation is attending school poorly or has been excluded. 5.4. Responding to the needs of young people who have had severe adverse experiences and become persistent offenders 5.4.1. This section of the report highlights some of the difficulties faced by professionals working with young people who have had severe adverse  5 For example, see Croydon LSCB (2019) Vulnerable Adolescents Review, https://croydonlcsb.org.uk/2019/02/croydon-vulnerable-adolescent-review-report-2019/  6 HM Government (May 2019) CP92, Timpson Review of School Exclusion   19 | P a g e  experiences in their early childhood and persistently commit criminal offences as adolescents.  5.4.2. Child E’s mother has expressed a very firm and sceptical view on the emphasis that professionals commonly place on the impact of early adverse experiences and trauma, and its role as a factor in causing youth violence. She speaks with some authority as someone who, before coming as a refugee to the UK, saw and suffered harms incomparably more grave than any of those experienced by the young people who harmed her son. She is clear in her belief that having suffered harm does not diminish their moral responsibility for their actions. Evidence from the reviews 5.4.3. At least three of the young people grew up in families known to children’s social care and experienced neglectful parenting, domestic abuse and physical abuse. Two spent time periods in the care of the local authority. It is not possible to judge the role played by these background factors in the genesis of their offending, or of others such as exposure to criminality in their family and environment. Professionals believe that the impact of these experiences may have made it particularly difficult for professionals to find ways of engaging with the young person and form the kind of trusting relationship necessary to support work to enable the young person to desist from their involvement in crime. Learning and recommendations 5.4.4. Much professional experience suggests that young people who have suffered serious harm may find it more difficult to understand the impact of their behaviour on victims of crime, and to appreciate the negative consequences for their own life.  5.4.5. This may give rise to persistent non-engagement with professionals, repeat criminal behaviours and breaches of orders. Professionals need to be supported to address these challenges in order to understand potential risk and to prevent more serious offending. Young people need to be helped to understand the support available to inform authorities of incidents and to understand the implications of associating with those who carry knives. 5.4.6. Local Authority 4 has considered this in detail in relation to Young Adult 1. The planning of residential placements and new school settings needs to take account of potential influence from associations with other vulnerable peers. This is particularly important where it has been established that due to childhood experiences, mental health needs and diagnosed disabilities a child/young adult has difficulties forming relationships and lacks the ability to speak out about their own needs. The lack of suitable placements and limited choice make this more difficult for professionals. 5.4.7. No specific recommendation arises from this; however, the review report should be used as a tool to highlight the importance of these factors in a  20 | P a g e  young person’s background and the additional difficulties that professionals can face. Professionals faced with young people who are particularly difficult to engage need support, guidance and training on how best to do this, balancing the need for engagement with a clear understanding of the risk to the young person and (in some instances) to the wider society.  5.5. Responding to the needs and circumstances of black children and their families 5.5.1. This section of the report considers the experiences that are specific to young people and families who are black or from a minority ethnic background. It highlights a small number of issues raised in discussion with the family of Child E and in other material reviewed: • A suspicion that at significant points black boys had been treated less favourably • Challenges that arise for parents bringing children up in a societal context which differs, in important ways, from their own • Decisions made by families to move boys who have experienced difficulties in school or in the local community overseas. 5.5.2. The aim is to identify specific topics which should inform policy and practice, rather than to draw broader lessons about the significance of ethnicity, racism, and religion. Information provided to the review 5.5.3. All three stabbing victims were black. The three boys who were known to have been carrying knives during Incidents 1 and 2 were black, though some of the others involved carried other weapons and shared responsibility for developing the plans to cause violence. There is no indication that there was any racial motivation to either of the incidents. The interactions on social media between groups of young people that preceded the death of Child E refer to geographical loyalties, not race, ethnicity, or religion. 5.5.4. The review author discussed the following episodes with Child E’s mother and another family member: his managed move from one secondary school to another; the decision of the school to suspend Child E following conflict with other pupils; and the decision to temporarily place Child E in an alternative educational setting after further conflict with pupils. None of these episodes had any connection to his subsequent death, but they might have been important in terms of his overall education, his view of himself and his family’s trust in those in positions of authority.  5.5.5. Although it is not her initial instinct to see any of these incidents through the perspective of race, Child E’s mother has wondered whether her son might have been treated differently and more harshly because he was black. She notes that other children were involved in the incidents, but is not aware how the school dealt with them. She has also questioned whether she was given full explanations for all the decisions taken. Given the public attention  21 | P a g e  that has focused on disparities in education and policing, it is natural that black parents will ask these questions. 5.5.6. One of the schools in question closed shortly after Child E left, so it is not possible to explore the event and the response to it. The other believes that the decisions taken were justified and proportionate, and does not believe that race was a factor. It is not possible for the review to reach a judgement on the validity of these concerns. 5.5.7. Data on school exclusions provided by the local authority where these schools are located show that black boys from Caribbean backgrounds are more likely to be permanently excluded than their white counterparts. However black boys from African backgrounds (and boys from some other minority ethnic backgrounds) are less likely, so race or ethnicity cannot in isolation be the decisive factor. These findings mirror the national picture.7 Nevertheless, the over representation of black boys from Caribbean backgrounds, and from mixed white and Caribbean backgrounds, is an important disparity that needs to be addressed.  5.5.8. Given these disparities, schools and other institutions should recognise the understandable concern that black parents may have about the fairness of decisions and should take particular care to ensure that they are communicated fully and openly. 5.5.9. Although the circumstances and problems faced are very different, and a different school was involved, there is perhaps a parallel in the response of Child 3’s parents to the difficulties that they faced and the offers of professional help that they received. The records suggest that Child 3’s parents believed that their child was being treated differently to others, and did not understand or accept that their son should have been excluded from primary school or that he would benefit from being assessed by an educational psychologist. The failure to bridge this gap in understanding led the parents to move him to another school and then overseas.  5.5.10. Child E’s mother has also reflected on her experience of bringing up children in circumstances where she has had to adapt to values and attitudes in wider society that differ in important respects from her own. Child E’s mother described her approach to her children as being rooted in African and Muslim values, which are reflected, for example, in her expectations about the need for children to be obedient and to be courteous to family members and adults generally. These values should in her view be collectively supported by the wider community, and if her children were not acting in line with them, she would expect to know about this. In contrast her experience of bringing up children in the UK had been that outside the  7 See for example, Ethnicity Facts and Figures, (2021), ‘Permanent exclusions’ available at: https://www.ethnicity-facts-figures. service.gov.uk/education-skills-and-training/absence-and-exclusions/permanent-exclusions/latest, cited in Commission on Race and Ethnic Disparities: The Report (March 2021). The commission concluded that, ‘the causes for ethnic disparities in the rates of exclusions and suspensions are complex and multifaceted, and can not be reduced to structural racism and individual teacher bias’. (page 79).  22 | P a g e  home children were provided with much less structure, and that attitudes to behaviour were much more liberal. Her belief was that she was not always told what was happening with her children, leaving her with a sense of bringing up her children in a way which did not have the support of the wider society. 5.5.11. Other parents may have experienced or may view these issues differently. Whatever the particular situation, this underlines the need for professionals to have the confidence to explore an individual family’s specific experience and values in order to find the best ways to help children. This goes beyond recognising that families from minority ethnic groups may have experienced racism. It requires professionals to recognise that families may have a distinct cultural experience and outlook that needs to be understood. 5.5.12. Although Child E’s mother has not said that she ever considered moving her son overseas, concerns similar to the ones she expresses have been a factor in decisions made by many parents to do this when they perceive that their child is failing in the education system, or has been excluded from school, or is at risk of violence in the community.8 Such decisions are often underpinned by a belief that services either have not understood the child’s difficulties or responded effectively. Parents often hope that additional support will be provided by the extended family, which is not available in the UK, and that a social and educational environment in which adult authority is clearer will benefit the child.  5.5.13. Child 3’s parents moved him to their country of origin after he had been excluded several times from primary school. They had not been willing to take up offers of support in the UK. As they were not in contact with services when they made this decision, and they have not contributed to this review, their precise reasoning is not known. Nor does the review know how anything in detail about how Child 3 fared when he was overseas. From what is known, it appears that the outcome was not positive. Child 3 attended a boarding school where it is reported that he was not happy. By the time he returned to the UK, his parents had split up. Child 3 then attended a secondary school at some distance from the family home (though near where his father lived). The school had not reported difficulties and it is not clear if the school was aware of his previous educational history. 5.5.14. This matches the experience of the review author, based on other safeguarding reviews. Many young people moved overseas in these circumstances struggle with a culture and environment very different to the one they are used to in the UK, particularly if they do not speak their parents’ language fluently. Often arrangements for education and care have to be made with little money. When the child returns to the UK, the young person has often lost contact with friends. School places are commonly lost, so there is further educational disruption. Both factors make young people  8 Families from a very small sample known to the author who have taken this step include those from the following backgrounds: Somali, Kurdish, Turkish and West African. The author believes it is a step taken much more commonly.  23 | P a g e  keen to find peers to fit in with, which in some circumstances can heighten the risk of exploitation. 5.5.15. The author’s own experience of discussing this issue with parents is based on a very specific sample of boys who 1) came back to the UK and 2) were either seriously harmed or killed after their return. It is therefore unlikely to be representative. The review is not aware of any systematic study of the experience of children who have moved to a parent’s country of origin because of the fear of violence. This is a topic that would benefit from further research. Recommendations 5.5.16. Local safeguarding children partnerships should promote discussion about the effectiveness of responses to families from black and minority ethnic communities to consider how best to promote a greater ability among professionals to understand and discuss their experiences, values and perspectives. 5.5.17. Local safeguarding children partnerships should promote an awareness of the particular circumstances and potential vulnerability of children who have been moved overseas by their families as a result of school difficulties or risk of criminal exploitation or violence and then returned to live in the UK.    24 | P a g e  5.6. The role of social media and the professional response 5.6.1. This section of the report considers the role played by young people’s use of social media in the build up to the incidents, in the aftermath and more generally. Young people’s lives social interactions rely heavily on the use of social media, which may have many benefits. However, there are challenges (both for families and professionals working with young people) when conflicts between young people are played out on social media. Information provided to the review 5.6.2. Chronologies and reports on individual young people provided to the review give no information about young people’s use of social media. The police have given the review very useful information about its role drawing on information obtained during the criminal investigation. There is no indication that professionals should have been aware of this ahead of Child E’s death or that knowing more about this would have changed the course of events. However, there may still be useful learning. 5.6.3. In the weeks before the death of Child E there was conflict between groups of boys in local authority areas 1 and 2 on social media. This included claims or threats about youths travelling to rival territories, using weapons to stab one another, denigrating opponents as weak, fearful, or worthless, and giving motives or pretexts for attacks.  5.6.4. It is not possible to reconstruct these exchanges in full because the most popular medium used was Snapchat, in which images and messages appear for only a few seconds, though they can be screenshot and saved. It is also encrypted. Snapchat also allows users to keep scores of interactions and the number of followers that a young person has, adding a competitive element between users making claims and counter claims.  5.6.5. Three young people were convicted of conspiracy i.e. planning and preparing for violent disorder in Incident 2, but for the most part this did not rely on evidence from social media. Improved understanding young people’s use of social media may point to the general climate of conflict and violence, but will not necessarily help pinpoint particular young people who are at risk. Some young people featured heavily in the social media exchanges but were not present at either physical confrontation. There is no evidence that Child E posted or saw comments. 5.6.6. These conflicts continued after the death of Child E, with posts making specific threats of revenge or providing a motivation for future attacks. The  25 | P a g e  police were able to track some of these and employ a range of tactics to prevent violence escalating further. Wider information, learning and recommendations 5.6.7. More widely professionals frequently report fears about the negative impact of social media on young people, including the following: • Bullying, threats, and coercion which may begin during face-to-face interaction and then continue on social media • The ease with which young people are able to access or upload violent or sexual material, including sexual images created by children  • The posting of violent images to amplify rivalries between young people and to promote gang image and organised criminal activity 5.6.8. Notwithstanding this general professional awareness, none of the case summaries indicate that young people’s use of social media was a topic that had been discussed during assessments, in any service. That may be because these assessments were not focused on the risk of exploitation or had only recently begun at the time of the death of Child E.  5.6.9. The difficulties presented to parents and professionals in keeping up with young people’s use of social media are widely noted. The comments made above about the platform that featured most heavily in this case, could soon be out of date, or the popularity of the platform may decline. Professionals should consider this from two perspectives. Recognising that social media platforms used by young people evolve and change frequently, the professional focus should be on the behaviour of the young person and risks associated with the use of social media (such as those described above). While professionals have neither the time nor the ability to keep abreast of the technicalities of every social media platform and the way that young people are choosing to use it, there are services which seek to provide regular updates on the features of social media platforms and their potential impact on children’s safeguarding.9 Recommendation 5.6.10. The LSCPs that participated in the review should take steps to promote a greater awareness among professionals working with young people of the role that social media may place in heightening risk to young people, including in relation to serious youth violence and carrying weapons. Member agencies should be asked to include this issue in assessments of risk and need for young people, and to demonstrate that this has been  9 One such service is found at https://ineqe.com/safeguarding-hub/ No doubt there are others.  26 | P a g e  attempted, recognising that it will often be a difficult topic on which to initiate discussions. 6. LOCAL LEARNING AND ACTIONS PROPOSED AND TAKEN 6.1. This section of the report describes the steps that are being taken by the statutory safeguarding partners to implement learning in relation to serious youth violence and exploitation in the localities covered by the review. Not all these initiatives result directly from the work of the review, because much work is already in place to combat serious youth violence, but they are judged to be relevant to the topics under consideration. The initiatives and service developments are described and organised thematically, rather than by local authority area. Some specific examples are given. 6.2. Services have developed further in some local authority areas than others, but all the examples given are potentially useful. The review expects that all the LSCPs involved will consider their potential relevance. The review will recommend that all LSCPs take an active role in providing oversight of the effectiveness of services to safeguard children from exploitation and extra-familial harm. Reduction of school exclusions and improved attendance of vulnerable pupils 6.3. All local authorities have told the review of initiatives to reduce school exclusion and to ensure that – if a child does need to be excluded or moved to an alternative educational setting – the school retains responsibility for the pupil.  6.4. In Local Authority 1 specific services are being developed, linked to a national safeguarding initiative, which enable schools to build their capacity to support children and young people who may be at risk of non-attendance and exclusion. The aim is to develop a sense of belonging in their school and local community and a whole family approach, working with parents and teachers to engage children in positive activities. The scheme will be expanded in 2023 following successful pilots.  Contextual interventions within the local authority and across local authority areas 6.5. All the local authorities and police services are seeking to reduce serious youth violence, often through initiatives led by the local Violence Reduction Unit (VRU). In Local Authorities 2 and 4, the VRUs produce monthly tactical reports which detail youth violence in the area and provide a detailed analysis of trends.  6.6. There is a growing recognition of the risks that can arise when children move across local authority borders either to attend school or because of family relocation, parental separation or family breakdown. Local Authorities 1 and 2 are delivering diversion programmes that provide a contextual response  27 | P a g e  across local authority areas. In order to do this, they are developing close working links with community safety partnerships in neighbouring boroughs, working with schools, hospitals, police, housing providers and voluntary sector partners, sharing information, and training together. Local authorities and police services are beginning to map the incidents and individuals who are affected by serious youth violence to build an accurate and informative picture of the experience for young people and the community in which they live. As part of this there is increased use of mapping in schools and complex strategy meetings to understand the dynamics of children’s relationships and interactions better.  6.7. An important part of the assessment of risk for children remains on episodes when children and young people go missing. This can be more difficult to recognise when children travel long distances to go to school and transport links are sometimes unreliable. Local Authority 2 has recently introduced a toolkit to help professionals have conversations with young people who have gone missing. 6.8. All authorities and police services work to understand the reasons why young people carry knives, creating resources that can be used by all professionals working with young people to reduce and prevent knife carrying. Authorities should ensure that the programmes they use have been shown to be effective. Overcoming the effects of trauma 6.9. All the local authorities have worked with children and young adults (sometimes up to the age of 25) supporting them to cope with trauma they may have experienced as victims of crime. Local authorities are working with young people who have been affiliated with gangs, supporting them to break with associates or, if they are not yet ready, to think about how they can make future change, be safer and more aware of the impact of their behaviour.  6.10. This cohort of young people is particularly difficult to engage, so local authorities have tried to work creatively, working with friendship groups rather than individuals, looking at the places where they are more comfortable to meet and addressing the issues they have highlighted as what they would want to be different as a start to engagement. Local Authority 1 has introduced group work for vulnerable young women which is delivered in schools.  6.11. All local authorities in London are now participating in the ‘Your Choice’ initiative which enables professionals working with young people affected by serious youth violence to deliver support using cognitive behavioural  28 | P a g e  therapy methods.10 This can assist in the intensive work required to build stable and trusting professional relationships with young people. Improved assessment quality  6.12. Local Authority 2 has taken steps to improve professional understanding the impact of serious youth violence and exploitation on young people in its social care and early help assessments of need and risk. This includes recognising the impact on children and young people of offending behaviour, whether it be their own, that of peers or other family members.  Serious Violence Duty: Police, Crime, Sentencing and Courts Act 2022 6.13. The service developments set out above should be viewed in the context of the new duties placed on local authorities, police services and partner agencies under the Police, Crime, Sentencing and Courts Act 2022.11 This requires agencies to work together to formulate an evidence-based analysis of the problems associated with serious violence in a local area, and then produce and implement a strategy detailing how they will respond to those issues. It is expected that LSCPs will take a keen interest in the development of these strategies and ensure that the interests of children and young people are central to them. 7. THE ABILITY OF PARTNERSHIPS TO REVIEW THE SERVICES PROVIDED TO SUSPECTED PERPETRATORS OF SERIOUS YOUTH VIOLENCE – SUGGESTED REVISION OF STATUTORY GUIDANCE 7.1. This section of the report develops the argument, referred to briefly in Section 1 above, that opportunities for learning in relation to serious youth violence are being missed because child safeguarding practice reviews are obliged to focus primarily on the circumstances of the young person who was killed and to services that were provided to the victim and his family. The same concerns apply to other forms of child exploitation. 7.2. The following comments apply to incidents that fall within the statutory guidance, in which a child has been killed or suffered serious harm (and there has been abuse or neglect (which is generally taken to include child criminal or sexual exploitation). For such incidents the current guidance allows for only three outcomes: 1) a local child safeguarding practice review, 2) a child safeguarding practice review commissioned at national level, or 3) no review. For incidents that do not meet the statutory criteria for notification, an agency or partnership may respond in any way it wishes and  10 https://liia.london/liia-programme/adolescent-safeguarding-and-youth-justice  11https://www.gov.uk/government/publications/police-crime-sentencing-and-courts-bill-2021-factsheets/police-crime-sentencing-and-courts-bill-2021-serious-violence-duty-factsheet#   29 | P a g e  convene a different kind of review under its framework of learning and improvement or quality assurance. 7.3. Following the fatal stabbing of Child E, the rapid review meeting decided that further substantial learning could only occur through a review of the services provided (or not provided) to seven of the young people involved in the critical incidents. Given the lack of a statutory framework within which this could happen, a number of the participating agencies and LSCPs involved subsequently decided that written agreement from the families of the children involved should be sought. The reasons for this and the impact on the review are set out in Sections 1.8 – 1.15 above. This limited the effectiveness of the review leading it to consider how the existing guidance might be amended to allow for learning that includes an evaluation of services provided to suspected perpetrators. Current statutory guidance and comparison with the review of deaths and serious harm in other circumstances 7.4. The statutory guidance requiring the review of services provided to children who have been killed or suffered serious harm is contained in Part 4 of Working Together to Safeguard Children 2018.12 Historically this guidance was developed in order to provide a framework for the review of children who had been killed or seriously injured by a parent or close family member. Whether or not they have yet been found criminally responsible, review of those believed to have caused the death usually happens automatically because most agency records cover both child and family members. The same approach has also been applied to children harmed by those working in a professional capacity with the child such as nursery workers and foster carers.  7.5. Working Together to Safeguard Children 2018 requires the LSCP to consider the need for a local review when the following criteria apply: • ‘abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed’ ‘Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health.’  7.6. The guidance sets out a range of other factors that those making the decision either ‘must take into account’ or ‘should have regard to’.13 These address both the likely learning from a review as well as the circumstances of the young person. A footnote to the guidance confirms that ‘child perpetrators may also be the subject of a review, if the definition of ‘serious child safeguarding case’, in other words, if the perpetrator has himself been  12https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf  13 Part 4, Section 18.  30 | P a g e  abused or neglected and is dead or is likely to suffer long-term impairment of mental health or intellectual, emotional, social or behavioural development. (Footnote 78, Page 85). 7.7. Whilst recognising the potential need for review of the services provided to alleged perpetrators of abuse, the wording of the current guidance makes it more difficult for safeguarding partnerships to evaluate the services provided for young people who have killed or seriously harmed another child. The emphasis on ‘child perpetrators’ causes difficulty because it may be some months or even years before anyone is found to be criminally responsible for the death. Prior to that a partnership may be unwilling to initiate a review. As in the case of Child E, suspected perpetrators may include both children and adults, but current guidance would exclude the adult from review. The fact that a person has killed someone does not meet the criteria for an adult safeguarding review. The current formulation assumes that a child accused of killing another has both suffered abuse and is likely to suffer long term impairment. This will sometimes be so, but often will not. At the very least these difficulties are likely to lead to protracted discussions within the safeguarding partnership and inconsistency in practice.  7.8. The focus on the victim is unique to the statutory review requirements for children’s cases. It can be argued that the heavy concentration on victims has reduced the effectiveness of reviews, for example in relation to child sexual exploitation.14 In contrast domestic homicide reviews are required to focus on the circumstances of both victim and perpetrator, and the relationship between them.15 An approach focusing on the victim alone would be unimaginable. Mental health homicide reviews usually focus largely on the perpetrator, recognising that the victim may not even be known to mental health services.16  7.9. There would appear to be a straightforward solution to this anomaly. The Home Office has produced draft statutory guidance for the conduct of Offensive Weapons Homicide Reviews which will become a statutory requirement under the Police, Crime, Sentencing and Courts Act 2022.17  14 For example, reviews of child sexual exploitation in Oxford and Rochdale focused almost exclusively on the victims and the services provided for them, with little learning on the characteristics, circumstances, motivation of perpetrators or the response of services. See for example, Rochdale Borough Safeguarding Children Board (2015) The Overview Report of the Serious Case Review in respect of Young People 1,2,3,4,5 & 6, https://www.rochdaleonline.co.uk/uploads/f1/news/document/20131220_93449.pdf and Oxfordshire Safeguarding Children Board (Serious Case Review into Child Sexual Exploitation in Oxfordshire - from the experiences of the children involved,  http://www.oscb.org.uk/wp-content/uploads/Children-and-young-peoples-summary-of-the-SCR-FINAL.pdf  15 https://www.gov.uk/government/collections/domestic-homicide-review  16 https://www.england.nhs.uk/south-east/wp-content/uploads/sites/45/2019/10/independent-investigations-for-mental-health-homicides-in-england-exec-summary.pdf  17https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1040762/Draft_OWHR_Guidance.pdf   31 | P a g e  This sets out arrangements for the review of homicides that involve the use of a weapon where the victim is 18 or older. In order to learn from an adult homicide involving use of a knife or gun, the draft guidance requires any review to consider the following: (i) the circumstances of or relating to the death, (ii) the circumstances or history of the person who died, or (iii) the circumstances or history of other persons with a connection to the death (emphasis added) 7.10. Although it does not apply to child victims, the Offensive Weapons Homicide Reviews guidance sets out an approach that, if applied to children’s safeguarding guidance, would enable local children safeguarding partnerships to review the services that had been provided for alleged perpetrators in both serious youth violence and child sexual exploitation cases. Appropriate measures would still be required to ensure that those involved were aware of the review and could participate, but there would be no expectation that their consent was required. Difficulties might still arise as a result of the parallel criminal and review proceedings, but these are now regularly addressed in other reviews. 7.11. The review will therefore recommend that the wording of Working Together to Safeguard Children 2022 cited above is replaced by the wording currently contained in the draft Police, Crime, Sentencing and Courts Act 2022 guidance, together with any additional information required. 8. OVERVIEW OF RECOMMENDATIONS  Introduction  8.1. The following recommendations are made to the four LSCPs that participated in the review. Their aim is to promote greater oversight of the response of services to topics that have arisen in the review. Each local  32 | P a g e  partnership should consider how far they apply locally and develop a plan of action in accordance with this assessment. Responding to rapid escalation in violence when a young person may be at risk of exploitation or serious youth violence 8.2. The LSCP should test whether local arrangements for the referral and assessment of adolescents who are at risk respond effectively to the rapid escalation in risk that can sometimes occur when there is child exploitation. This should include the following: • General awareness among professionals of signs and symptoms of child exploitation • The need for information gathering about context and peer groups in responding to referrals • Avoiding delay and breakdown in communication that can occur when young people live or go to school in different local authority areas. LSCP oversight of measures being taken to promote attendance and reduce suspensions and exclusion 8.3. The LSCP should test the effectiveness of arrangements made by the local authority and schools to 1) promote better school attendance among young people who may be at risk of exploitation and 2) to reduce rates of exclusion among young people who may be at risk of exploitation. Service responses should be in place so that there is a rapid response if a child who is at risk of exploitation is attending school poorly or has been excluded. Responding to the needs and circumstances of black children and their families 8.4. The LSCP should review the effectiveness of responses to families from black and minority ethnic communities to consider how best to promote a greater ability to understand and discuss their experiences, values and perspectives. 8.5. The LSCP in each of the areas involved in this review should promote an awareness of the particular circumstances and potential vulnerability of children who have been moved overseas by their families as a result of school difficulties or risk of criminal exploitation or violence and then returned to live in the UK. Social media 8.6. The LSCP should take steps to promote a greater awareness among professionals working with young people of the role that social media may place in heightening risk to young people, including in relation to serious youth violence and carrying weapons.  8.7. The LSCP should ask member agencies to include information on the young person’s use of social media in assessments of risk and need for young  33 | P a g e  people, and to demonstrate that this has been attempted, recognising that it will often be a difficult topic on which to initiate discussions Oversight by LSCPs 8.8. The LSCP should take an active role in providing oversight of the effectiveness of services to safeguard children from exploitation and extra-familial harm, including the coordination of multi-agency activity. Review the services provided to suspected perpetrators of serious youth violence – need for review of statutory guidance 8.9. The Child Safeguarding Practice Review Panel should promote learning from the review of services provided to suspected perpetrators of serious youth violence and criminal exploitation, both through guidance issued by the panel and by seeking changes in the statutory guidance Working Together to Safeguard Children 2018. Consideration should be given to the potential use of wording currently contained in the draft Police, Crime, Sentencing and Courts Act 2022 guidance on the review of offensive weapons homicides.   