Death of 17-year-old male child from Vietnam in December 2016 by drug misuse. Child C presented to services as an unaccompanied asylum-seeking child in April 2016 after being discovered in a lorry in Shropshire. Child C was suspected to have been trafficked into the UK. During the review process it was established that Child C was in fact an adult being 21 years of age. Child C went missing from his foster care placement within days of being placed. He remained as a missing person, until he was found deceased in Derbyshire. Child C was known to police, social services and health services. Learning includes: a number of issues concerning agencies' awareness of the indicators of trafficking and associated risks, their assessment of young people who present as unaccompanied asylum seekers, the management of risk in cases where children remain missing for a long time and the impact of a child's status on how they are managed and reviewed. Recommendations include: interagency guidance on children who present as unaccompanied asylum seekers and trafficked children should have a dedicated referral pathway that outlines the role of each agency; national guidance should be issued to clarify how Police and Local Authorities work together and agree on who takes primacy in the identification and confirmation of age of a person who presents as an unaccompanied asylum-seeking child.
      
 Title:  Serious case review: Child C. LSCB: Shropshire Safeguarding Children Board Author: Geoff Corre Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1   Foreword to the Serious Case Review (SCR) -  Child C Published 7th November 2018  This SCR was commissioned by the Independent Chair of Shropshire’s Safeguarding Children Board (SSCB) following the death of Child C who presented to services as an unaccompanied asylum-seeking child (UASC), and was suspected to have been trafficked into the UK.  Child C went missing from his foster care placement within days of being placed.  He remained as a missing person, believed to have been within the West Midlands area until he was found deceased in Derbyshire.    This serious case review was commissioned to identify any lessons that the agencies involved could learn in order to improve practice and better improve their services to unaccompanied asylum-seeking children in the future. During the review process it was established that Child C was in fact an adult being 21 years of age. It is important to note that prior to this case Shropshire had no or very little previous experience for a case such as this. Since that time significant improvements have been made across agencies which have been evidenced most recently through an SSCB multi-agency audit of safeguarding practice in respect of a number of UASC’s who subsequently presented in Shropshire.  6 cases were audited with 5 being graded as ‘Good’ and 1 graded as ‘Outstanding’. The SCR overview report makes a number of recommendations for the agencies involved in Child C’s care - for Shropshire’s Safeguarding Children Board, and for the government – and does report on some of the improvements which have already been made to practice. Whilst acknowledging the work of the Independent Reviewer in respect of this review, as has been indicated, SSCB is of the opinion that because the case dates back to 2016 not all of the improvements in practice have been included. In addition SSCB has identified a number of additional specific learning points for action over and above those recommended in the report.    2   This covering report outlines the progress made specifically in relation to the improvements in service that have been made by Children’s Social Care: • Policies and Procedures have been updated to reflect the learning from this case. • Significant improvements in the timeliness of assessments with assurance being provided to SSCB. • The introduction of a UASC Team/Worker who has become a subject matter expert and has built good relationships with these young people contributing to good outcomes for them. • All trafficked children are now referred to the National Referral Mechanism (NRM). • Commissioned Service with Refugee Action to provide additional support to UASC’s and trafficked young people.   Additional National Recommendation: On considering the final report SSCB identified that an additional national recommendation was required in order to keep UASC’s safer at the earliest opportunity.  The recommendation is as follows: • National guidance should be issued to clarify how Police and Local Authorities work together and agree on who takes primacy in the identification and confirmation of age of a person who presents as a UASC. SSCB are actively exploring this with the National Panel, the Home Office and the National Crime Agency to establish clarity on what processes currently exist and how gaps in that process should be closed. The learning from this SCR will continue to inform the on-going development of safeguarding systems and practice in Shropshire.  A multi-agency action plan has been developed which covers actions against all of the recommendations in the final report.  The SSCB Learning and Improvement sub-group will continue to monitor the multi-agency action plan and seek assurance from individual agencies that improvements have been made to safeguard this vulnerable group of young people.    INDEPENDENT AUTHOR;GEOFF CORRE         SERIOUS CASE REVIEW; CHILD C                           SHROPSHIRE SAFEGUARDING CHILDREN BOARD         1  Table of Contents  1. Introduction  2. Process of the Review  3. Family engagement   4. The facts   5. Key Practice Episodes  6. Context   7. Analysis of Terms of Reference  8. Informing local and national policy and procedure  9. Conclusion and themes   10. Good practice   11. Lessons learned   12. Recommendations         Appendices               2  1 Introduction  1.1 At the time of his presentation to agencies in Shropshire, Child C gave his date of birth as 4 May 1999 in Vietnam, his country of origin. During the course of this review, it was discovered that his actual date of birth was 5 April 1995.His body was found on 25 December 2016 in Derbyshire. He had presented as an unaccompanied asylum seeker in Shropshire on 16 April 2016 when he was discovered, with a group of other men, to have jumped out of a lorry that had been parked on the A41 in Shropshire.  1.2 Child C informed the Police and the local authority that his parents were dead and that he had been brought up in Vietnam by two uncles.  1.3 He stated that he had come to the United Kingdom via Moscow, where he alleged that he had been kidnapped and brought to the United Kingdom.  1.4 Child C claimed that he was 17 years old and there was no evidence to disprove this. An age determination concurred with this and he was received into the care of the local authority under Section 20, the Children Act (1989) and placed with foster carers in Shropshire on 17 April 2016. He absconded from the foster home on 23 April 2016 and was found dead in Derbyshire on 25 December 2016.  1.5 Child C was reported as missing to West Mercia Police on 23 April 2016. During the time that he was reported as missing, there were reported sightings in Birmingham where he was known to have links with a nail bar and a lap dancing club. Multi-agency strategy meetings were held in April, May, June and November 2016.The missing person´s enquiry was transferred to West Midlands Police on 19 May 2016.The police missing person´s enquiry status was altered to inactive on 6 July 2016, the police risk assessment level was altered from medium risk to low risk on 26 July 2016 and the social care status was changed from being a looked after child to being a child in need on 28 November 2016.  1.6  A serious case review should be instigated when (a) Abuse or neglect of a child is known or suspected; and   (b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child1  1.7 On 4 January 2017 and 3 February 2017, the Learning and Improvement sub group of the Shropshire Safeguarding Children Board received requests to consider a Serious Case Review or Learning Review from the Head of Children’s Services at Shropshire Council.                                                                  1 Working Together to Safeguard Children HMG (2015) P75  3  Immediately following his death, it had been uncertain as to whether Child C was a child so Shropshire Safeguarding Children Board sought advice from the National Panel on Serious Case Reviews.  They advised that a Serious Case Review should be commissioned on two grounds; agencies had understood that he was a child, and there were lessons to be learned as a result of the manner in which his case had been managed.  On 11 February 2017, the Independent Chair of the Shropshire Safeguarding Children Board agreed to commission a Serious Case Review on the grounds that Child C was believed to be a child who had died and abuse or neglect was suspected.   1.8  Working Together to Safeguard Children (2015) states that serious case reviews and other case reviews should be conducted in a way which:   • recognises the complex circumstances in which professionals work together to safeguard children • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight • is transparent about the way data is collected and analysed and makes use of relevant research and case evidence to inform the findings.   1.9  This review has been undertaken in a way that ensures these principles have been followed.  2 Process of the Review   2.1 This review was conducted by Geoff Corre, a Safeguarding Consultant with over 40 years’ experience in child protection, who is independent of the Shropshire Safeguarding Children Board and of the agencies involved. He has inspected child protection services with Ofsted and her Majesty’s Inspectorate of Constabulary. He is currently a trainer and consultant on Human Trafficking and Modern Slavery and is the former Chair of the Board of Trustees of the National Working Group on Child Sexual Exploitation and Trafficking.   2.2 The scope of the review covers the period from 16 April 2016 when Child C first came to the attention of agencies having jumped out of a lorry, along with other young men, which had been parked on the A41 in Shropshire to 25 December 2016 when his body was found in Derbyshire following an anonymous phone call to the police. The primary focus of the review is on Child C but it has also considered whether there is wider learning to be obtained regarding the arrangements for young unaccompanied asylum seekers and children who have or may have been trafficked.   4   2.3 The following terms of reference were agreed by the Learning and Improvement sub group of Shropshire Safeguarding Children Board on 27 March 2017. • Were the care planning arrangements for Child C appropriate and timely?   • Were agencies aware of the issues and risks associated with unaccompanied asylum seekers? • Was consideration given within this assessment to the possibility that Child C may have been trafficked? • Were appropriate measures put in place to mitigate any risks?  • Were suitable measures taken to locate Child C after he had been reported as missing?  Was information effectively shared between agencies? Did strategy meetings and reviews effectively assess the risks? Did his status have any impact on efforts to locate him? • Was sufficient consideration given to Child C’s status, cultural and linguistic needs?  • How appropriate did agencies use terminology and to what extent did this impact on their decision making? • Was practice in line with current policies and procedures? Were they effective in addressing the issues? • Does any learning from this case need to inform local policy and procedure and need to be communicated nationally?  2.4 The following agencies were involved in the review;   • Shropshire Council Children’s Services  • West Mercia Police • West Midlands Police • Derbyshire Police • Shropshire Community Health NHS Trust   2.5 A learning event was held on 13 April 2017 and this included representatives from West Mercia Police, West Midlands Police, Derbyshire Police, Shropshire Council and Shropshire Community Health NHS Trust.    5  Pen Picture; Child C2  Child C came to Shropshire from the Socialist Republic of Vietnam. He was approximately 5’ 8”-5’ 9, slim in stature and when he arrived had a shaven head.    Child C said he was from Quang Binh, but  also stated that he attended Tran Phu High School which is in Ho Chi Minh City, and some distance away. Over 80% of the population live on agricultural production in Quang Binh, where education is valued as a means to escape poverty. Child C described family members working as market traders and an uncle who worked as a taxi driver.   Child C reported that he had left school early due to his low attainment in Maths and Science, but that he did well in all his other subjects including History and Geography.  He reported that he had not worked in Vietnam but had assisted around the house after leaving school.  Child C was described by the foster carers as a confident young man, and although quietly spoken he was able to articulate his views to them and to others. He ate and slept well. He did not appear to have any health problems, although he did say that he had asthma which had been controlled by medication whilst living in Vietnam. Child C’s health and well-being was not assessed by a health professional because he went missing prior to his statutory Initial Health Assessment appointment with a paediatrician.   3  Family engagement  3.1 After his death, contact was made with a man in Vietnam who alleged that he was the father of Child C. This man e-mailed a photograph which, along with fingerprints, confirmed the identity of the deceased.  3.2  Attempts have been made via Derbyshire Police for the independent author to speak to Child C’s father but he has not responded to any requests to do so.  3.3  Child C’s father stated to police that his only concern was to have the body of his son repatriated to Vietnam. It has therefore not been possible to include the family’s perspective in this review.  3.4  It is not possible to ascertain why he did not wish to engage with the review.                                                                   2 This information was obtained by Shropshire Council Children´s Services during the short period of  their engagement with Child C   6  4  The facts; Summary of agency involvement   4.1  On 16 April 2016, West Mercia Police received three telephone calls relating to a lorry     that was parked in a lay by on the A41 in Tong, Shropshire. A number of men were seen to emerge from the rear of the lorry, three of whom, including Child C, were detained and taken to Malinsgate Police Station, Telford, where he was arrested on suspicion of entering the United Kingdom without leave to remain.  4.2  He remained in custody overnight, and on 17 April 2016 an age determination concluded that he was 17 years old. On 18 April 2016 he was accommodated by Shropshire Council under S20 of the Children Act (1989) and placed with foster carers.   4.3  On 19 April 2016, Child C was visited by the allocated social worker and it was noted that   he had been skyping unknown persons via a tablet that the foster carer had given him access to, and that he had 260 Euros in his possession which  he was eager to be changed into British pounds.  4.4  On 22 April 2016, the allocated social worker and fostering social worker visited Child C in the placement and noted a photograph of him on his Facebook page that had been taken in Moscow four weeks earlier. When he was challenged that he had previously stated that he had only been in Russia for five days before being allegedly kidnapped, it was reported that his demeanour changed and that he had tried to retract his earlier statement.  4.5  On the following day, 23 April 2016, there were two episodes of his going missing. The first had occurred at 09:30 hours, prior to which Child C had obtained the foster carer’s iPad and was searching for the port of Calais.  He was returned and was noted to have written on the reverse of a magazine that he wanted to go to Birmingham. He also had the address of a lap dancing club in the city.  Later, he asked the foster carer to either take him to Birmingham or to arrange a taxi to take him there. When she refused, he left the foster home one hour after the first incidence of going missing.   4.6 Child C was reported as missing with West Mercia and Warwickshire Police and assessed as being at medium risk. Enquiries ascertained that he was active on Facebook and associated with a night club in Birmingham.  4.7 A telephone discussion between the Social Worker and Police Officer noted that officers had visited the club in Birmingham but that no-one had seen or heard of Child C. A decision was made for him to remain as a missing person and for this to be reviewed on a daily basis.  4.8 An initial strategy meeting was held on 29 April 2016 during which officers from West Midlands Police informed colleagues that they had visited the night club in Birmingham, where staff had denied knowledge of him. The meeting concluded that the police missing  7  person investigation would continue, attempts would be made to access a laptop computer that had been used by Child C and his mobile phone, and the enquiry would be reviewed on a daily basis.  4.9 On 30 April 2016 digital enquiries provided further evidence that Child C was associating with the night club, and on 3 May 2016 this information was conveyed to the Multi-Agency Safeguarding Hub (MASH) in Birmingham.  4.10  A Review Strategy Meeting was held on 16 May 2016 and, as a result, a photograph of Child C was sent to the Birmingham MASH in support of the information that had previously been sent.   4.11  On 16 May 2016 Child C was identified via Facebook as attending the night club in Birmingham. At the behest of the police, the manager of the club agreed to contact them if Child C were to appear there again.   4.12  Due to his known associations in the Birmingham area, responsibility for the missing person enquiry was transferred from West Mercia Police to West Midlands Police on 19 May 2016.  4.13  On 27 May 2016, the social worker contacted West Midlands Police who agreed to contact the Department for Work and Pensions to ascertain if Child C had made a claim. There was no information regarding his attendance at either night club or the nail bar.  4.14  A Review Strategy Meeting was held on 8 June 2016, in which the West Mercia Police representative reported that he had requested to colleagues at West Midlands Police that Child C’s risk assessment be reviewed. It was assessed as medium risk at the time but more in depth enquiries would be possible if it were assessed as high.  It was also reported that all actions from the previous meeting had been completed and that all avenues of the missing person enquiry had been exhausted.   4.15  On 1 July 2016 enquiries were obtained from his Facebook account which provided information that Child C had been active from 8 - 10 May 2016 in the Brownhills area of the West Midlands, but it was not possible to determine the specific location.  From 13 - 18 May 2016, digital enquiries indicated activity in Vietnam, which suggested that either Child C had returned there, or had allowed someone in Vietnam to access his Facebook account. The last access to the Facebook account was recorded as 18 May 2016.  4.16  On 6 July 2016, a telephone conversation took place between a social worker from Shropshire Council and a Sergeant from West Midlands Police. The social worker was informed that all existing lines of enquiry had been completed and that the missing person enquiry was to be designated as inactive on the police missing persons’ case management system.  8   4.17  On 26 July 2016 West Midlands Police altered the risk assessment from medium to low on the grounds that Child C was considered to be an adult  4.18  On 2 August 2016, the social work assessment was completed. It concluded that consideration should be given to convening a further strategy meeting with a view to altering Child C’s looked after status.  4.19  On 17 November 2016, a Review Strategy Meeting was held. Due to the fact that West Midlands Police were not in attendance, a decision was made to arrange a further meeting to confirm the actions taken since the previous meeting on 8 June 2016.  4.20  On 28 November 2016 a further review strategy meeting was held at which it was decided to alter Child C’s status from being a Looked After Child  to being a Child in Need. The rationale for this decision was based on the decision of West Midlands Police to alter the status of the missing persons’ enquiry to inactive.  It was agreed that should Child C be found he would immediately become subject to Looked After Child status again.  4.21  On 22 December 2016, Child C was identified by digital enquiries on Facebook to have attended a residential address in Birmingham.  4.22  On the night of 24-25 December 2016, Child C was reported to have attended a night club in Birmingham where witnesses described a male fitting his description as leaving the club in an intoxicated state and as requiring assistance to get into a taxi. Information from the police suggests that he was supplied with controlled drugs in the nightclub and that individuals who were with him refused to call an ambulance and carried him into a taxi.   4.23  Later on 25 December 2016, Child C went to an address in Derbyshire where it is suspected that he died. On the same day, his body was located behind a wall in Derbyshire. Derbyshire Police commenced an investigation regarding the circumstances surrounding his death.  4.24  The police had been alerted by a representative from the Buddhist temple in Birmingham which had received an anonymous phone call informing them of the whereabouts of the body.  5.   Key Practice Episodes Key Practice Episodes are defined as the most significant episodes in the case that require further analysis. They are set out in chronological order and are to be analysed in order to gain a clear oversight as to agencies’ engagement with Child C. They are as follows;  Key Practice Episode One; Arrival in Shropshire, 16 April 2016     9  Key Practice Episode Two; Initial Care Planning Arrangements, 17 April 2016   Key Practice Episode Three; First period of going missing, 23 April 2016    Key Practice Episode Four; Second period of going missing, 23 April 2016 and Initial Strategy Meeting, 29 April 2016    Key Practice Episode Five; Review Strategy Meeting, 8 June 2016   Key Practice Episode Six; Decision to alter Child C’s risk level and status of missing person´s enquiry, 26 June to 26 July 2016    Key Practice Episode Seven; Review Strategy Meetings, November 2016  The following paragraphs outline the factual details of each key episode which are then the subject of analysis in the following sections.  5.1  Key Practice Episode One; Arrival in Shropshire, 16 April 2016   5.1.1  On 16 April 2016, Child C, along with six to eight other young men was seen to jump off a lorry that was parked on the A41 at Tong, Shropshire near Telford. Following several telephone calls from members of the public to the Police, he was arrested but not charged with any offence and taken to Malinsgate Police Station, Telford.   5.1.2  Police enquiries revealed that a Hungarian lorry driver had entered the UK at Dover from Calais bound for Market Drayton, Shropshire. He had stopped on the M1 en-route before continuing his journey. He then had a second break on the A41 at Tong, near Shifnal where he heard banging noises from the rear. On inspection he noticed that the clamp fastening on the rear doors had been damaged and on opening the doors, eight to fifteen young men jumped out of the lorry and into the surrounding fields.  5.1.3  Child C was found to be in possession of 260 Euros, a five Euro mobile phone top up card, miscellaneous papers with a route, a wallet containing pictures and a mobile phone all of which were seized for safe keeping, and then returned to him after he was released from custody. In addition, his fingerprints were taken.  5.1.4  A telephone call was made by the police to the Telford and Wrekin Emergency Duty Team (EDT) as they had thought that Child C had arrived in that local authority area. However,  10  the police received a message from the Telford and Wrekin EDT informing that it would take at least five hours for them to arrive and that the case may therefore be passed on to the day time team.   5.1.5  On 17 April 2016, Telford and Wrekin EDT telephoned West Mercia Police to state that Child C had been located within the local authority boundary of Shropshire Council, and subsequently, a social worker from Shropshire Council determined the age of Child C via an interpreter as being 17 years old.  5.2  Analysis of Key Practice Episode One   5.2.1  On his arrival in Shropshire, agencies were presented with several indicators that suggested that Child C was likely to have been a victim of trafficking; the manner of his arrival in a lorry with other young men, the fact that he was in possession of a fairly large amount of cash and a payment card in Euros, and papers which contained a route. Despite these indicators, agencies did not operate with sufficient awareness and nor did they follow up on some critical issues, such as interviews with Child C himself or  with the other young men with whom he had been transported, or the sharing of information about  Child C’s allegation that he had been kidnapped in Russia.  5.2.2  Child C was detained in police custody on suspicion of committing immigration offences, and was not taken into Police protection.   His detention was authorised by the custody officer who considered that there were reasonable grounds to believe that it was necessary to prevent the prosecution of immigration offences being hindered by the departure of Child C, and to allow a prompt and effective investigation. His detention was in accordance with S34 (2) of the Police and Criminal Evidence Act (1984).  5.2.3  The West Mercia Police custody unit had initially contacted Telford and Wrekin Emergency Duty Team who responded over ten hours later to inform them that the responsible authority was Shropshire Council. It then took a further four hours for a member of that team to undertake the assessment.   5.2.4 The Police power to examine information concerning his mobile phone was not exercised because he had been age determined as a juvenile and the immigration enquiry had ceased. His status, therefore, did not comply with the statutory purposes in operation at the time under which communications data may have been accessed.3 Similarly, his fingerprints were not submitted to the authorities in Vietnam due to the fact that he was believed to have been under 18 and he was not under investigation for an alleged offence. However, they were checked against the UK database and no record was found.                                                                  3 The Data Retention and Investigatory Powers Act(2014)   11  Items such as 260 Euros in cash, a map and a mobile phone were kept for safekeeping, and then returned to him, but the fact that he was in possession of such items was not analysed within the context of the an hypothesis that he may  have been  subject to continuing risk as  the victim of trafficking.  5.2.5  Child C was not interviewed by West Mercia Police concerning an allegation of kidnapping in Russia due to the fact that they were not aware of this allegation until they were informed of it by Shropshire Council Children’s Services on 29 April 2016.By this time Child C had gone missing and it was not possible to pursue any enquiry.  5.2.6  A local authority age assessment is be required when there is significant reason to doubt an individual’s claimed age in order to be sure they are treated appropriately and that they receive the necessary services and support. Although there is no prescribed way in which local authorities are obliged to carry out such assessments, general guidance has been provided by the courts4. This states, among other issues, that an assessment should not be based solely on observation except in exceptional circumstances.           The Department of Education provides statutory guidance for local authorities on the care of unaccompanied and trafficked children. It states under Age Determination that “Many unaccompanied and trafficked children arrive in the UK without documentation or with fake documents. Where the age of a person is uncertain and there are reasons to believe that the person is a child, that person is presumed to be a child in order to receive immediate access to assistance, support and protection in accordance with Article 10(3) of the European Convention on Action against Trafficking in Human Beings. Where an age assessment is required, local authorities must adhere to standards established within case law. Age assessments should only be carried out where there is significant reason to doubt that the claimant is a child. Age assessments should not be a routine part of a local authority’s assessment of unaccompanied or trafficked children.”5  5.2.7  Child C was not initially subject to an age assessment6, as an age assessment is a longer piece of work and this would not be carried out by the Emergency Duty Social Worker.  Instead, she undertook an age determination by meeting with him briefly and interviewing him via an interpreter.  This age determination accepted Child C’s statement that he was 17 years old, and was based on the stated assumption that there was no evidence with which to disbelieve Child C’s account that he was 17 years old or that he had come to the UK because his parents were dead.                                                                             4B v London Borough of Merton [2003] EWHC 1689 (Admin) 5 Care of Unaccompanied and Trafficked Children, (DfE, 17 July 2014) 6 The process for undertaking such assessments is set out in Assessing Age for Asylum Applicants (UK Visas and Immigration,15 June 2015) and in  Age Assessment Guidance (Association of Directors of Children’s’ Services October 2015)   12  5.2.8   Had the police and local authority demonstrated greater awareness of how to respond to the indicators of trafficking at the outset, it is possible that their subsequent risk management may have been more informed and therefore more robust.  The first 24-48 hours are an essential period for gathering information from young people who have potentially been trafficked to safeguard their welfare should they go missing or be abducted.  5.3  Key Practice Episode Two; Initial Care Planning Arrangements; 17 April 2016  5.3.1  Following the assessment, Child C was accommodated by Shropshire Council under S20 Children Act (1989). This requires local authorities to accommodate children for any child in need within their area who appears to them to require accommodation as a result of-  (a) There being no person who has parental responsibility for him;  (b) His being lost or having been abandoned; or  (c) The person who has been caring for him being prevented (whether or not permanently, and for whatever reason) from providing him with suitable accommodation or care.  5.3.2  Child C was placed with registered foster carers in Shropshire.  5.4  Analysis of Key Practice Episode Two; Initial Care Planning Arrangements, 17 April 2016  5.4.1  Safeguarding Children Who May Have Been  Be Trafficked (para 5.74) states that “ It is … essential that, where a trafficked child is identified and placed in local authority care, specific arrangements are put in place to safeguard the child from the risks of going missing or being re-trafficked. Where a child goes missing, these cases should be urgently reported to the police…Local authorities should consider seriously the risk that a trafficked child is likely to go missing and take this into account in planning that child’s care. A contingency plan could include contact details of agencies that should be notified if a potentially trafficked young person goes missing, including the police and the UK Border Agency”7 In view of the fact that agencies were insufficiently aware of the issues and risks associated with children who may have been trafficked, no contingency plan was in place for Child C in the event of his going missing.   5.4.2  On 17 April 2016, the local authority social worker explained, by means of the police telephone interpreting service, to Child C that he would be placed in foster care. At a                                                                  7 Safeguarding Children Who May Have Been Trafficked, Department  for Education and the Home Office (18 October 2011)  13  meeting on 19 April at the foster home, he is reported to have confirmed his understanding.  5.4.3  The social worker provided some information about Child C to the foster carers by telephone but he was taken to the foster home by police officers without being accompanied by a social worker. Shropshire Council Children’s Services acknowledge that he should have been transported by a social worker. Such a course of action would have represented a minimal level of expected practice, but it may also have been reassuring to a young man from a country in which expectations of the police may have been more fearful than in the United Kingdom.  5.4.4  The foster carers had received equal opportunities training in 2010 - some six years previously - but did not have any knowledge of the Vietnamese language and therefore had to communicate by means of an application on their mobile telephones and tablets. The foster carers had a limited appreciation of Vietnamese culture as they had recently had a holiday there, but communication via a digital application cannot be a substitute for clear communication on a daily basis and will inevitably have made it difficult for Child C and his foster carers to have formed a relationship. In addition, the foster carers had not received any training on human trafficking and would not have been aware of the specific risks and vulnerabilities of young people such as Child C.  5.4.5  Several internal systems issues impacted negatively on information sharing within Shropshire Council Children’s Services, as follows; The EDT were able to place initial records but were not able to add new records to the Shropshire Children’s Services Integrated Children’s System. As a result, new information was not recorded on the system but on an excel spreadsheet instead. Following the interview with Child C, the EDT Social Worker was not able to follow up on the work with Child C due to other commitments and therefore handed over responsibility for the care admission forms to a colleague verbally. Some information was therefore not passed on and this was compounded by the fact that the EDT Social Worker who had undertaken the initial assessment then lost some notes. The subsequent referral from the EDT for an assessment therefore contained limited information about the circumstances of Child C’s arrival and family details.  5.4.6  Child C was visited in the foster home by the social worker, the foster carers’ supervising social worker and an interpreter on 19 April 2016, within statutory time scales, with a view to completing the assessment.   5.4.7  Information received on a visit the following day regarding inconsistencies in Child C’s account as to how long he had allegedly been in Russia was interpreted as an indicator that he may have been trafficked . However, neither this information nor the evidence about his being in possession of a large amount of cash was used to inform an analysis of an  14  increased risk of Child C going missing from the foster home within a short time of his placement there. As a result, no additional safeguards or contingency plan were put in place.  5.4.8  An initial Looked After Child Review took place on 20 April 2016, but this was the only such review to be held, despite the fact that Child C had remained accommodated by the local authority until November 2016.The strategy meetings that were held after he had gone missing were regarded as a substitute for reviews, but both should have been conducted in parallel during the time that Child C remained a Looked After Child.  5.4.9  This review has concluded that a combination of factors prevented appropriate and effective initial care planning arrangements for Child C; a failure to appreciate the likelihood of his going missing soon after placement, the absence of a contingency plan, the fact that he was not accompanied to the foster carers by a social worker and the lack of specific training for the foster carers on caring for  children who may have been trafficked. These issues, together with inadequate systems of communication both within the EDT and from the EDT to colleagues in Children’s Services resulted in initial care planning arrangements which were insufficiently robust and lacked sufficient information with which to make an effective care plan for a young person in Child C’s circumstances.  5.5  Key Practice Episode Three; First period of going missing, 23 April 2016 5.5.1  Child C went missing on 23 April 2016 three days after an interview with the social worker which revealed some discrepancies in his original story. He was located within one hour and returned to the foster home twenty minutes after being located.  5.6  Analysis of Key Practice Episode Three; First period of going missing, 23 April 2016  5.6.1.  Although discrepancies in Child C’s story had been identified prior to the first missing episode, they did not result in any contingency planning in the event of his going missing.  5.6.2  On his return, Child C had informed the foster carers that he had gone missing because he had wanted to go to a particular night club in Birmingham. This information was conveyed to the Social Worker.    5.6.3  Child C’s absence was not reported to the police as the West Mercia Joint Runaway and Missing from Care Protocol in operation at the time did not include a requirement to report absences to the police if they are defined as absent (i.e. missing) for a period of up to six hours.  5.6.4  However, it was not possible to conduct a return interview, as set out in that protocol, because Child C went missing within an hour of his return.                            15   5.6.5  The protocol also requires a risk assessment but this was not implemented. A risk assessment may have identified the heightened risk of Child C going missing soon after placement and the need for a suitable contingency plan.   5.6.6  A toothbrush belonging to Child C was seized by officers from West Mercia Police on 29 April 2016 but was not subject to DNA analysis. Such analysis would only be instigated in the event of concern that a missing person was deceased. At this time, there were no such concerns and the item was therefore not submitted for such testing.  5.7  Key Practice Episode Four; Second period of going missing, 23 April 2016, Initial Strategy Meeting, 29 April 2016,Looked After Review,12 May 2016  and Review Strategy Meeting, 16 May 2016   5.7.1  Within one hour of his return, Child C went missing again and his precise whereabouts remained unknown although there were reports of his being in the West Midlands area.  5.7.2  As a result of Child C being known to be active in the West Midlands area, the missing person enquiry was transferred to West Midlands Police and the missing person report conducted by West Mercia Police was concluded on the 19 May 2016.  5.7.3  Officers from West Midlands Police visited a nail bar on 19 May 2016 to which Child C had been located via Facebook postings and showed staff a photograph of Child C and asked if they knew of him or his whereabouts. They all denied any knowledge of him despite the fact that the police had evidence that he had accessed an encrypted password belonging to the Wi-Fi service there over fifty times. The officer also checked that there were no accommodation premises belonging to the building and also some adjacent flats to determine if Child C was living in the vicinity.  5.7.4  On 21 May 2016 further enquiries were made at a night club in Birmingham known to have been frequented by Child C. A press release and the issuing of photographs to the local Neighbourhood Police teams and British Transport Police were both actioned on the same day.  5.7.5  In view of the fact that Child C’s Facebook account was linked with that of another person with a Vietnamese name, enquiries were made at the address to which the account was linked and to the letting agency for the premises, but did not produce any information that would assist with the enquiry.  5.8   Analysis of  Key Practice Episode Four; Second period of going missing, 23 April 2016, Initial Strategy Meeting,29 April 2016, Looked After Review,12 May 2016 and Review Strategy Meeting, 16 May 2016   16   5.8.1  The West Mercia Police missing person record includes an entry dated 23 April 2016 which states that Child C had expressed to the foster carer that he wanted to go to Birmingham and had repeatedly asked for directions to a particular night club there. This entry concludes “He (Child C) said [to the foster carers] he did not want the Police involved”. However, this was not reported to the social worker and was therefore not subject to any further scrutiny. Had the foster carer informed the social worker of Child C’s intentions it may have afforded additional evidence of the possibility of the continuing influence of traffickers on Child C.  5.8.2  A Strategy Meeting was held on 29 April 2016. The primary area of risk was defined as emotional, but the rationale for this was not specified and nor was the evidence that he was at risk of emotional abuse as opposed to other categories of abuse. The meeting concluded that the threshold for enquiries under S47 of the Children Act (1989) had been met.  Reference was made to Child C’s assertion that he had gone on holiday to Moscow and was kidnapped, his possession of large amounts of cash and, his links with night clubs in Birmingham. However, these factors were not aggregated to provide an assessment of increased risk to Child C. The strategy meeting noted appropriate efforts to locate Child C as a missing person, and that he may have been at risk of trafficking, but it did not recommend a referral to the National Referral Mechanism 8 .However, the meeting appropriately recommended that the Police inform the United Kingdom Trafficking Centre (UKTC) and UK Visas and Immigration   5.8.3  On 12 May 2016, Child C’s only Looked after Children Review was held. Strategy Meetings and Review Strategy Meetings were regarded as a substitute for future reviews.              The absence of any national guidance as to whether children should retain their status as looked after in this circumstances contributed to the local authority’s uncertainty as to how to proceed. Whilst Child C remained accommodated by the local authority, he should have remained subject to statutory reviews. The fact that he had remained missing should have prompted the local authority to act as his advocate and his voice rather than be seen as a reason not to hold reviews.                                                                    8 The National Referral Mechanism (NRM) is a framework for identifying victims of human trafficking or modern slavery and ensuring they receive the appropriate support. The NRM is also the mechanism through which the Modern Slavery Human Trafficking Unit (MSHTU) collect data about victims. This information contributes to building a clearer picture about the scope of human trafficking and modern slavery in the UK. The NRM was introduced in 2009 to meet the UK’s obligations under the Council of European Convention on Action against Trafficking in Human Beings. At the core of every country’s NRM is the process of locating and identifying “potential victims of trafficking”. From 31 July 2015 the NRM was extended to all victims of modern slavery in England and Wales following the implementation of the Modern Slavery Act 2015   17  5.8.4  A Review Strategy Meeting held on 16 May 2016 also agreed on a number of appropriate measures to locate Child C such as a press release, and the production of photographs on billboards, both of which were actioned on 21 May 2016. In view of the fact that Child C had been seen at a night club in Birmingham, officers contacted the owners of the night club and made an agreement with them that they would contact the Police if Child C were to appear there.   5.8.5  The minutes of this meeting held on 16 May 2016 are incomplete. The section that sets out attendees lists the participants who were invited to the meeting but is not clear as to which professionals actually attended and from whom apologies were received.         Other key sections that were incomplete are those relating to Child C’s status as a Looked after Child, whether a social work report was to be required and whether S47 enquiries should be instigated. Although these sections are recorded in the initial strategy meeting held on 29 April 2016, their absence in this review meeting results in an incomplete record.          For Strategy Meetings to be effective, it is essential that they consider all key issues and that the minutes provide a complete and comprehensive record of attendees, discussions, decisions and actions.  5.9  Key Episode Five; Review Strategy Meeting, 8 June 2016  5.9.1  A further Review Strategy Meeting was held on 8 June 2016. At this meeting, West Midlands Police requested information about the two other young men with whom Child C had arrived in Shropshire and it was reported that enquiries had been made at a hostel and hotel at which the men had been staying. However, by the time of the enquiries, they had left and one of them had failed to appear, as required, at a meeting with UK Immigration and Visas.  5.9.2  The strategy meeting concluded that the threshold for a S47 enquiries had been met and that Child C remained at risk of harm as a trafficked young person.     5.10  Analysis of Key Practice Episode Five; Review Strategy Meeting, 8 June 2016 5.10.1  The Review Strategy Meeting held on 8 June 2016 was highly significant. Although the missing person enquiry had been transferred to West Midlands Police on 19 May 2016, there were no officers from that force present. Representatives from the force were invited but did not attend, and, at their request, they were informed of the outcomes via the police missing persons’ system rather than via the minutes of the meeting. It is reported that it is difficult to send such minutes directly other than to a named Police Officer   5.10.2  At this meeting, the  West Mercia Police Harm Assessment Unit Manager requested to colleagues at West Midlands Police that Child C’s risk assessment be reviewed with a view to his being considered as high risk on account of the fact that he had been  age determined  18  as a child. The manager reported to the meeting that he was awaiting a response to his request for a review from colleagues at West Midlands Police,   or for clear reasons as why this was not to be undertaken. This would have enabled more in depth enquiries as Child C was considered to be a child. However, in view of the fact that responsibility for the management of the enquiry had been transferred, he did not have the authority to insist on this.   5.10.3  This review has concluded that Child C remained a vulnerable young man who had appeared to have been trafficked and that he remained at risk of harm. In spite of this assessment and the request from West Mercia Police, decisions were taken only three weeks later which ran contrary to this assessment.  Despite the fact that the management of the missing persons enquiry had transferred to West Midlands Police, it would have been good practice to have consulted with colleagues in West Mercia police and to have taken account of the transferring force’s recommendations in undertaking their own risk assessment.   5.10.4 It is important to ensure that information from strategy meetings is effectively shared via official minutes.               At the request of West Midlands Police, information regarding the meeting held on 8 June 2016 was instead conveyed via the police missing persons’ case management system by colleagues in West Mercia Police.   West Midlands Police should seek to resolve the systemic issue regarding the difficulty of sending minutes in the absence of a named officer.   5.11.  Key Practice Episode Six; Decisions to alter Child C’s risk level and status of the missing person’s enquiry, 26 June to 26 July 2016  5.11.1  The missing persons case management  system used by over twenty-two police forces, including West Mercia Police and West Midlands Police includes three risk assessment categories; high, medium and low. In addition, enquiries are designated as active or inactive.9                                                                  9 The College of Policing provides guidance as to how officers should determine the level of risk as follows; Low risk The risk of harm to the subject or the public is assessed as possible but minimal. Proportionate enquiries should be carried out to ensure that the individual has not come to harm. Medium risk   19   However, this does not include any specific reference to high risk groups such as children who are considered to be at risk of trafficking or who are unaccompanied asylum seekers, These groups are included in other statutory guidance such as Statutory Guidance on Children who Run Away or Who are Missing 10  and Care of Unaccompanied Migrant Children and Child Victims of Modern Slavery11.         In order to facilitate closer links between risk assessments and these vulnerable groups, joint guidance for Local Authorities and Police Forces would enable professionals to work more effectively in identifying and protecting such groups of young people.  5.11.2  On 6 July 2016, there was a telephone call between a social worker from Shropshire Council and a Sergeant from West Midlands Police in which the social worker was informed that the status of the missing enquiry was about to be  altered from active to inactive on the police system. (Such a change would indicate that all existing lines of enquiry had been exhausted and would not be revisited, but any new lines of the missing person’s enquiry would be followed up).This alteration from active to inactive  was subsequently authorised by a Superintendent.  5.11.3  Child C’s risk category was changed on the police missing person system from medium risk to low risk on 23 July 2016 by West Midlands Police on the grounds that agencies considered that it was likely that he was an adult based on photographic evidence of his                                                                  The risk of harm to the subject or the public is assessed as likely but not serious. This category requires an active and measured response by the police and other agencies in order to trace the missing person and support the person reporting.  High Risk The risk of serious harm to the subject or the public is assessed as very likely. This category almost always requires the immediate deployment of police resources – action may be delayed in exceptional circumstances, such as searching water or forested areas during hours of darkness. A member of the senior management team must be involved in the examination of initial lines of enquiry and approval of appropriate staffing levels. Such cases should lead to the appointment of an investigating officer (IO) and possibly an SIO, and a police search adviser (PolSA). There should be a press/media strategy and/or close contact with outside agencies. Family support should be put in place where appropriate. The MPB should be notified of the case without undue delay. Children’s services must also be notified immediately if the person is under 18. Risk of serious harm has been defined as (Home Office 2002 and Offender Assessment System   2006): ‘A risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible.’ Where the risk cannot be accurately assessed without active investigation, appropriate lines of enquiry should be set to gather the required information to inform the risk assessment.  10 Department of Education (last updated April 2017) 11 Department of Education (,last updated November 2017)  20  physical appearance. The decision to regrade the missing person’s enquiry to inactive was made by a neighbourhood inspector and a sergeant and was authorised by an inspector after a review on 26 July 2016 in accordance with force policy. The overriding rationale for the decision was that Child C was considered to be an adult based on a consideration of his age from photographs, although evidence from the missing person’s enquiry concerning his life-style, his actions and expressed desires and an assessment that he did not appear to represent a risk to himself or the public, was also taken into account.             West Midlands Police do not have a policy of determining age from photographic evidence alone, or of determining age in the absence of the individual concerned, or of any anthropometric measurements.              The age determination by the local authority was not taken into account in reaching this conclusion, as there is no specific requirement for the police to consult with partner agencies before altering a missing person’s risk category.   5.12  Analysis of Key Practice Episode Six; Decision to alter Child C’s risk level and status, 26 June 2016 to 26 July 2016    5.12.1 The decision by West Midlands Police to alter the status of the missing person´s enquiry played a part-along with other considerations - in Children’s Services’ own subsequent decision about Child C’s status as a Looked after Child.  5.12.2  The decision to alter the risk level of the missing person enquiry made on 26 July 2016 was made in accordance with force policy by an Inspector and reviewed by another Inspector.           The decision was taken on a single agency basis.  5.12.3  Whilst there is no requirement for agencies to consult with their partners about internal decisions, there is a requirement on all agencies to work together to safeguard children.12         The decisions to alter Child C’s risk level and status of the missing person’s enquiry by West Midlands Police should therefore have been discussed at a Review Strategy Meeting in which all agencies would have had an opportunity to share information, to provide a forum for a consideration of Child C’s age assessment and risk level and to enable a more integrated approach to important decisions. West Midlands Police should have attended all of the strategy meetings to have enabled such opportunities.         The issues identified in this review concerning age determination and assessment and changes to Child C’s missing person’s status indicate the need for new joint guidance. This should include the requirement for police services to take account of local authorities’ age determinations and assessments in assessing risks to missing persons.         5.13  Key Practice Episode Seven; Review Strategy Meetings, November 2016                                                                   12 Working Together to Safeguard Children(HMG 2015)  21   5.13.1  The next Review Strategy Meeting was not held until 17 November 2016. This stated that its purpose was to review Child C’s missing status, review actions taken and to review his looked after child status. It also noted that the case had been designated as an inactive missing person case by the police on 26 July 2016. It recommended that a full multi-agency case discussion  be convened, that the police were to confirm actions taken in view of the inactive status and that Child C should no longer be designated as a looked after child.  5.13.2 Although the minutes of the Review Strategy Meeting held on 17 November 2016 refer to the need to convene a full case discussion, the next meeting held on 28 November 2016 was designated as a further review strategy meeting. This unanimously concluded that Child C’s Looked After Child status should be ended and that he should be categorised as a Child In Need. In addition, it reversed the decision of the previous meeting by concluding that the threshold for S47 enquiries had not been met.  5.14  Analysis of Key Practice Episode Seven; Review Strategy Meetings, November 2016   5.14.1  No Review Strategy Meetings took place between June 2016 and November 2016, which was too long a period for the case not to have been reviewed and monitored.            Despite the fact that no new lines of enquiry had been identified, Review Strategy Meetings should have been held on a regular basis at defined intervals.       5.14.2  Two critical Review Strategy Meetings were held during November 2016, following a recommendation in the social work assessment for a meeting to reconsider Child C’s looked after status.  5.14.3  The first meeting took place on 17 November 2016 and no representative from either  West Midlands or West Mercia Police was present; it is not possible to determine from the minutes as to whether they were invited as they do not specify those agencies that gave apologies for non-attendance. West Midlands Police have no record of their having received an invitation.   Although reference is made to attempts to locate Child C, it concludes by recommending a review to consider Child C’s status as a looked after child.  5.14.4  The second meeting took place on 28 November 2016 and included representation from the West Mercia Police Harm Assessment Unit Manager. The minutes inaccurately refer to Child C’s status as being on the missing persons system to West Mercia Police when in fact the enquiry had been transferred to West Midlands Police in May 2016. The representative from West Mercia Police was unable to correct this as he did not receive a copy of the minutes.   22  Contrary to the conclusion made at the meeting that had been held two weeks earlier, this meeting decided that the threshold for S47 enquiries had not been met. The rationale for this decision was that all attempts to locate Child C had been futile and that agencies were to contact Shropshire Council in the event of Child C being located.   This meeting is identified as a strategy meeting. It concluded that all agencies agreed that his status should be altered to that of a Child in Need, but there is no reference to the threshold criteria for determining a child in need as set out in the local threshold document that was in operation at the time.  The use of a strategy meeting instead of a looked after review to consider such issues did not comply with Working Together To Safeguard Children (2015) which states that “Local authority children’s social care should convene a strategy discussion to determine the child’s welfare and plan rapid future action if there is reasonable cause to suspect the child is suffering, or is likely to suffer, significant harm”13. This review has concluded that any decision regarding Child C’s Looked After Child status should have been made at a statutory review which would have more effectively enabled a fuller analysis of his needs and enabled the child to be the focus of the meeting. Critically, a review would have included an Independent Reviewing Officer (IRO) whose role is to represent the child’s voice, to challenge the local authority and to prevent drift in planning.  There is no evidence that, in coming to the decision to alter Child C’s status to that of a Child in Need, agencies took account of the threshold criteria that were in place at the time. An examination of the criteria indicates that he probably did meet the criteria, namely a) he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority under this part; (b) his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or (c) he is disabled.14  It is the conclusion of this review that Child C should have remained subject to statutory reviews until he had reached the assumed age of 18 as a means of quality assuring care planning, scrutinising decision making and tracking progress.   It is important that the status and precise nature of meetings should be specified and documented so that all agencies are clear as to their purpose and function.                                                                   13 Working Together to Safeguard Children (HMG 2015) p36 14 Accessing The Right Service at the Right Time ;   Multi-agency Guidance on Threshold Criteria to help support Children, Young People and their Families in Shropshire.  23  Multi-agency meetings have a vitally important role in ensuring robust and positive outcomes for children. As such, they need to be attended by all key agencies, enable appropriate professional challenge and provide clear rationale for decisions. This did not happen in all of the meetings held about Child C.   5.14.5  Despite the fact that there had been too long a gap between the Review Strategy meeting that was held on 8 June 2016 and the Review Strategy meetings held in November 2016, agencies did not consider the likelihood of increased risk to Child C as a result of his remaining missing for a longer time, nor is there any reference in the minutes to a consideration of the possibility that he may have been controlled or influenced. Whilst there is no definitive evidence that this was the case, agencies should have considered the hypothesis that a range of factors may have been indicators of increased risk. Instead, the minutes indicate too strong an emphasis on his status and do not focus on what may have been going on in his life whilst remaining missing for such a long time.  6.   Context  The following information is provided due to the fact that this review has concluded that there are a number of indicators in Child C’s life which lead to the hypothesis that he may have been trafficked into the United Kingdom.  At the same time, it is recognised that some people may choose to enter the country in a clandestine manner.  The National Context 6.1  The United Nations estimates that human trafficking is one of the most profitable forms of criminal activity globally (UN International Labour Organisation Report 2014). In the UK, the National Crime Agency (NCA) includes human trafficking as one of the major strategic threats from serious and organised crime 15.It is estimated that, globally, it is worth $32 billion a year and that around 2.45 million people are trafficked.  6.2  In 2011, the Child Exploitation and Online Protection Centre (CEOP) in conjunction with the British Embassy in Hanoi produced a report entitled The Trafficking of Women and Children from Vietnam16. This noted that CEOP’s Strategic Threat Analysis (STA) in 2010 concluded that the largest identified trend was of Vietnamese women and children trafficked into the UK. The report identified 58 children potentially trafficked from Vietnam to the UK over the 12 month period of the study, 37 of whom were exploited in cannabis farms, with a number being exploited in brothels, nail bars and for street crimes.  6.3  The most recent Strategic Threat Assessment produced by the National Crime Agency (NCA) published in December 2015 reported on activity for the calendar year 2014. It noted the following significant issues;                                                                   15National Crime Agency Strategic Threat Analysis (2016) 16The Trafficking of Women and Children from Vietnam (CEOP 2011)  24   6.4  Vietnam was the eighth most prevalent country of origin for all victims of trafficking (adults and children) with an increase of 18% from the 2013. Vietnamese children represented the second most prevalent group (13%) after UK children (16%). The most common type of exploitation for girls was sexual exploitation (49%) where boys were mainly exploited for criminal exploitation (35%). 21 % of potential child victims of criminal exploitation were trafficked for cannabis cultivation, of whom 86% were Vietnamese.  6.5  The most recent analysis of referrals of potential victims of human trafficking made via the National Referral Mechanism for the calendar year of 2016 identified Vietnam as the second most prevalent country of origin after Albania for all referrals, an increase of 8.6% from the previous year.    Referrals of children were reduced from the previous year, 2013, by 8.5% but Vietnamese children represented the second most prevalent group along with children from Albania.17  6.6  The 2010 Child Exploitation and Online Protection Centre (CEOP) Strategic Threat Analysis highlighted the fact that the first leg of the trafficking route for many children trafficked into the UK was to fly from Vietnam into Russia. According to information supplied by the Russian Embassy, Russia issues approximately 50,000 visas to Vietnamese citizens every year. There are no Russian immigration staff based in Vietnam, and officers issue visas, for the most part without referral and with few, if any, checks. The report noted that there appear to be few barriers to trafficking networks moving victims into and through Russia.18The report noted that “The trafficking of Vietnamese children into and within the UK is the largest and most significant trend  ... Most victims are trafficked overland from Vietnam by lorry and enter the UK by clandestine methods via seaport. The criminal networks involved in the recruitment, transportation and exploitation of children are well organised, flexible and generate large finances, mainly from the cultivation and wholesale distribution of cannabis.”19   The Local Context 6.7  Within the West Midlands region in 2016, Vietnam was the sixth most prevalent country of origin of trafficked children20  6.8  For the period 2015-16, the West Midlands region had 370 unaccompanied asylum seekers, which represented the fourth highest region in England 21                                                                  17Modern Slavery Human Trafficking Statistics(National Referral Mechanism), August 2017,National Crime Agency  18 Child Exploitation and Online Protection Centre, Strategic Threat Analysis ;Child Trafficking in the UK(2010) 19 Child Exploitation and Online Protection Centre, Strategic Threat Analysis ;Child Trafficking in the UK(2010)P23 20 National Crime Agency Strategic Threat Analysis (2016) 21 Unaccompanied Asylum Seekers and Refugee Children ;Safeguarding Pressures(Association of Directors of Children’s Services November 2016)  25   6.9  At the time of Child C being received into the care of Shropshire Children’s Services, they were inexperienced in the care of young people who presented as unaccompanied asylum seeking children. Child C was their fourth such young person in two years and the second young person from Vietnam who had been in their care. Since 2016 the numbers have significantly increased, along with their experience in caring for young people from Vietnam. It is reported that their awareness of specific vulnerabilities and risks for young people who arrive unaccompanied in the UK from Vietnam has increased and that they have now implemented a range of strategies and services in place to keep this particular group of young people safe, as well as regularly liaising with other Local Authorities who have high numbers of trafficked young people to share best practice.  7.  Analysis of Terms of Reference  In addition to the Key Practice Episodes, a number of specific questions have been formulated in order to identify the learning from this review.  7.1  Were the Care Planning Arrangements for Child C appropriate? 7.1.1  The Children Act (1989) Guidance Volume 2 states that “Robust assessment underpins the effectiveness of all subsequent actions and interventions and is essential to ensure improved outcomes for children.”  7.1.2  In view of the fact that Child C went missing from his placement five days after being placed in foster care, there was insufficient time for a comprehensive assessment to be undertaken.  7.1.3  Although several risk factors were identified, these factors are not linked to provide an evaluation of the likelihood that together, they constitute a risk that Child C was trafficked into the country, nor is there any evaluation of the likelihood of his going missing or continuing to be under the influence of traffickers once he had been accommodated  7.1.4  The assessment was not completed until 2 August 2016 and was therefore well outside the required timescale of 45 days. It was not signed off by the manager until 29 September 2016, almost two months after its completion.          There is insufficient evidence of management oversight and challenge to the recommendation regarding the change in looked after child status. There is no evidence of any management analysis of the assessment or interpretation of Child C’s statements or behaviours as described in the assessment report.   26          Neither the social worker nor the manager made reference to the Modern Slavery Act (2014) nor to the possible need to make a referral to the National Referral Mechanism (NRM) in the event of Child C being found.  7.1.5  The assessment of Child C was insufficiently robust with regard to the risk factors associated with trafficking and absconding, was not timely and was not subject to adequate management scrutiny.  7.2  Was consideration given within the assessment to the possibility that Child C may have been trafficked? Were agencies aware of the issues and risks associated with unaccompanied asylum seekers? 7.2.1  These terms of reference are linked and will be considered together.  7.2.2  At the time of Child C’s arrival in Shropshire, consideration was given to the possibility that he may have been trafficked and it was concluded that this may have been the case. However, a lack of experience and training in the needs of trafficked young people meant that his social media contacts were not   subject to evaluation by the Local Authority, there was no contingency plan in place in the event of his going missing soon after placement and the social worker from the EDT did not accompany the police officer and Child C to the foster carer placement.   Although the foster carers checked his social media, information gleaned from his digital activity was not used by Children’s Services to inform their risk assessment.   7.2.3  Child C arrived in Shropshire via what has become known as a ‘lorry drop’, an illegal means of transporting immigrants into the UK via goods vehicles. At the time of his arrival, West Mercia and Warwickshire Police had not implemented its current Clandestine Entry Procedure which includes guidance to the effect that a) Every clandestine entrant has the potential to be a victim of modern slavery or human trafficking; b) Every driver has the potential to be in involved in human trafficking or modern slavery; c) Every ‘lorry drop’ should be treated as a potential crime and a proportionate level of investigation completed.  7.2.4  At the time of Child C’s arrival, officers from West Mercia Police responded to calls from members of the public and regarded their primary role as to locate and detain anyone who was considered to have entered the country illegally and to take them to the nearest custody unit where their identity and status could be verified by UK Immigration and Visas  As a result, no   immediate enquiries were made in respect of Child C’s mobile phone, or the photographs or route that were in his possession on being admitted to custody.  7.2.5  Although reference is made to the risk of emotional abuse, other potential risk factors such as physical abuse, sexual abuse, labour exploitation and criminal exploitation are not identified.  27   7.2.6  The assessment of risk was too narrowly focused on the categories of abuse as defined for purposes of instigating S47 enquiries and child protection plans and did not take account of the wider risk factors to which a young man who may have been trafficked such as;  • The inconsistencies in his story as to how he arrived in the UK • The manner of his arrival in Shropshire • His reference to being allegedly kidnapped in Moscow • His use of social media  • His apparent links to Calais  • The fact that he went missing soon after being placed in foster care • The length of his remaining a missing person  7.2.7   This review has concluded that conventional strategy meeting agendas and categories, whilst consistent with Working Together to Safeguard Children (2015) are not appropriate in the case of children who remain missing for a long period who may have trafficked and who are at risk of remaining under the influence of traffickers.  7.2.8  The categories of risk and abuse used in child protection strategy meetings and the thresholds with regard to the instigation of S47 enquiries are applicable to children at risk who are living in their own homes or in establishments but do not always apply to the combination of risks for trafficked children or for those who may have been trafficked.         This review includes a recommendation to HM Government that a dedicated risk assessment and strategy system be devised for such children.  7.3  Were appropriate measures put in place to mitigate any risks?  7.3.1  Safeguarding Children Who May Have Been Trafficked requires the local authority to assess the child’s needs in accordance with the same domains as any other looked after child but also requires them to establish relevant information about the child’s background, including understanding the reasons the child has come to the UK, to assess the child’s vulnerability to the continuing influence or control of his or her traffickers and the risks that they will go missing. It goes on to state that responding to this information ensures that the care plan includes a risk assessment setting out how the local authority intends to safeguard the young person so that, as far as possible, they can be protected from any trafficker to minimise any risk of traffickers being able to re-involve a child in exploitative activities. This plan should include contingency plans to be followed if the young person goes missing.22  7.3.2  This was not carried out in the Case of Child C due to the emergency nature of his admission to care and the short period that he was in placement before he went missing.                                                                  22 Safeguarding Children Who May Have Been Trafficked(DfE and Home Office ,2011) p30  28  Nevertheless, the risk of his being under the influence of traffickers was not cited and no contingency plan was put in place.  7.4  Were suitable measures taken to locate Child C after he had been reported as missing?   7.4.1  A series of measures were taken to locate Child C, such as enquiries at locations which he had been known to have frequented, a press release, checks with hospitals and the release of photographs   7.4.2  The missing person enquiry was conducted in accordance with force and national policy. Lines of enquiry were pursued and officers from West Mercia joined colleagues from the West Midlands in visiting locations that Child C was known to be frequenting.   However, no attempts were made by any agency to contact the authorities in Vietnam to ascertain information or to seek to verify Child C’s account of his family history or how he had arrived in the UK. Agencies did not demonstrate sufficient professional scepticism regarding these matters.  7.5  Was information effectively shared between agencies? 7.5.1  Interagency coordination and communication have been well-documented as having the potential to enhance or undermine child protection case management, and the decisions professionals make.23 Collaboration between agencies, however, is highly complex and involves interpersonal, inter-professional and inter-organisational dimensions, such as different levels of accountability and decision making.   7.5.2  Strategy meeting minutes indicate a reasonable level of information sharing between the local authority and the police, but no representatives from the health service were invited as they should have been, in accordance with Working Together (2015). This review has also concluded that a key issue-the allegation made by Child C to the social worker that he had been kidnapped in Russia – was not shared with the police in a timely manner and nor was it followed up with regard to enquiries with the authorities in Russia.  7.5.3  The police were not informed of Child C’s disclosure to the local authority that he had allegedly been kidnapped via Russia until the second strategy meeting and this meeting did not consider whether a referral should have been made via the National Referral Mechanism to the UK Human Trafficking Centre. In addition, no arrangements were made between the local authority and the police to secure a copy of Child C’s statement to the social worker for police records.                                                                  23 Morrison, T. (1998). Inter-agency collaboration and change: Effects of inter-agency behaviour on management of risk and prognosis for change in dangerous family situations. Paper presented at the Twelfth International ISPCAN Congress on Child Abuse and Neglect, ‘Protecting Children: Innovation and Inspiration’, Auckland, New Zealand, September 6-9, 1998.  29   7.5.4  The minutes of the second strategy meeting held on 8 June 2016 were not attached to the police record and the information it contained was not disseminated on Child C’s police missing person’s case management record.  7.5.5  This review has concluded that communication and information sharing between agencies was insufficiently effective with regard to the conduct, composition and recording of strategy meetings and the sharing of information between Children’s Services and the police.  7.6  Did strategy meetings and reviews effectively assess the risks?  7.6.1  When he had been reported as missing, Child C was assessed as medium risk in accordance with the Police National Compact System which defines a person as being at medium risk if the risk posed is likely to place themselves in danger or they are a threat to themselves or other people. This review has concluded that this assessment of risk was accurate given the information available at the time.  7.6.2  Agencies also assessed risk in accordance with the categories in Working Together (2015), and the primary risk to Child C was identified as emotional, but the evidence indicated a broader category of risk in view of  his presentation as an unaccompanied asylum seeker and the possibility of his being trafficked. These broader risk categories were not considered at any of the strategy meetings and this indicates that the classifications in current statutory guidance do not always lend themselves to enabling agencies to consider the risks associated with young people who may have been trafficked.  7.6.3  The fact that Child C had remained missing for a long period of time should have resulted in a heightened level of risk analysis rather than a reduction and the subsequent alterations in his status.  7.6.4  This review has concluded that any alteration in internal agencies’ risk categories should be subject to inter-agency discussion and scrutiny and that agencies should consider the implications of any such decisions for multi-agency working.  7.7  Did Child C’s status have an impact on efforts to locate him?  7.7.1  Child C’s status was altered from that of a Looked After Child to that of a Child in Need by Children’s Services and from active to inactive and from medium risk to low risk by West Midlands Police    30  7.7.2  The police decision concerning Child C´s missing status was one of several factors  that contributed to the decision of Children´s Services to alter his status to that of a Child in Need  7.7.3  Whilst it is not possible to determine whether these decisions impacted on efforts to locate him, they indicate a lack of priority accorded to him by the respective agencies.   7.8  Was sufficient consideration given to Child C‘s status, cultural and linguistic needs?  7.8.1  Child C came from the Socialist Republic of Vietnam and claimed that he had travelled from Vietnam to Moscow and from Moscow to Shropshire.   7.8.2  Appropriate measures were taken to obtain interpreters to enable police interviews and the social work assessment   7.8.3  Child C was placed with white British foster carers who had received some training in equal opportunities some six years previously, but they had not received training in caring for children from specific backgrounds and there was insufficient time for them or the social worker to explore with Child C his specific cultural, linguistic, dietary or religious needs prior to his going missing.  7.8.4  This review has concluded that some consideration was given to Child C’s needs in the limited time that was available to agencies, but that the foster carers had not received appropriate, specific and up to date training to enable them to care for a child from Child C’s background.   7.9  How appropriate did agencies use terminology and to what extent did this impact on their decision making? 7.9.1  Terminology is defined in the Oxford English Dictionary as the set of technical words or expressions used in a particular subject.  7.9.2  Child C was variously described as an illegal immigrant, an unaccompanied asylum seeking child and a child who may have been the victim of trafficking.  7.9.3  Illegal immigration is the migration of people across national borders in a way that violates the immigration laws of the destination country.  Immigration, including illegal immigration, is usually from a poorer to a richer country.  7.9.4  Child trafficking is defined as the “recruitment, transportation, transfer, harbouring or receipt” of a child for the purpose of exploitation. The internationally accepted definition of human trafficking comes from the Protocol to Prevent, Suppress and Punish Trafficking  31  in Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime (2000, ‘Palermo Protocol’), which the UK ratified in February 2006.  7.9.5  The United Nations Convention on the Rights of the Child defines an unaccompanied child as a “child who has been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so”.24  7.9.6  Each of these terms was used in regard to Child C and there is often an overlap between them. However, the links are complex and it is important not to conflate them. For example, trafficked children are not always unaccompanied and they may not always claim asylum; they may be European Union or British nationals and, therefore, not be subject to immigration control. Conversely, not all unaccompanied children are victims of trafficking, although being unaccompanied significantly increases their vulnerability to exploitation. At times, Child C was referred to as an unaccompanied asylum seeker rather than as a young person who had presented as such.   7.9.7  This review has concluded that agencies did not always use terminology appropriately and lacked sufficient awareness to identify the complex inter-relationships between the terms. There is no evidence to indicate that the use of terminology per se had an impact on decision making but staff at all levels would benefit from increased awareness as to how to use the terms with precision and with appropriate linkages so as to ensure early identification of risk.  7.10  Was practice in line with current policies and procedures? Were they effective in addressing the issues?  7.10.1  During the period of the review, the key local policies in place were local adaptations of national guidance, namely Safeguarding Children Who May Be Trafficked and Safeguarding Children from Abroad.25  7.10.2  Safeguarding Children Who May Be Trafficked sets out additional child protection measures that may be required in the case of actual or potentially trafficked children, and stresses the need for robust assessment and strategy meetings to decide whether to instigate S47 enquiries. Strategy meetings were held in respect of Child C after he had gone missing and their focus was on enquiries as to his whereabouts.                                                                   24 UNICEF (1989) 25 Safeguarding Children who May  Have Been be Trafficked (DfE and Home Office) ) 2011 and Safeguarding Children from Abroad(DfE)    32  7.10.3  Safeguarding Children Who May Be Trafficked also includes guidance on the management of missing children and, in the case of Looked after Children who go missing, it directs the reader to the West Mercia Joint Protocol for Missing Children and Young People.  7.10.4  Safeguarding Children from Abroad also refers to the need to seek information from other countries, but no enquiries were made with the authorities in Russia or in Vietnam at the time of Child C’s arrival.  7.10.5  The West Mercia Joint Protocol for Missing Children and Young People was in operation. This specifies that a Risk Assessment must be completed prior to placement, but this was not possible in the case of Child C because he had been admitted on an unplanned basis due to the circumstances of his arrival in Shropshire.  7.10.6  The two guidance documents that were in place set out the policies and procedures to be adopted in respect of safeguarding children who may be trafficked and safeguarding children from outside the UK ,and include procedural guidance. This guidance was incorporated into local policies and procedures with cross referencing to other local procedures, but it would have been clearer if they had been more specifically customised as local documents that set out the steps to be taken by practitioners in Shropshire. For example, the guidance concerning enquiries from abroad would have benefitted from a procedure outlining timescales and agency responsibility for this action.   7.10.7  Statutory Guidance on Children Who Run Away or Go Missing 26 includes a section on children who may have been trafficked from abroad. This states that “Some looked after children are unaccompanied asylum seeking children or other migrant children. Some of this group may have been trafficked into the UK and may remain under the influence of their traffickers even while they are looked after. Trafficked children are at high risk of going missing, with most going missing within one week of becoming looked after and many within 48 hours. Unaccompanied migrant or asylum seeking children who go missing immediately after becoming looked after should be treated as potential victims of trafficking”. It goes on to stress the need for an immediate assessment and for the local authority to work in close conjunction with the UK Human Trafficking Centre and immigration staff.          This review has concluded that this guidance was insufficiently adhered to in the case of Child C.  Local agencies did not liaise with central government agencies appropriately and did not recognise the possibility of Child C being under the continued influence of traffickers.  8.  Informing local and national policy and procedure Does any learning from this case need to inform local policy and procedure and need to be communicated nationally?                                                                  26 Statutory guidance on Children who Run Away or Go Missing(DfE 2014)  33  8.1  It is apparent that local policies and procedures on trafficking and missing children in place during the period of this review were based on national guidance. However, local safeguarding boards should customise such national guidance to local need and clearly distinguish between policy and specific procedural steps for agencies to follow.  8.2  In addition, this review has concluded that the use of strategy meetings and S47 enquiries in accordance with Working Together (2015) has limitations and is not appropriate when applied to children who may be trafficked and children who remain missing for a long period of time. Although they may be subject to emotional, physical or sexual abuse and neglect, it is also necessary for agencies to consider the additional categories of labour exploitation, criminal exploitation, sexual exploitation, organ harvesting, domestic servitude and benefit fraud in strategy meetings and risk assessments.   8.3  The Police Missing Person investigation was conducted in accordance with national and force policy using standard risk management categories.   8.4  This review has concluded that consideration should be given to the inclusion of indicators of trafficking to enhance risk assessments in cases in which it is suspected that a young person may have been trafficked. In addition, it recommends that there should be joint guidance for Local Authorities and police services that incorporates guidance on age assessment, risk assessments of missing people and children at risk of trafficking.  9  Conclusions and themes 9.1  This review has concluded that it is highly unlikely that the tragic and untimely death of Child C could have been foreseen by the agencies with whom he had contact.   It has demonstrated that the way in which agencies managed the case has provided an opportunity to learn a number of significant lessons as to how they may improve practice and better improve their services to young people such as Child C in the future.  9.2  The following key themes have emerged from the review;  • The level of awareness of agencies about  the implications of indicators of child trafficking and the associated risks  • The process of initial assessment of young people who present as unaccompanied asylum seekers.  • The assessment of risk in cases in which children remain missing for a long time   • The use of terminology    34  • The appropriateness of current risk categories  in  statutory guidance  to young people who may have been trafficked   • Inter-agency communication   9.3  It is apparent that, at the time of their contact with Child C, agencies did not have sufficient awareness or experience of child trafficking to fully evaluate the various indicators or to fully evaluate the risks at the outset. The fact that he had arrived on a ‘lorry drop’, that he maintained that he had arrived via Moscow after an alleged kidnapping and was claiming to be a juvenile did not alert professionals to the prospect that he may have been trafficked or that he may have been coached to provide information that would result in his being admitted to care. The Children’s Services assessment was not completed in a timely manner and nor was it subject to sufficient scrutiny and management oversight. Staff were not trained in age determination and therefore relied too heavily on Child C’s physical appearance. Child C’s admission to care should have been undertaken by a social worker rather than a police officer. It is clearly the responsibility of the local authority to receive children into care and also to provide assurance and information to the young person during the process.  9.4    The guidance in use at the time, Assessing Age 27 has since been updated to take account of case law and the following is now required in undertaking age assessments;  • The assessment must be carried out by two  trained social workers in cases where whether the claimant is an adult or a child is objectively borderline and therefore a more in-depth assessment of their age is necessary   • An interpreter must be provided if this is necessary    •  The individual must be offered the opportunity to have an independent appropriate adult present   •  Local authorities must comply with their own guidance when carrying out the assessment  •  If the circumstances of the case are such that the individual is being reassessed (for example, they are undergoing a second age assessment), it is preferable for those who undertook the first assessment not to take part in the second                                                                    27 Assessing Age, Home Office(June 2011), updated in February 2017    35  • Except in clear cases (where it is obvious that a person is under or over 18 and there is normally no need for prolonged inquiry), those who are assessing age cannot determine age solely on the basis of the appearance of the claimant  9.5  As the length of time in which he had been missing increased, agencies reduced the risk level. They did not consider the possibility that the long period in which he had remained as missing may have represented an increased risk due to the possibility of his remaining under the influence of traffickers. This possibility –along with a consideration of other reasons for his long period of remaining missing-should have been subject to inter-agency consideration   9.6  Child C was referred to, inter alia, as an unaccompanied asylum seeker and a potentially trafficked child without a clear appreciation of these terms, or of the possible links between a young people who claimed to be an asylum seeker but who may have been doing so at the behest of traffickers.  9.7  Written communication such as strategy meeting minutes were insufficiently accurate and were not subject to quality assurance.  9.8  This review has also concluded that agencies were constrained by the statutory guidance contained in Working Together to Safeguard Children (2015) which is not designed to assess the risk and take measures for children who present as unaccompanied asylum seekers and who may have been trafficked  9.9  During the period covered by the review, agencies lacked sufficient experience in the issues associated with trafficking. As a result, professionals did not recognise three linked risks; the likelihood that a young person presenting as an unaccompanied asylum seeker may have been trafficked and the subsequent probability of their remaining under the influence of traffickers, resulting in a strong risk of absconding soon after placement in care  10.  Good practice   10.1  Whist it has not been possible to identify any elements of practice above expected standards during the period covered by this review, it is apparent that all agencies have been open to learning lessons , have engaged fully in the process of the review and have implemented some changes to policy and practice since the events covered by this review.   11.  Lessons learned 11.1  This review has identified a number of issues concerning agencies’ awareness of the indicators of trafficking and associated risks, their assessment of young people who present as unaccompanied asylum seekers, the management of risk in cases where  36  children remain missing for a long time and the impact of a child’s status on how they are managed and reviewed.  11.2  Examples of improved practice include the following; photographs are now taken of all young people on admission to care, an emergency response plan is now in place to be implemented in the event of a large number of unaccompanied young asylum seekers arriving at the same time, biometric and DNA tests have been undertaken in liaison with Immigration Compliance and Enforcement, weekly intelligence sharing meetings are being held with partners from West Mercia Police on children missing from care and contact has been made with relevant embassies to locate the families of these children.  11.3  Similarly, since the period of the review, West Mercia Police have implemented a new set of policies and procedures on Clandestine Entry into the UK and have trained staff in their application.  11.4  West Midlands Police have implemented a new policy and procedure for managing the transfer of missing person’s investigations. This includes an agreement between Duty Inspectors and an escalation procedure in the event of disagreement.         Where it is proposed to transfer responsibility for managing an investigation between police areas, the matter should be agreed between Duty Inspectors. Where an agreement cannot be reached, a Chief Inspector or Superintendent will speak to their counterpart and agree the transfer.   11.5  Shropshire Council Children´s Services have altered their systems to enable the Emergency Duty Team to add records and have improved the communication systems between the local teams and the Emergency duty Team to enable more effective care planning  11.6  Shropshire Council Children´s Services now maintain the looked after status of missing children who are unaccompanied asylum seekers and hold statutory reviews in accordance with national guidance  11.7  Shropshire Council Children´s Services now hold review strategy meetings at agreed intervals  12.  Recommendations  Agency report writers have made a number of single agency recommendations which are listed in Appendix 1. In addition, the Lead Reviewer has identified some further recommendations for HM Government, West Midlands Police and the Shropshire Safeguarding Children Board.     37  Recommendations for central government  1.  Consideration should be given to reviewing the guidance in Working Together to Safeguard Children(2018) and  Safeguarding Children who May be Trafficked (2011) to determine the suitability of the system of risk assessment, S47 enquiries and Child Protection Plans to children who are at risk of trafficking or who may have been trafficked. 2.   Children who go missing from care should retain their status as looked after children, should remain subject to the scrutiny of looked after children reviews and remain   the responsibility of the Council as Corporate Parent until the child reaches the age of 18.   3.  The Home Office, College of Policing and Association of Directors of Children’s Services should give consideration to the development of a national multi-agency procedure on age determination and age assessment, to include: • How common agreement with supporting rationale should be reached between a local authority and partner agencies where contrary evidence is gained through missing persons investigations, and  • There is no documentary or factual evidence to determine age and    • The Local Authority is unable to conduct a review of age assessment or determination because the subject is not available for such an assessment to take place.   Recommendations for West Midlands Police  1.       West Midlands Police should ensure that accurate records are maintained in relation to strategy meetings and that the detail of the meetings and any decisions is made available to the investigating officers and their supervisors / managers.  2.       West Midlands Police should inform partner agencies of any change to the risk levels, status or categorisations of missing children and should consider any information that partner agencies hold in making such a decision.   Recommendations for the Shropshire Safeguarding Children Board 1. Inter-agency guidance on children who present as unaccompanied asylum seekers and trafficked children should be more clearly customised for the region. It should include dedicated referral pathway and a set of procedures that establish a plan of action indicating the role of each agency.   38  2. A dedicated strategy meeting agenda and risk assessment tool in respect of children who remain missing for long periods should be devised, along with a policy as to the minimum frequency for such meetings.  3. Dedicated inter-agency training on the trafficking of children and adults should be commissioned so as to raise awareness of indicators of trafficking and how to take all necessary steps to safeguard children who are victims or potential victims. As a minimum, this should include general awareness training, risk assessments and case studies.  4. Agencies designated as first responders in accordance with the Modern Slavery Act(2015) should  develop a protocol to agree on the process and responsibility for referrals of victims and potential victims of trafficking in accordance with the National Referral Mechanism (NRM)28  5. The Board should assure itself that child protection strategy meeting minutes specify the rationale for the specific harm test and dates for the implementation of actions.                                                                       28 See National Referral Mechanism :Guidance for Child First Responders; Home Office 2016   39  Appendix 1; Recommendations from West Mercia Police    1. The alleged kidnapping and trafficking offences reported by Child C should be recorded on the Force Crime recording system and a referral made to the United Kingdom Human Trafficking Centre(now the Modern Day Slavery Trafficking Unit)  2. All the strategy meeting minutes relating to Child C should be attached to the Risk Management Plan  3. The Home Office Counting Rules for recorded crime and the associated Force Policy adequately caters for the recording of crime within West Mercia. In addition, Officers and Police Staff to be reminded in relation to the processes in place regarding the identification and recording of Human Trafficking and Modern Slavery investigations   Appendix 2 Recommendations from Shropshire Council; Children’s Services 1. The Emergency Duty Team should be able to add new records to the client information system, CareFirst   2. Children’s Services to undertake an audit of strategy meetings and their timeliness is to be tracked.   3. New agendas for strategy meetings are to be embedded  4. Refresh of policy and procedures for unaccompanied asylum seekers and young people from abroad   5. Continued roll out of the training for foster carers and workers on working with Unaccompanied Asylum Seeking Children  6. Children’s Services to commission training on Child Trafficking   7. Continue with planned development and support of the Unaccompanied Asylum Seekers Team  8. Emergency Duty Team workers to undertake age assessment training  9. Develop a template for initial visits with unaccompanied asylum seekers   10. All children and young people to be escorted to any new placement by a social worker   40  Additional Recommendations for Shropshire Council Children’s Services In addition to the recommendations above, the Serious Case Review author has added the following;   1. Foster carers should receive cultural awareness training that is regularly updated  so that they are familiar with the diverse needs of children in care    2. Foster carers should receive training in human trafficking and modern slavery with a specific emphasis on the risks of young people going missing from care   Appendix 3; Additional Information On 6 March 2017, Derbyshire Police informed the Shropshire Safeguarding Children Board that Child C was, in fact, an adult and that information received from the authorities in Vietnam indicate that his date of birth was 5 April 1995 which would make him 21 years old at the time of his death.   In retrospect, there are reasons to doubt the statements that Child C made about his early life. He claimed that he was born on 4 May 1999, that his parents had died in a road traffic accident when he was a small child, that he had been brought up by two uncles and his paternal grandmother, and left Quang Binh in April 2016 to go to Moscow on holiday, where he was kidnapped and taken to the UK on a lorry. Following his death, the police made contact with a person in Vietnam who is alleged to be his father. This man   e-mailed a photograph which, along with fingerprints, confirmed the identity of the deceased. Derbyshire Constabulary undertook an investigation into the circumstances leading to Child C´s death, concluding that there was no sign of third party involvement.  Wider coronial offences continue to be investigated.           41  Appendix 4; Definitions Migrant The International Organisation for Migration   defines a migrant as any person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involuntary; (3) what the causes for the movement are; or (4) what the length of the stay is.29 Asylum seeker An asylum seeker is a person who has claimed asylum under the United Nations  1951 Convention on the Status of Refugees on the grounds that if they are returned to their country of origin , they have a well-founded fear of persecution on account of race, religion, nationality, political belief or membership of a particular social group.30 Refugee A refugee defined as “ a person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it." 31 Absent  The National Police Chiefs’ Council (NPCC) definition of ‘absent’ is: “A person not at a place where they are expected or required to be and there is no apparent risk.” Absent cases are required to be monitored over certain periods of time with consideration given to escalating to an at-risk category if the level of risk increases. The interpretation of the definition differs across police forces, making it difficult to directly compare data. From March 2015, the ‘absent’ category was developed to include the term ‘no apparent risk’. Child  The United Nations Convention on the Rights of the Child (Article 1) defines a ‘child’ as a person below the age of 18. ‘Children’ therefore means ‘children and young people under the age of 18’ .Note that, where the person’s age is in doubt, they must be treated as a child unless, and until, a lawful age assessment shows the person to be an adult. Child Trafficking Child trafficking is defined as the “recruitment, transportation, transfer, harbouring or receipt” of a child for the purpose of exploitation. The internationally accepted definition of human trafficking comes from the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women                                                                  29 https://www.iom.int/who-is-a-migrant 30 UNHCR Convention and Protocol Relating to the Status of refugees(1951) 31 Ibid ; Section 1(A)  42  and Children, supplementing the United Nations Convention against Transnational Organized Crime (2000, ‘Palermo Protocol’), which the UK ratified in February 2006. Article 3 states:  “(a) ‘Trafficking in persons’ shall mean the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include,  at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs  “(b) The consent of a victim of trafficking in persons to the intended exploitation set forth in subparagraph (a) of this article shall be irrelevant where any of the means set forth in subparagraph (a) have been used “(c) The recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation shall be considered ‘trafficking in persons’ even if this does not involve any of the means set forth in subparagraph (a) of this article “(d) ‘Child’ shall mean any person under 18 years of age.” Missing The National Police Chiefs’ Council (NPCC) definition of missing is: “Anyone whose whereabouts cannot be established and where the circumstances are out of character to the context suggests the person may be subject of crime or at risk of harm to themselves or another.” Missing from care Missing from care refers to a looked-after child who is not at their placement or the place they are expected to be (e.g. school) and their whereabouts is not known.32 Unaccompanied asylum-seeking child (UASC)  The Department for Education’s Statutory guidance for local authorities on the care of unaccompanied migrant children and child victims of modern slavery defines an unaccompanied asylum-seeking child as a “child who is applying for asylum in their own right and is separated from both parents and is not being cared for by an adult who in law or by custom has responsibility to do so”33 Unaccompanied child  The United Nations Convention on the Rights of the Child defines an unaccompanied child as a “child who has been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so”.34                                                                  32 Statutory Guidance on children who run away or go missing from home or care(  DfE January 2014) 33 Statutory guidance on the care of unaccompanied migrant children and child victims of modern slavery (DfE November 2017) 34 UNICEF (1989) 