Life-changing injuries to a 17-year-old boy who was the victim of a shooting in March 2020. Daniel was a child in care at the time of the incident. Learning includes: where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child's safety or long term outcomes should be formally scrutinised by safeguarding partners; unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement; early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people. Recommendations include: safeguarding partnership should urge the Department of Education to to set out a strategy for how it intends to improve residential care for looked after children in England; explore how schools and academies can be supported and challenged, but also held to account, by partner agencies when there is evidence that school exclusions or non-attendance is placing, or would place, a vulnerable child at greater risk.
      
 Title:  Child safeguarding practice report: Daniel. LSCB: South Tees Safeguarding Children Partnership Author: South Tees Safeguarding Children Partnership Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission  CSPR/Daniel/FINAL REPORT/LR/May 2021               Child Safeguarding Practice Report  DANIEL      FINAL  17 May 2021    This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission  CSPR/Daniel/FINAL REPORT/LR/May 2021  Key   Family Pseudonyms Daniel    not his real name Daniels’ mother    DM Daniels’s father    DF Partner of mother   PDM Half sister of Daniel   HSE born to DDM  Maternal Grandmother  MGM Maternal Grandfather  MGF    Agencies involved and abbreviations  *Redcar and Cleveland  (R&C) Children’s Services  RCCS *Cleveland Police Complex Exploitation team  CPCE *Tees, Esk and Wear Valleys NHS Foundation Trust TEWV *South Tees Hospitals, NHS Foundation Trust  STHFT *Youth Offending Service     YOS *R&C Health Visiitng and School Nursing Service   SN *R&C Education Department  Vulnerable, Exploited, Missing, Trafficked   VEMT (Strategic Group) *VEMT Practitioners Group     VPG  Child and Adolescent  Mental Health Service  CAMHS Primary School      SCH1 *Secondary School     SCH2 Education Other Than At School; EOTAS   SCH3    Education provision     SCH4 Education Service Provider (Fairfeld )   ESP1  Drug and Alchol Service (CREST)     SP1  -    Support service for young people  (Junction)  SP2  -   Service (Care) Provider       SP3  Service (Care) Provider      SP4   Please note: :   The agencies  marked with *  were represented on the Review Team  The shaded text provides  brief comments  which are addressed in more detail later in the report  The text in boxes  provides brief details on current policy and practice in Redcar and Cleveland.   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   3  Contents   1. Child Safeguarding Practice Reviews  2. The approach used   3. Daniel as a young child  4. Daniel in the care of the local authority  5. The views of Daniel and his family  6.  Summary of Agency interventions   7. Key Lines of Enquiry  KLE1: To what extent was there a collective understanding of Daniel’s needs and vulnerabilities and the risks to which was exposed.  KLE2: To what extent were interventions and plans effective in meeting Daniel’s needs and keeping him safe?  KLE3: How did professionals manage and respond to Daniel’s refusal to engage with them and the services they offered? KLE4:  How well did agencies collaborate and work together? KLE5: To what extent were locally agreed pathways effective in providing support and protection to Daniel?   8. Appraisal of Practice and Safeguarding Systems   9. Concluding Comments    10. Summary of Learning Points  11. Recommendations            This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   4   This page is blankThis document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   5  Daniel   Daniel was a child in the care of Redcar and Cleveland Borough Council  when,  aged  17 years old,  he was  the victim of a shooting, believed to  have been made in retaliation for an assault committed by Daniel a few days earlier. Daniel  was taken to  hospital where,  as a result of his injuries,  his  left leg was amputated  below the knee.   Between  2016, when Daniel was accommodated by  the local authority and March 2020, when he sustained his life-changing injuries, interventions by key agencies were not able to keep Daniel safe; professionals struggled to engage Daniel  and he persistently rejected  services aimed at reducing the risks to which he was very clearly  exposed.            This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   61. Child Safeguarding Practice Reviews   1.1. A Child Safeguarding Practice Review (CSPR) is undertaken when a child dies or has been seriously harmed and there is cause for concern as to the way organisations worked together.1 The purpose of a CSPR, undertaken locally, is for agencies and individuals to learn lessons that improve the way, in which they work, both individually and collectively, to safeguard and promote the welfare of children. 1.2. Local safeguarding children partnerships have a responsibility to ensure that within 15 days of being notified about what has happened to a child, a local panel must hold a Rapid Review involving partner agencies: local authority, Police, Health, Education and Social Care. This review is to ascertain whether a CSPR is appropriate, or whether the case raises issues, which are complex or of national importance such that a national review is more appropriate. 1.3. South Tees Safeguarding Children Partnership  (STSCP) held a rapid review meeting in April 2020 and a decision was taken that the involvement of key agencies in at certain points in Daniel’s life should be subject to a CSPR. An independent reviewer was commissioned to lead the review which was to focus on agency interventions between June 2016 when Daniel he became a Looked After Child and July 2020 when he reached his 18th birthday. 2. The approach used   2.1. Following the appointment of the independent reviewer, the Business Manager for STSCP established a review team to support the review process. This team comprised of senior professionals, representing the agencies that had been involved with Daniel and family members. Their role   was to provide strategic information about their agencies’ involvement; to identify learning for their agency and to assist the independent reviewer’s understanding of agency involvement, what happened and why.  2.2. Members of the review team identified frontline practitioners and first line managers who had been in contact or had worked with Daniel and his family. These professionals were invited to contribute to three practitioner events so more detail could be provided about their involvement and help the review team understand how key decisions were made and why professionals acted as they did or why they might not have acted at all. Some practitioners also met with the independent reviewer on a one to one basis. Importantly, professionals were asked to consider what safeguarding systems were in place both locally and nationally which supported their practice or made it harder to do their job well.  2.3. In the early stages of the review, a timeline of agency interventions was collated to illustrate multi-agency activity and who knew what and when. Each member of the review team completed an Agency Learning Report, the aim of which was to provide a description and analysis of practice within their own agency and to identify where changes for improvement were needed or where system changes had already been put in place to improve practice. Additional information was accessed through scrutiny of various documents and agency records.                                                          1 Working Together to Safeguarding Children (2018) This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   72.4. Given the country was in the midst of the COVID 19 pandemic, throughout the review process, all meetings with key individuals and groups were conducted remotely using various communication platforms which allowed the review to continue, albeit at a much slower pace that was originally anticipated. 2.5. This report has been produced in consultation and collaboration with the review team. The independent reviewer had oversight of the process and identified areas to support multi-agency learning as well as offering commentary upon single agency practice. This report includes detailed findings from the review and includes recommendations agreed by the review team for consideration by STSCP.  3. Family Involvement  3.1. Daniel was contacted directly and indirectly on four occasions by the independent reviewer and offered opportunities to contribute to this review. MGM also agreed to pass on contact details but sadly, Daniel did not respond to any overtures aimed at trying to ensure his voice and lived experiences were reflected in this report.  3.2. Daniel’s parents were also contacted and invited to speak with the independent reviewer but they also did not respond and the review team was left to progress the review without their input.  3.3. The independent reviewer was however able to speak with MGM whose insights and reflections were immensely helpful and are referenced at various points throughout this report. MGM was grateful for the support she had received from services during what she described as tough times trying to keep her grandson safe. She continues to be in touch with Daniel. The review team extend their thanks to MGM for her contributions to the review process.  4. Daniel as a young child    Daniel’s  family and early years 4.1. According to agency records, Daniel’s parents were about 16 years old when he was born in 2002 and it would seem they did not provide him with a secure and nurturing base as he grew up; he was, the review team was told, never allowed to express himself verbally or emotionally and was frequently given messages by DM that he was a ‘bad person’ who would never achieve anything. The relationship between DM and DF ended when Daniel  was a young child and according to agency records, DF had intermittent contact with his son during his childhood years.  Daniel’s maternal grandmother (MGM) frequently stepped in to care for her grandson and continued to do so as he was growing up and throughout his teenage years.   4.2. There are some references in agency records, which suggest that the family were reluctant to share any detailed information about Daniel’s childhood history and there are also references in agency records linking both Daniel’s parents to drug misuse and that Daniel witnessed domestic violence in the home as he was growing up. DM appears to have struggled not only to cope with Daniel’s angry and challenging behaviours, as he grew older, but also to display any empathy or affection towards him, which according to professionals left Daniel with feelings of rejection and low self-esteem.   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   84.3. At some point, a partner of DM (PDM) moved in with the family and  Daniel’s half sister was born when Daniel was about 3 years old. According to agency records, PDM remained a significant adult  in Daniel’s life until his death in May 2019, from a drug-related overdose.  4.4. Primary school reports indicate that Daniel was a pupil who met all of his milestones and achieved well. He was reported to be generally a quiet child and followed school rules throughout his primary education, until Year 6 when he started to display some challenging behaviours. At the start of that school year, Daniel had only just turned 11 and was described by staff in SCH1 as being generally engaged and eager to please but, as the year progressed he was noted to becoming more disruptive, especially at unstructured times such as breaks and lunch breaks. However, school reports indicate that these behaviours were manageable and were never such as to warrant referrals to other agencies.   Daniel as a young adolescent  4.5. MGM recalls there were no significant worries about Daniel until he began secondary school in September 2013, when he had just turned 11 years old. As the school year progressed, concerns began to emerge about Daniel’s difficult behaviours at school and at home, which DM found difficult to manage. MGM recalls that at the time, SCH2 worked closely with the family to offer Daniel support, providing time-out and access to pastoral support. Daniel began to go missing from home around this time. 4.6. By the time Daniel was 12 years old, Daniel’s missing episodes and anti-social and offending behaviours had come to the attention of police and he was at risk of being excluded from school. The family sought help from Early Help services in April 2015 and targeted time limited intervention was provided to help Daniel manage his behaviour at school. Agency records suggest involvement of Early Help services ended when there was some improvement, although MGM recalls the intervention was largely ineffective and the family saw very little change. MGM was of the view that Daniel’s ‘real problems’ began when SCH2 became an Academy in September 2015 and he was permanently excluded, under ‘new’ behaviour management procedures, in March 2016. According to MGM, Daniel was transferred to EOTAS, a Pupil Referral Unit 2 but would not always attend as some young people from ‘rival gangs’ were also there.  4.7. In January 2016, DM contacted RCCS asking Daniel to be removed from her care because he was beyond parental control, going missing and was thought to be experimenting with drugs. Early Help services were again provided. Records suggest that Early Help professionals struggled to engage with Daniel or to sustain a positive or effective working relationship with DM, whose fractured relationship with Daniel continued. Daniel’s father at this time appears to have been an inconsistent and unpredictable presence in his son’s life. Daniel’s behaviour, described as aggressive and unpredictable at times, continued to cause concern for the family.                                                          2 Education Otherwise. Pupil Referral Unit (PRs) are PRUs types of school that caters for children who aren't able to attend a mainstream school. Pupils are often referred there if they need greater care and support than their school can provide.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   95. Daniel in the care of the local authority   5.1. In May 2016, just before his 14th birthday, Daniel was accommodated3 by the local authority on a s204 having allegedly been assaulted by DM, who told professionals she had been trying to restrain her son, who was beyond her control and she could no longer care for him. Records indicate that no other family members were able or willing to care for Daniel as they had all expressed concerns about his aggressive behaviours, use of drugs and involvement with local street gangs. Daniel was placed with foster carers, but went missing for several days soon after being placed and was then placed in a residential children’s home  (RCH) over 100 miles away from his hometown.  5.2. Agency records from RCH indicate that after a troubled start, Daniel made good progress; he accessed education and there were improvements in his behaviour, although Daniel refused to engage with CAMHS to help with his angry feelings. Daniel maintained contact with DM and MGM who visited usually every two weeks and as the placement progressed there were occasional overnight stays with his family. After several months, according to MGM, plans were made to move Daniel to a residential children’s home nearer to his hometown, MGM recalls this was a ‘halfway’ move back to live with DM. When this placement fell through, MGM described this yet another rejection for Daniel and remembers him being upset that he was not moving as planned. According to MGM, DM was not willing to ‘suddenly’ have Daniel returned to her care, so MGM agreed with social workers that Daniel could live with her. This decision apparently caused a deep rift between MGM and DM, which lasted for several months.  5.3. In June 2017, Daniel moved to live with MGM and she recalled that for a short period life was relatively calm until Daniel’s relationship with his girlfriend ended and he began to go missing again. It then became apparent that Daniel was in touch with ‘old’ contacts. According to records, Daniel became more aggressive towards MGM and other family members; his missing periods escalated and there was clear evidence that he was misusing substances and offending. Professionals also observed Daniel with various injuries at times and following arrests for various offences, he was found, on occasions, to be in possession of knives and had access to unexplained funds. Police records indicate that Daniel was tagged as being involved with local criminals groups. Daniel was not accessing any education provision. In January 2019, Daniel was charged with a number of offences to which he pleaded guilty. He was made subject to a 12 month Referral Order5 and was referred to YOS. 5.4. Daniel’s placement with MGM broke down in May 2019 when MGM again reported her concern about Daniel’s aggressive and volatile behaviours and said she could not keep him safe. MGM was also concerned for her own safety. There being no other residential placement available which could safely                                                        4 Section 20 of the Children Act 1989 sets out how a Local Authority can provide accommodation for a child within their area if that child is in need of it, due to the child being lost/abandoned or there is no person with parental responsibility for that child. 5 A referral order is an order available for young offenders who plead guilty to an offence whereby the young offender is referred to a panel of two trained community volunteers and a member of the youth offending team. It can be for a minimum of three months and a maximum of twelve months. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   10 accommodate him, Daniel, not yet 17, was moved into semi-independent accommodation with a support package which included access to staff support and supervision during the night. 5.5. In July 2019, Daniel was referred to the VEMT Practitioners Group (VPG)6 where he was assessed as being a ‘very high risk’ child. According to agency records, social workers and other professionals were still unable to engage with Daniel; he declined referrals to access support for his substance misuse, and resisted attempts by professionals to address the risks he posed to others and the risks to which he himself was continually exposed. Agency records refer to Daniel insisting that he was ‘in charge’ and that he ‘knew’ what he was doing.  Daniel, then experienced a further seven placement moves before March 2020, all of which were in response to the need to manage risks from known, and unnamed, individuals.  5.6. Daniel was suspected by police of being involved in a number of offences including assaults on others with weapons and firearms just prior to him being shot in March 2020. Daniel later described his shooting as ‘warning’ and following a threat to life 7 notice. He was consequently, safeguarded through the use of Deprivation of Liberty safeguards (DoLS) and was moved by social workers to a confidential location upon his discharge from hospital. These restrictions remained in place until his 18th birthday and were overseen by the High Court.  5.7. After Daniel was injured, he informed family members and his social workers that all he wanted was a ‘quiet life’, to repair his relationships with family members and live in safely in accommodation near them. Adult services were contacted and discussions were held with Daniel, DM, and MGM regarding what support would be provided and the gradual transition of support to adult services. However, once Daniel knew that rehabilitation services would be deferred due to COVID-19 and he did not have a date for this support to commence, he ‘shut down’ again and a ‘reachable moment’ was lost. His relationships with family members quickly deteriorated with only MGM maintaining contact.  5.8. Daniel’s behaviours escalated and he reportedly made threats to his care team staff and they eventually gave notice. This resulted in the LA commissioning a bespoke package of support from an organisation highly experienced at working with young people with complex needs. The risk management plan was extended to include external sanctions agreed by Court to restrict his liberties in terms of not having a mobile phone or use social media devices as the concerns were gang members were attempting to locate him.  5.9. Despite Daniel having limited access to phone and Internet services, he was able to re-establish contact with some associates and information came to light which suggested he was planning retaliation against his perpetrators. Daniel left the accommodation of his own accord and was picked up in a vehicle and driven away.  5.10. Daniel was transferred to Adult services in July 2020.                                                         6 The VEMT Practitioner Group (VPG) provides support for practitioners who work with children who are or believed to be ‘Vulnerable, Exploited, Missing or Trafficked ‘   7 Osman warnings are issued if police have intelligence of a real and immediate threat to the life of an individual.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   11 6. Summary of agency interventions   6.1. Agencies provided this information from their own records and chronologies and were asked to include any relevant background information which might help the review team understand some of Daniel’s past history.  Cleveland Police   6.2. Daniel first came to the attention of police in 2013, when he was 11 years old and was reported missing from home. Police records indicate that soon after this Daniel was linked to ‘anti-social behaviour’ and ‘low level’ criminal offences. At 13, police records refer to Daniel’s ongoing drug use, an increase in missing from home episodes and an escalation of offending behaviours, including violent offences. Daniel received a Youth Conditional Caution (YCC).8  In April 2016, for an offence of Criminal Damage and was referred to South Tees Youth Offending Services.  6.3. According to agency records, Daniel’s offending behaviours and missing episodes then increased steadily and significantly over a 2 year period and by the age of 15, police intelligence indicated he had links with known crime groups in his community. Police records also refer to Daniel not being willing to engage with professionals and using intimidation techniques with witnesses to ensure that prosecutions could not be followed through.   6.4. During the period under review, Daniel was involved in a number of police investigations including alleged stabbings, drug possession and criminal damage and was listed in police records at various times as being ‘wanted’ and a ‘person of interest’, rather than as a missing looked after child. Following the death of PDM in early 2019, Daniel was suspected of stabbing the individual who he believed had supplied the drugs, which led to PDM’s death.  6.5. The first police record of Daniel using a firearm was in December 2019. Three days prior to Daniel’s injury, he was involved in a firearms shooting but this information was not shared with Children’s Services. A threat to life notice was given to Daniel whilst he was in hospital but this information was also not shared with social workers as would be expected.  Comment: Intelligence about Daniel’s contacts and associates in the community and his links with known criminals in the area was not shared with safeguarding partners and this, together with him being viewed through the lens of an offender/suspect made plans for keeping Daniel safe less effective.  Youth Offending Service (YOS)  6.6. South Tees Youth Offending Service became involved with Daniel in April 2016. When Daniel was moved to PL1, his YCC was managed by the YOS in that area on behalf of STYOS. This was in line with usual practice and there is evidence of continued liaison between the services until Daniel returned to live with MGM.                                                        8 Children aged 10 – 17 years old can be given a Youth Conditional Caution if they admit a criminal offence. Youth conditional cautions are a caution with one or more conditions attached. If a child does not keep to the conditions they could be prosecuted for the original offence. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   12 6.7. STYOS became involve again in January 2019, when Daniel was sentenced to a 12 month Referral Order9for offences of Robbery and Possession of a Bladed Article. At the time of his initial assessment, YOS records indicate there was no concern that Daniel was a victim of exploitation or was involved in drug dealing activity. There were concerns however about the males, known to YOS, with whom he was spending his time but Daniel told YOS1 that he made his own decisions and was not influenced by others. According to agency records Daniel initially engaged well with YOS1 and complied with the requirements of his order. 6.8. Following further arrests for violent incidents, Daniel’s initial YOS assessment was reviewed and he was re-assessed at being at ‘High Risk of Serious Harm’ and ‘High Risk to his Safety and Wellbeing’. As a consequence, and in line with YOS case management guidance, responsibility for working with Daniel was, appropriately, transferred from YOS1, to YOS2, a more experienced case manager.  6.9. According to agency records, Daniel’s level of risk both to himself and to others significantly and steadily increased during 2019. In December 2019, YOS2 referred Daniel to MAPPA10 following police information that he had been involved in stabbings in the community. This referral was declined given there was already a ‘significant level of multi-agency involvement’ but this decision was challenged and following further arrests, YOS2 submitted a second referral over a week later. This time the referral was accepted and a meeting was scheduled for late January 2020.  6.10. Daniel at this point began to disengage from YOS and the requirements of his court order, he missed key appointments, and when contacts did happen, records suggest Daniel was often volatile and verbally aggressive. As Daniel was breaching his order, he was required to attend a court hearing in January 2020 but he failed to attend and a Warrant was issued for his arrest. Daniel was subsequently subject to bail supervision and support and was required to contact his YOS worker, 3 times per week, but at this point Daniel began to disengage with YOT2.  Comment: Daniel’s working relationship with his YOS worker appears to have worked at times. Analysing why this was the case would have been a useful topic for professionals to explore.  VEMT Practitioner Group (VPG) 6.11. The VPG is a multi-agency operational group in Redcar and Cleveland, which supports frontline practitioners who work with children and young people who may be at risk of exploitation or have been groomed and ‘captured’ through that process.   6.12. Daniel was first referred to VPG in July 2019. Records from the first VPG meeting in September 2019 note that Daniel had again begun to engage with YOS, his missing episodes were decreasing and risks appeared to be reducing. However by November 2019, minutes of the VPG meeting that month acknowledged that risks were ‘escalating rapidly’ and in December notes refer to Daniel not having a  ‘sufficient realisation’ of what he was involved in and that  ‘dealing drugs and stabbing people’ would                                                       9 A referral order is an order available for young offenders who plead guilty to an offence whereby the young offender is referred to a panel of two trained community volunteers and a member of the youth offending team. It can be for a minimum of three months and a maximum of twelve months. 10 MAPPA stands for Multi-Agency Public Protection Arrangements and is a process through which various agencies such as the Police, the Prison Service and Probation work together to protect the public by managing the risks posed by violent and sexual offenders living in the community  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   13 ‘have consequences’. Concerns were raised about Daniel’s safety and his involvement with different criminal groups and plans for the local authority to make an application for a secure accommodation order11 in late December 2019 were noted and supported. The application for this Order was however refused due to no secure placement being available.   6.13. Between January 2020 and March 2020, Daniel’s whereabouts been largely unknown. Intelligence linking Daniel to carrying and possession of knives and firearms, drug dealing, drug use and multiple feuds in several local areas were increasing. Following the second referral to MAPPA in December 2019, Daniel registered as ‘Very High Risk’. Notes from the VPG meeting around the same time, state ‘there are concerns that [Daniel] is involved in criminality; possession of weapons and drug dealing’, and he was ‘vulnerable to Child Criminal Exploitation’ so ‘multi-agency support’ would continue.  Comment: There needs to be clarity about what additionality the rating of ‘Very High Risk’ brings or can bring. Daniel was subject to VEMT and was registered as a very high-risk offender with MAPPA. Neither of these forums brought about any increase in safety for Daniel. Both forums have a high level of multi-agency input, but they did not have any impact on either securing placement stability for Daniel nor provide access to a secure bed, although they did ensure that the search for secure accommodation continued.  Education 6.14. Daniel moved from his primary school, SCH1 to a secondary school (SCH2) in September 2013, by which time SCH1 had already noticed a change in his behaviour and he began about that time to be known to police. In 2013/2014, an Ofsted inspection placed SCH2 in special measures12 and this resulted SCH2 becoming an Academy in September 2015. (ACD1)  6.15. The review team have not been able to access any records from SCH2 including any which provide detail of concerns about Daniel and how or if these were reported or managed at the time. It would appear that Daniel’s school attendance at SCH2 gradually and significantly declined during his first two years; arrangements for him to attend EOTAS, were unsuccessful as was the managed transfer to another mainstream school which, after two weeks, Daniel refused to attend, because rival gang members attended that school.  6.16. There are no records of Daniel’s time in EOTAS. It has not been possible to ascertain whether this is due to loss of records, ineffective recording systems or poor record keeping by staff. In October 2016, an investigation, not related to safeguarding, was instigated in relation to leadership and management of EOTAS and this resulted in a number of staff leaving their employment. It has therefore not been possible to follow up this line of enquiry with any staff.                                                         11 Secure accommodation orders are used in cases where a child or young person who is looked after by the local authority is assessed as needing to be accommodated in a placement, provided for the purpose of restricting their liberty 12 The term 'Special measures' is a term used by Ofsted following inspections and refers to the need for the school to receive additional, external support in order to secure required improvements.  12 Every child who is accommodated by the local authority and has a Care Plan must also have Personal Education Plan (PEP). This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   14 6.17. Personal Education Plan (PEP)13 for Daniel was completed by the Virtual School Head 14in early May 2018. The plan was discussed with professionals in order to progress the education offer being arranged in order to enable Daniel to access a level of education. MGM recalls that after Daniel had been placed with her in June 2017, she was told by a tutor that the education sessions he was delivering to Daniel each week were ending as he had been informed that Daniel was unlikely to pass his exams so the sessions were not required. This information is contained in LAC review minutes in October 2018.   Comment: The impact of exclusions and the increased risk they place on vulnerable young people are well documented. The risks for Daniel were not explored in multi-agency meetings. Daniel’s Education needs as a Looked after Child were neglected.  Redcar and Cleveland School Nursing and Health Visiting Service  6.18. Daniel was referred to the School Nursing service in July 2019. SN1 initially spoke with MGM who indicated that Daniel had no specific health needs. Although active in seeking information to support a looked after child health review, SN1 had no documented contact with Daniel.  Comment: Although there is evidence that concerns about Daniel were evident by the time he was referred to SN1, there should have been direct contact with Daniel rather than accepting an assurance from MGM that he had no specific health needs. Redcar and Cleveland Children’s Services: Early Help Services 6.19. Daniel first came to the attention of Redcar and Cleveland Children’s Services in April 2015 when he was 12 years old. According to agency records, an Early Years practitioner (EH1) undertook eight short sessions with Daniel, which were deemed successful as the threat of exclusion then diminished.  6.20. In January 2016, agency records indicate that DM again contacted children’s services to advise she was struggling with Daniel’s behaviour and considered him to be beyond parental control. By this time Daniel had been excluded from mainstream school and was meant to be attending EOTAS. Early Help services were again put in place and although records refer to limited engagement from DM or Daniel, there are no detailed accounts to indicate exactly what work was undertaken with the family.   6.21. Three separate referrals were received from police during March 2016 requesting a child and family assessment but decisions were taken to continue to work with the family through the provision of Early Help services. Daniel continued to go missing but records suggest that he and DM refused to engage in return (from missing) interviews and in April 2016, DM, is recorded as being unwilling to undertake any further work with Early Help, which she believed was ineffective.  Comment: Whilst the first intervention with Early Help may have been appropriate, the second request for help with Daniel should have led to Child and Family assessment. As concerns continued to be reported, CSC should have intervened much earlier.    Redcar and Cleveland Children’s Services:  Children’s Social Care                                                        14 Virtual school heads (VSHs) are in charge of promoting the educational achievement of all the children looked after by the local authority in which they work. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   15 6.22. Following another missing from home episode in May 2016, DM refused to allow her son to return to her care and Daniel was accommodated by the local authority under s20 15. A child and family assessment undertaken during this time highlighted concerns regarding Daniel’s welfare, there were concerns about his missing episodes and his involvement with criminal groups and peers known to CSC and police.  6.23. As no family members were able to care for Daniel, coming into care was considered the only option for him. Daniel was initially placed, with foster carers outside of Area1 but went missing. Believing him to be at risk within his community, Daniel and DM were accommodated in a Premier Inn for several days whilst another more suitable placement was found. Daniel was then 13 years old. Daniel was moved to a residential provision in Area2 where he remained for almost 12 months. Daniel made sufficiently good progress for key professionals to be optimistic about his return to live with MGM, where he stayed for almost two years.  6.24. In January 2018, Daniel was made subject to a Care Order s31 16 in response to escalating concerns by professionals and family members about Daniel’s safety, his involvement with known criminals, and his offending behaviours involving knives and weapons. LAC reviews and multi-agency meetings to progress Daniel’s care plans took place within required timescales. Daniel’s social worker was unable to engage Daniel to offer support and to discuss the risk to which he was exposed and how he could be kept safe.  6.25. In May 2019, just before his 17th birthday, Daniel was moved into semi-independent accommodation in response to family concerns about his violent and aggressive behaviours. From that point, concerns about Daniel and how to manage these were discussed with safeguarding partners almost on a weekly basis. Daniel appears to have stayed only for limited periods in the supported accommodation placements provided by the local authority, and for much of the time his whereabouts were unknown and he was frequently sought after by police. According to agency records, professionals could not engage with Daniel and he was particularly hostile and verbally aggressive to his social worker.  6.26. In December 2019, professionals concerns continue to increase when it became apparent that Daniel was not only using weapons but was also using firearms. The local authority made an application to the Court for a Secure Accommodation Order but whilst the threshold for this was met, the order could not be granted because a secure placement was not available anywhere in the UK at the time. The local authority continued to search for a secure placement up until, and after, the assault on Daniel in March 2020.  Comment: Daniel, unusually, moved from being a child in receipt of Early Help services to being accommodated, suggesting that statutory interventions should have happened much earlier. The challenges of finding secure accommodation for a 17 year old are well known; when the child concerned                                                       15 Section 20 of the Children Act 1989 sets out how a Local Authority can provide accommodation for a child within their area if that child is in need of it, due to the child being lost/abandoned or there is no person with parental responsibility for that child 16Section 31 of the Children Act 1989 – Care Order. The court can create a care order under Section 31(1) (a) of the Children Act, placing a child in the care of a designated local authority, with parental responsibility being shared between the parents and the local authority.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   16 is known to use weapons and firearms and is suspected of having links with OCGs, that challenge is even greater.  TEWV Child and Adolescent Mental Health Services (CAMHS) 17 6.27. Tees, Esk and Wear Valley (TEWV) CAMHS provides assessment and appropriate treatment or intervention for children and young people who are experiencing mental health problems up to their 18th birthday. Daniel was referred to CAMHS by his GP when he was around 11 years old following concerns by his mother about his aggressive and out of control behaviours at home and his pending school exclusion. According to agency records, Daniel was not taken to any of the appointments offered and was discharged from the service.  6.28. In early 2016, Daniel was referred on three occasions to CAMHS Liaison and Diversion team 18 in response to his offending behaviours. The initial screening processes following all three referrals established that Daniel did not have any mental health needs and no additional assessments were undertaken.  6.29. In early summer 2018, Daniel was referred by his social worker19 to the CAMHS LAC team as the placement with MGM was on the verge of breakdown. Daniel refused to engage but an initial consultation was carried out with MGM, which offered some insights into Daniel’s early life experiences. MGM shared with the independent reviewer that Daniel had experienced a number of rejections emerging from family relationships as he was growing up and this impacted upon his self -esteem and his need to ‘be recognised and belong’. Attempts to then meet with Daniel and DM were unsuccessful, so he was closed to the CAMHS LAC team.  6.30. Between November 2018 and February 2020, referrals continued to be made to the Liaison and Diversion team following further arrests. Although screened face to face, Daniel consistently refused assessments and any support offered. On each occasion there were no indications from mental health clinicians that Daniel suffered from any mental health condition. Following his injury, Daniel did consent to be seen by a Forensic Psychiatrist, which led to an assessment and recommendations for intervention, but Daniel did not wish to engage and no work was undertaken.  Comment: Daniel was clearly seen on several occasions by mental health practitioners, but notwithstanding his refusal to engage with any assessments, agency records state there were no indications of any identifiable mental health issues.   Clinical Commissioning Group (Primary Care)  6.31. Daniel attended only one GP appointment during the review period. Although medical records refer to Daniel’s ‘self-reported trauma and aggressive behaviours’, no further information was available.  South Tees Hospital NHS Foundation Trust (STSFT)                                                       17 Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV)  18 The Liaison and Diversion team offers assessment and advice for people who are in police custody and who may present with mental-ill health or other vulnerabilities.  19 At this point, Daniel was a Looked After Child (LAC) This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   17 6.32. STSFT had minimal contact with Daniel prior to him being shot in March 2020. In early December 2019, Daniel was taken to the hospital by police. Whilst attempting to evade officers, he jumped from the second floor of a building, he was brought back into the hospital and treated but was later discharged.  6.33. Daniel was taken to hospital when found by police with a gunshot wound and was later advised there was no possibility of saving his fractured leg. Daniel was noted, to be ‘devastated’, but nevertheless refused to cooperate with children’s services or police and offered no information about the shooting or the individuals involved.   7. Appraisal of practice and safeguarding systems   7.1. The purpose of CSPRs is to support improvements in safeguarding practice. This means it is not enough just to describe professional activity in a case or to identify elements of practice that were problematic without seeking to understand why they occurred. The analysis needs to explore what systems, if any, were in place to support professional activity and decision-making at key points in work with the family and what systems may have made it difficult for them to do so.  7.2. It is also important to be aware how much hindsight can distort judgement about the predictability of an adverse outcome. Once a serious incident to a child or young person is known it can become easy to look back and conclude that certain actions or the absence of these, were critical in leading to that outcome. The review team was mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and importantly, what systemic factors in place then, might still be impacting upon practice in Redcar and Cleveland in 2021.  7.3. The challenge of reviewing what happened to Daniel over a 4 year period is that, not only do organisational structures change during that time, so do safeguarding systems as they respond to emerging knowledge and evidence about the harms children can face and from whom. Agencies across the UK now understand much more about the risks that children and young people can face from peers and groups outside the influence or protection from their families and in response have begun to develop and embed services that address those risks.  7.4. Towards the end of the period under review, namely from 2019, Redcar and Cleveland had already begun to consider how they could develop services and different ways of working with children who were being criminally exploited, or who were suspected of being exploited by criminal groups outside of the family environment. Managing change in organisations is complex and very rarely straightforward, requiring review at key steps along the way and going back to adjust when there is evidence of any less than-intended results. The review team is aware than much has changed in Redcar and Cleveland since 2016 and developments are ongoing; the findings contained in this report nevertheless remain relevant.  7.5. The review team identified five lines of enquiry, which provided a framework around which the review team could appraise practice and safeguarding systems. The recommendations listed at the end of this report emerge from learning points discussed and debated within the review team and with key practitioners. The KLEs are listed below and an appraisal of practice under each key line of enquiry follows.   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   18 KLE1: How well did agency assessments contribute to a collective understanding of Daniel’s needs and vulnerabilities and the risks to which was exposed. KLE2: To what extent were interventions and plans effective in meeting Daniel’s needs and keeping him safe?  KLE3: How did professionals manage and respond to Daniel’s refusal to engage with them and the services they offered? KLE4:  How well did agencies collaborate and work together? KLE 5: To what extent were national and locally agreed pathways effective in keeping Daniel safe?   7.6. KLE1: To what extent was there a collective understanding of Daniel’s needs and vulnerabilities and the risks to which was exposed.   7.6.1. There is currently no straightforward way to clearly define vulnerable children. Adversity, risk, and vulnerability are terms that have a long and significant history in child protection. ‘Adversity’ is often defined as those life events and circumstances which can combine to threaten or challenge healthy development in children such as experience of abuse, neglect rejection; loss and bereavement, living with domestic abuse or with a parent or adult who misuses drugs and alcohol.  The term ‘risk’ denotes the chance of these adverse factors leading to actual negative outcomes for children whilst the concept of ‘vulnerability’ generally refers to the environmental or contextual factors that increase a child’s susceptibility to an adverse event. The importance of family history  7.6.2. Various agency reports refer to how quickly Daniel’s criminal activities and violent behaviours appear to have escalated between end of 2019 and March 2020. Viewing the chronology of agency interventions, there is some evidence to suggest that Daniel was struggling with anger, rejection, and isolation when he was as young as 11 and these factors, combined with continued unstable family relationships, may have made him more vulnerable to adverse influences outside of his family.  7.6.3. What emerges from documents seen by the independent reviewer is that some of the concerns about Daniel at the age of 13, going missing, drug use, offending behaviours and connections with individuals well-known to police and CSC, were the same concerns, albeit of a more serious nature, noted in agency records in 2020, as Daniel was approaching his 18th birthday. Whist, there were references in various agency records to Daniel’s ‘adverse childhood experiences’20, there was actually very little information contained in any agency assessments about Daniel’s childhood other than that provided by MGM and this left professionals with limited understanding about the extent of Daniel’s vulnerabilities. 7.6.4. At the point at which Daniel came to the attention of Early Help, expected practice would have been for a detailed assessment to determine Daniel’s needs and this should have included gathering                                                       20 Adverse childhood experiences range from experiences that directly harm a child (such as suffering physical, verbal or sexual abuse and physical or emotional neglect), to those that affect the environment in which a child grows up (including parental separation, domestic violence, mental illness, problematic alcohol or drug use, and a family member being in prison). This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   19 information about Daniel’s childhood and family experiences, but this information is not available on records seen by the review team. The assessment did not explore the impact of DF’s inconsistent involvement in his life, his attachment to DM, or her parental capacity to protect Daniel and in this respect it would have been difficult to understand Daniel’s lived experiences. Consequently, Daniel was perceived to be the problem and services were provided to address his behaviours.  7.6.5. Neither is there evidence of that a robust assessment was undertaken when the family were again provided with Early Help services in early 2016, when Daniel was 13 and DM requested that he be ‘taken into care’. Good assessments matter; they are key to effective intervention and to improving outcomes for children as significant decisions are made on the basis of these assessments which affect outcomes for children in both the short and the long term. 7.6.6. Whilst, agency records indicate that DM was resistant to working with EH1, and placed the responsibility for change on Daniel and the agencies supporting him, the implications of this for Daniel were not explored as well as they might have might been. Given the known concerns about Daniel and the risk of family breakdown, expected practice would have been for CSC to have undertaken a Child and Family Assessment in January but the focus remained on Daniel’s presenting behaviours and Early Help continued to try and engage Daniel and his family to little effect. There is no evidence that a referral was made by Early Help to CSC, highlighting concerns or the escalating risk of family breakdown and consequently Daniel’s pathway into becoming a looked after child in May 2016, bypassing the child in need and child protection processes was sudden, and not foreseen by Early Help professionals and their managers.   7.6.7. The Child and Family assessment undertaken in June 2016 when Daniel became a looked after child still did not explore Daniel’s family history and background in any detail and this left professionals focusing only on Daniel’s behaviour rather than exploring the family and environmental factors which may have contributed to it. The review team had a sense that Daniel was seen at that time as a troublesome adolescent rather than as a troubled child.   7.6.8. Daniel’s Care Plan outlined the changes that Daniel was expected to make and the support he would receive from social care, education health and youth justice professionals to help him in this task but there were no actions for DM or any family members. More might have been achieved with Daniel had professionals been more curious and sought to learn more about his early life and how the impact of any childhood experiences influenced and continued to influence the core beliefs he held about himself and the world around him. It is important that professionals explore these childhood experiences so they can ensure that work focuses not only on presenting issues but also addresses the visible and hidden complexities of any childhood traumas. Learning Point 1: The connection between the past, present and the likelihood of future risk for children is about understanding the patterns of problems and needs in families that require something to change. Unless assessments are robust in exploring a child’s history, their needs may not be as well understood as they could be and this may leave some children vulnerable.   Understanding complex behaviours in adolescents  7.6.9. Adolescence encompasses elements of biological growth and major social role transitions, both of which have changed significantly in the last few decades. The ‘adolescent’ period is now understood This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   20 to span ages 10 – 19 years, with the age 10- 13 years being commonly referred to as ‘early adolescence’.21 7.6.10. ‘Risk-taking is a normal part of adolescent development and most young people experiment with the increased opportunities for risk that their growing independence allows’22. For some young people, this includes experimenting with drugs and alcohol, testing out their independence or perhaps mixing with older peers who appear more ‘streetwise’ than them.  It is not known whether Daniel was testing out boundaries when his first missing periods began but MGM recalled that in her view Daniel was highly susceptible to influences outside his family and enjoyed being seen as part of a group or gang. MGM recalled that as a young adolescent, Daniel would have wanted to have to ‘fit in’ and could have been easily influenced by others.    7.6.11. Numerous serious case review reports have highlighted the importance of professionals in all agencies understanding the complex behaviour of adolescents and the notion of adolescent choice. There is wealth of information, which suggests that too often professionals assume that some of the risks encountered by adolescents are a result of choices that are ‘freely made, informed and adult-equivalent’.’ 23   Professionals can also compound misconceptions through their attitudes and inappropriate language, the phrase ‘lifestyle choice’ was common parlance a few years ago and sadly, there is still evidence of its use today highlighting that members of the general public and some professionals can hold views that the harms young people experience are self-determined and self-inflicted.  7.6.12. Research and practice experience now clearly demonstrates that the pathways leading to the harms that adolescents experience are complex, not least because they often appear to involve choices which are assumed to be rational and akin to adult decision-making.  Experimentation and impulsive behaviour are part of normal teenage experience and with support; most young people navigate these challenges and emerge as healthily functioning adults. However, the interaction of individual, family, and environmental factors can greatly increase a young person’s vulnerability to risk and the potentially adverse consequences of risk-taking.24  7.6.13. The review team was interested to note the occasional reference in records to Daniel needing to ‘understand the risks he was taking’ in ‘associating with inappropriate [people]’. Using this language was very probably not helpful as it presented a view that Daniel was indeed making deliberate rational choices about his behavior which, would change if he was indeed educated about the risks. Language provides a medium for describing perceptual experiences and views and therefore has an extraordinary capacity to influence the way professionals think and consequently the way they act.25  Hence the plans made for Daniel charged only him with the responsibility for changing his behavior.  7.6.14. Adolescence is a time of changing social relationships and there is a plethora of research, which highlights that peers become increasingly important to young people in a number of ways – as                                                       21 The World Health Organisation defines 'Adolescents' as individuals in the 10-19 years age group and 'Youth' as the 15-24 year age group.  22 Risk taking adolescents and child protection Research in Practice (2014) 23 That Difficult Age: Developing a more effective response to risks in adolescence. Research in Practice November 14 24 Risk -taking adolescents – A strategic briefing Research in Practice 2014 25 This is called the Sapir-Whorf hypothesis. ‘Language may indeed influence thought’ Jordan Slatev and Johann Blomberg. Phil Papers October 2015 This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   21 friends, protectors, confidants and consequently they have an enormous capacity to influence. Daniel’s contacts in the community were clearly important to him and became increasingly so as he grew older and sought to achieve status within those groups. Despite being helped to  ‘engage in more positive experiences’ and ‘understand the danger of mixing with certain peers,’ whatever it was that Daniel gained from these relationships, clearly significantly outweighed any perceived risks and known dangers.   7.6.15. The review team considered that at that time the extent to which Daniel was influenced by peer pressure was not well understood by professionals who at that time were of the view that Daniel could be supported and ‘educated’ from engaging in such ‘risky’ behaviours. The ‘risk-based’ terminology used to describe Daniel’s behaviours were not helpful as they initially implied that he was, even as a young adolescent, making unconstrained ‘choices’ when, in fact, his ‘choices’ and behaviours were underpinned by complex interacting developmental, social and psychological drivers, which professionals never got close enough to Daniel to explore in any depth.  7.6.16. There was a recognition that Daniel was significantly influenced by, and attracted to, the older peers and status-driven lifestyle he experienced outside his family but the nature of his ‘friendships’ and the links he had with groups of offending peers and adults were not built into assessments, so work focused primarily on Daniel and only to a very limited extent, on DM and MGM and their ability to keep him safe.   7.6.17. Although, some of the individuals with whom Daniel was associating were subject of interventions in their own right and actions were later taken to try and disrupt contact between them and Daniel, the plans formulated to keep Daniel safe were based on risks assumed to be in the family, i.e.   DM and MGM not able to keep Daniel safe keeping or with Daniel keeping himself safe, rather than with individuals in localities with whom he was spending most of his time.  7.6.18. There was no assessment or intervention in relation to Daniel’s self-harm and records do not refer to any triggers, which led to him cutting himself or for how long this behaviour continued. Daniel’s relationships with different females was concerning, so too was his violence and aggression within these relationships which was likely indicative of his own adverse childhood experiences where he was exposed to violence within the context of his mother’s relationships. Although Daniel became looked after in 2016, there is no evidence of work being undertaken to help him address any trauma or indeed no recognition that this work would be of any value. It was not until the CAMHS LAC assessment in 2018, that this work was considered. Daniel’s childhood experiences but Daniel’s   vulnerabilities to adverse influences outside his family were not recognised at that time.   Current Situation: STYOS has invested significantly in better understanding the Trauma Informed Pathway. This has been an area of development for the service since 2019.  7.6.19. Recent developments about understanding harms, which happen to children outside the family environment, have led to an approach developed at the University of Bedfordshire called Contextual Safeguarding. This approach attempts to address the contextual dynamics of peer to peer abuse by acknowledging the ‘weight of influence’ that different contexts have and suggests that professionals working in the field of child exploitation need to understand that for adolescents ‘peer influence appears to outweigh that of parents/carers in the escalation towards an abusive incident, and; risks This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   22 within extra-familial settings appeared to outweigh the relative safety within families when motivating young people’s actions’. 26  . 7.6.20. Local authorities in the UK have, over the past decade; developed responsive services to meet the needs of children who were being groomed and sexually exploited or who were at risk of becoming so.  By 2017, there were national calls for agencies to learn from the lessons of the past and develop services which acknowledged that children could not only be sexually exploited, they could also be criminally exploited (CCE) and pressured into committing crimes including transporting illegal drugs around the county, a practice known as County Lines.  7.6.21. Understanding CCE was, in 2018/2019 still emerging in agencies across the UK. The remit of the Tees wide VEMT arrangements in July 2019, had only just been extended to include consideration of children who were at risk of, or who were being, criminally exploited. Information-sharing and multi-agency arrangements for responding to concerns about CCE were for the most of the time under review not well established. Consequently, the very real risks to Daniel from outside influences beyond the family were not considered and the focus remained on helping Daniel adjust his behaviour and thinking and in so doing repair damaged family relationships.  Current Situation: RCCS is currently working with The Children’s Society and have set up a working group with nominated champions from early help, safeguarding, the review unit, children in care and health teams to focus on best practice working with children who have been sexually or criminally exploited. This work also involves collaboration with the regional National Crime Agency exploring agency responses to CCE and County lines activity.  Education: Exclusions and managed moves  7.6.22. Children excluded from school are often amongst the most vulnerable in our society. Any child can be at risk of exploitation but some vulnerabilities place children at greater risk, such as being excluded from school or being a looked after child, and Daniel was both of these. MGM expressed her views that Daniel’s exclusion from SCH 2, his transfer to EOTAS, A pupil Referral Unit, and then the attempted placement with another school at which young people from rival street gangs attended, significantly impacted on Daniel’s willingness and ability to engage with education.    7.6.23. According to research27, there is, despite the government’s cautioning against presuming links and causation, a ‘clear and near-universally acknowledged statistical link between exclusions and children and young people becoming involved in violent crime as either victim or perpetrator’’. To the review team it makes sense to presume that if children are missing from home, school or care, they are more, not less, likely to come across or be introduced to, individuals involved in criminal activities.  7.6.24. In its report ‘Back to School? Breaking the link between school exclusions and knife crime’ released in Autumn 2019, an All-Party Parliamentary Group on Knife Crime called for an end to part-time education for excluded pupils, and for mainstream schools to be more accountable for the children they exclude. Although CCE may not have been well understood when Daniel was permanently excluded from SCH2 in November 2015, the risks for children being out of school were well known and his exclusion should have prompted a Child and Family Assessment by CSC.                                                        26 Contextual Safeguarding. University of Bedfordshire November 2017 27 https://www.justforkidslaw.org This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   23 7.6.25. Education is a key area for consideration in social work assessments and where there are concerns about a child’s safety and welfare, any significant changes to a child’s education should be discussed and, where possible, agreed within a multi-agency setting. Although there are references to Daniel’s education in his Care Plans and in LAC reviews, the review team had a sense that Daniel’s education was ‘left’ to education professionals and plans and decisions around his education were not questioned. 7.6.26. Schools should be expected to take meaningful action to put in place support to keep a child in school where they can, and equally they should be supported to do so by meaningful partnership working with other services. Shaun Sawyer, national police lead for modern slavery and human trafficking (2020) writes ‘We are seeing more exploitation than before in modern times. For understandable reasons of austerity, state youth services have been vacated. This gap of youth provision between the school and family is the void that the exploiters are filling. Youth diversion services need to be hard wired in. Child criminal exploitation, it’s all about family, creating feelings of security, self-worth and power. This gap between the school gate and the front door is where the exploiters are attractive to youngsters.’  Learning Point 2: Where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child’s immediate safety or long-term outcomes, should be formally scrutinised by safeguarding partners so that decisions can be taken about the need to re-evaluate any risks to the child and/or escalate concerns.   KLE2: To what extent were interventions and services effective in meeting Daniel’s needs and keeping him safe?  Daniel’s placement in June 2016 7.6.27. The pathways to critical interventions for Daniel in 2016 were determined by concerns that neither DM nor any other family member was able to care for Daniel and keep him safe and he was at risk of significant harm. Daniel was therefore accommodated by the local authority and initially placed in a foster home. After a few days, agency records indicate that Daniel was reported missing, apparently after verbally and physically assaulting the foster carers. RCCS acted swiftly and provided DM and Daniel with hotel accommodation until another placement was found. It is not unknown how this placement impacted on DM and Daniel’s relationship or whether they did indeed end up staying there for almost a week. 7.6.28. The decision to accommodate Daniel in a placement (PL1) 100 miles from his hometown was based on an assessment, which indicated that his education and safety needs could best be met within an out-of- area residential setting with 24/7 supervision. Despite Daniel not wanting to be move from his family, he was placed in PL1 alongside one other young person. Whilst, this intervention removed Daniel from adverse influences in the community, it also reduced his contact with his family, but it did keep him safe. Contact with his family was maintained and was, it would seem, well supported and as the placement progressed.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   24 7.6.29. CSC records indicate that Daniel had support from PL1 including sessions about emotional regulation, drug misuse and anger management and that he had an assessment completed by the local CAMHS service which identified he needed additional support with anger management. However, there are conflicting reports in this respect, as according to PL1, Daniel refused to engage with CAMHS so no actual assessment was ever completed.  7.6.30. Daniel’s Care Plan, monitored through LAC reviews under Looked after Child procedures, clearly stated what was expected of him during his placement in PL1; Daniel was to work alongside youth offending and drug and alcohol services, engage with therapeutic services and his education and partake in leisure activities. There were, however no references in the plan as to what changes might be required of DM, DF and other family members and this left the onus only on Daniel to change his behaviours so he could return home. Living so far from home at 13 years old must have been difficult however ‘street-wise’ Daniel may have appeared, there is little in records or reports, which acknowledges this.  7.6.31. There is evidence that whilst Daniel was in PL1, social workers attempted to work with DM. This was good practice and although DM engaged in the early days of Daniel’s placement, as plans were made towards Daniel’s rehabilitation back home, records suggest that DM began to disengage with professionals who then struggled to make contact so plans could be progressed. The future risk and implications of this for Daniel and the rejection he might have felt, do not seem to have been well considered in part, professionals said, because MGM stepped forward to agree that Daniel could return to her care. This decision caused a rift in the family and meant that for some time after his return home, DM and MGM were not on speaking terms. This would have left MGM and Daniel isolated at a time when the need for wrap around family support was critical.   7.6.32. This decision to rehabilitate Daniel back to the care of his family was by virtue of a placement MGM. There were however some notable missing incidents when Daniel did not return to PL1 and this could have been an indication that more worrying patterns of behaviour were starting to re- emerge. When formulating the plan to return Daniel to MGM, the risk of Daniel re-establishing old contacts and reverting to previous patterns of behaviour was not assessed and he was in effect placed back into the same environment amid the same family tensions that had led him previously to being accommodated.  7.6.33. Daniel’s Care Plan focused from the outset on helping Daniel change his behaviours and ‘understand’ the risks to which he could be exposed if his behaviour did not change, but the plan did not, as would be expected, evolve during his time in PL1 and the wording and goals of his plan in June 2017 were almost identical to those captured in the LAC review on year later.  7.6.34. Making plans to support individuals and families is an essential component of social work activity. Like many plans seen elsewhere by the independent reviewer, Daniel’s plans contained goals to be achieved but did not contain the means by which progress could be measured, making difficult the task of monitoring progress and reviewing outcomes and, leaving professionals unable to easily identify what was working or not working, and why. In the plans seen by the review team, there were no references to any extra-familial harm to Daniel which, given what was known about his activities in the community, was a significant omission.    This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   25 7.6.35. There is a distinction in care planning between ‘goals’ and ‘objectives’, the former being continuous and longer term and the latter generally being more short-term and practical but still needing to evidence a credible link to the achievement of the longer-term goals. Daniel’s plans contained laudable goals, but without any functional, practical or SMART objectives, it was difficult to clearly identify exactly what had been achieved and what changes were evident to support Daniel’s return home to the care of his family.  Learning Point 3: Children’s plans should always include targets/objectives that are SMART, so work with families can be easily monitored and the effectiveness of key interventions and outcomes measured. Current Situation: RCCS have begun to utilise and embed the Signs of Safety approach and this will support improvements in practice especially in relation to drawing up plans for work with children and their families. Care should be taken however to ensure that plans for children include goals and objectives which are specific, measurable, achievable and realistic; without these, progress cannot be measured and work with children will be less effective.  Working with Parents 7.6.36. Developing a clear understanding of what is happening to a child within their family and community is vital to any assessment and the most usual and most effective way to achieve this is by engaging parents and children in that process, reaching a shared view of what needs to change, what support is needed, and jointly planning the next steps. A joint approach between families and practitioners is essential but there is no evidence of such a relationship between any professionals and DM or DF, although MGM was clearly   willing and motivated to do what was best for Daniel.  7.6.37. Professionals clearly found it difficult to engage with DM, and DF as he worked offshore and was therefore not always contactable. DM’s apparent resistance to fully engage with professionals should have prompted further exploration about to what extent DM was willing and motivated to do some things differently in Daniel’s best interests and how she might best be supported to do this. Whilst cooperation and partnership working is not possible in all cases and parents may respond to professional concerns with denial, resistance and outright hostility, the review team felt that MGM’s willingness to step forward and care for Daniel overshadowed the need for professionals to purse work with Daniel’s parents.   Learning Point 4: Unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement and this is likely to limit the effectiveness of any family work.   The Care Order 2018  7.6.38. A Child and Family assessment was undertaken just prior to Daniel’s return home. Again this was good practice, although there is little to evidence the assessment changes Daniel’s Care Plan. It did however highlight the progress that Daniel had made in PL1, and acknowledged DM’s negativity towards Daniel and that her resistance to working with professionals had significant implications for Daniel. It did not however lead to a change in Daniel’s Care Plan, address how MGM would be helped to prevent Daniel reverting to past behaviours or identified the need for a robust safety plan. The assessment carried a note of optimism, which was not tempered by managerial oversight or the This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   26 Independent Reviewing Officer (IRO). MGM was assessed28 and Daniel returned to live with her and a support package was put in place. The nature of this package was not clear to the review team. 7.6.39. However, the lack of engagement with MS, together with continued concerns about Daniel led CSC to seek legal advice and in January 2018, DM or DF made Daniel subject to a Care Order, which was not contested. This intervention was believed to be in Daniel’s best interest.  2018 - 2019 7.6.40. Between January 2018 and early 2019, Daniel had occasional contact with DM and DF but remained living with MGM. LAC reviews took place within expected timescales with each noting the same issues:  Daniel’s education supported through, what seems to be rather ad hoc arrangements, involving one to one tuition, Daniel’s continued drug use and missing episodes and Daniel’s continuing involvement in criminal activities. Records refer to Daniel consistently refusing to engage in any support or therapeutic services and MGM recalls that as time went by Daniel’s aggressive behaviours, occasional demands for money and involvement in what she described as ‘local gangs and turf wars ‘ escalated.   7.6.41. ‘Gangs’ is a broad term and it is important to recognise and not conflate, ‘street gangs’ operating in a locality and which seek to cause harm to others from different areas, with organised criminal [gangs] groups, referred to now as (OCGs) 29. It is not known exactly when Daniel’s involvement with street gangs  (social media sites confirmed his involvement in ‘turf wars’) shifted to an involvement with OCGs as information was not shared as might have been expected by police but by December 2019, there were evidence that Daniel was using firearms and was possibly offending to order.30 At this point, VPG sought to establish links between Daniel and OCGs in Area3.  Records suggest that professionals by this time were at a loss as to how to work with Daniel and keep him safe.   7.6.42. During this period, the review team was unable to determine exactly what pro-active interventions, if any, were in place to work with DM or Daniel. It would have been difficult to embark on any work without the cooperation and motivation of Daniel, but even so plans did not change to reassess risks, which were in fact steadily growing. Unknown to CSC, at that time, Daniel was in fact becoming embroiled in organised criminal activity, he had no supportive networks and family relationships, already strained because of safety fears, were at risk of breakdown. Agency records refer to Daniel being dismissive of anything social workers could offer and frequently expressed the view that he knew what he was doing and didn’t require any help.  Referral to VPG 7.6.43. By early 2019, professionals had begun to recognise that some of Daniel’s behaviours were indicative of him being criminally exploited; injuries, substance misuse, missing episodes, aggression towards professionals, possession of weapons and unexplained funds. It was however, not until May 2019 that Daniel was referred to VPG so data and intelligence about Daniel’s activities and the individuals with whom he was associating could be shared and plans formulated accordingly. From agency                                                       28 If the child is Looked After by the Local Authority they can be placed with connected persons such as relatives and friends. These relatives or friends must undertake a Friends and Family assessment and approved as local authority foster carers and to meet the required standards and responsibilities of foster carers.  29 Hidden in Plain Sight Gangs and Exploitation National Youth Agency (2020) 30 See RCCS Agency Learning Report This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   27 records, it would seem that by this time, Daniel may well have been involved in organised criminal activities for at least 18 months at the time he was referred to VPG, this information had not been shared by police with other agencies.  7.6.44. At the point of Daniel’s referral to VPG, the remit of the Tees VEMT arrangements had only just been extended to include consideration of children who were at risk of or who known to be criminally exploited. The detail of the strategy was however not to be finalised until the end of that year. Nevertheless, VPG acted swiftly in response to concerns and Daniel was listed as Very High Risk. Social workers were tasked with providing VPG with regular risk assessments and were challenged when these were not forthcoming.   7.6.45. The review team was told that whist work promptly commenced to map associates, given that Daniel refused to talk about people or places and important police information, at that time, had not been shared, it was difficult to properly understand the extent of these risk factors at that time. VPG meetings were held monthly, although as concerns escalated about Daniel, meetings tended are held almost on a weekly basis, so agencies could keep abreast of his placement moves   and share information about his whereabouts. The review team had a sense that whilst VPG was effectively driving forward work with Daniel, it remained difficult to put any measures in place that would demonstrate safety due to Daniel’s lack of willingness to engage with professionals and this left effectively left him vulnerable and at risk.   Current situation: VPG. VPG arrangements have been revised and weekly meetings now take place to consider all new referrals and share information about missing children and young people. For every child that is now subject to VEMT there is now an established professional email exchange so the information can be shared, assessed and responded to as it arises. Children’s services now work closely with police colleagues in the Complex Exploitation Team (formerly police VEMT team) to consider how children’s plans can properly encompass all known information to better contribute to safety planning for children. VPG chairs now attend police meetings where intelligence relating to OCG activity across South Tees is shared and analysed.    Placement sufficiency and the impact on planning and decisions  7.6.46. Once it became evident that Daniel could no longer live with MGM, Daniel was provided with semi-independent accommodation in his hometown and a support package was initially put in place, provided by SP3. Daniel at this time was almost 17 years old. It is of course, in the best interests of most young people of Daniel’s age to live in the family home, or, where this is not safe or appropriate, with responsible adults in their wider family and friend’s network. There is clear evidence that professionals working with Daniel recognised this and tried hard to identify and resolve the breakdown in family relationships. By this point, MGM had had her home windows broken and her car vandalised three times and she suspected these were  ‘threats’ or ‘messages’ to Daniel; she feared for her own safety from others and also from Daniel, who she described as becoming more violent and aggressive towards her. 7.6.47.  Daniel was referred to MAPPA following a Section 18 wounding and a series of significant offences including robbery and kidnap. He persistently, and perhaps not unexpectedly, failed to comply with his placement agreement and threatened staff in SP3 if they reported him missing which they were required to do.   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   28 7.6.48. A number of placements move in various settings followed in response to concerns about Daniel’s safety and the possibilities of retaliation due to him being involved in violent crimes. For much of the time, Daniel’s whereabouts were unknown, sometimes for days at a time. In December 2019, the local authority was granted permission to seek a Secure Welfare Order believing this was the only way that Daniel could be kept safe. Despite daily searches no suitable accommodation could be found. The possibility of placing Daniel in an unregulated placement and securing authorisation for a DoLS31 was discussed, but this option was dismissed as it was recognised that any staff ‘supervising’ Daniel would be at significant risk if they tried to curtail his liberty. By this time information had come to light that Daniel was using firearms. Whilst the search for secure accommodation for Daniel continued, risk assessments were undertaken in respect of the staff that were offering support and supervision and safety measures were put in place to ensure their protection. A note from a VPG minute in January 2020 states that [unless Daniel can be securely accommodated] he is likely to be seriously harmed or will seriously harm someone else.  7.6.49. The briefing by the Office of the Children’s Commissioner in November 2020 ‘The Children no-one knows What to Do With’ outlines that for children in residential care, ‘the standard of care is variable, there are not enough places; children are left at huge risk waiting for suitable accommodation, and the problem is getting worse’. The briefing further outlines the risks for children associated with unregulated placements and the acute lack of capacity in children’s secure accommodation settings. Searches for a secure bed for Daniel were made on a daily basis.  7.6.50. In January 2021, the government announced an independent review to address poor outcomes for children in care as well as looking to strengthen families to improve the lives of vulnerable children. The briefing and government action demonstrates that some of the challenges highlighted in this review have a national context that is, reportedly, high on the government’s agenda.  7.6.51. Each Local Authority/Children’s Trust has a ‘sufficiency duty’ 32  to ensure there is suitable accommodation to meet the needs of children that they are looking after. They have to demonstrate that they are doing all that is ‘reasonably practicable’ on a strategic level to meet the sufficiency duty. Meeting the placement needs of Daniel proved to be consistently problematic in that none of the placements were secure and Daniel could come and go as he pleased, and there was clear evidence that staff in SP3 colluded with Daniel and did not reporting him missing when they were required to do so.  7.6.52. Placing a child in an unregulated placement is a not a choice that any council would want to make, but it has become an increasing occurrence due to the national shortage of regulated settings able to meet the needs of children, like Daniel. Unregulated homes are not registered or inspected by the regulator Ofsted and as such are not required to meet any specific standards. They are often created in response to a crisis need and when there is no other option, it then falls to the local authority to conduct due diligence checks to be satisfied that all statutory requirements are met and that the care provided is lawful. In 2020, there were a number of High Court judgments involving young people for                                                       31  32The "sufficiency duty" was introduced by the Children Act 1989 and requires local authorities to take steps that secure, so far as reasonably practicable, sufficient accommodation within the authority's area which meets the needs of its looked-after children and those who would benefit from being accommodated.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   29 whom no suitable care home place could be found anywhere in England, even when the Court was advised that the lives of those children would be endangered if a home could not be found.  7.6.53. The background to this matter is one that is now depressingly familiar to the Family Division of the High Court 33and replicates the challenges faced by RCCS in finding a suitable, safe, and secure placement for Daniel.  7.6.54. A report from the National Audit Office – ‘Pressures on Children’s Social Care, 2019 states that  demand for residential placements, including the need for secure  accommodation has outstripped capacity. The [increase] in the use of residential care has exposed the lack of suitable placement capacity available to local authorities: only 32% of local authorities report that they have access to enough residential homes for children aged 14 to 15 years, and 41% for those aged 16 to 17. The lack of secure accommodation for children with complex needs compounds this challenge even further.  Learning Point 5:   Unless the lack of secure accommodation is addressed nationally, children like Daniel with complex needs and behaviours will continue to fall through the gaps that exist between secure accommodation, regulated accommodation and detention under the mental health legislation.  7.7. KLE3: How did professionals manage and respond to Daniel’s refusal to engage with them and the services they offered. 7.7.1. From talking to practitioners, a complex picture emerges of a young person who everyone felt was at the most serious end of the risk spectrum but with whom no individual could effectively engage. It is clear that professionals tried hard to communicate with Daniel about the risks he was facing and the consequences of his behavior and also tried to encourage him to seek help to mitigate those risks.  There is however much to evidence that Daniel remained adept at resisting any meaningful involvement with professionals and although there were times when professionals thought they might be ‘getting through’, later events suggested that Daniel was equally adept at displaying disguised compliance and giving the appearance of cooperation whilst his risky behaviours not only continued, but were seen to escalate.   7.7.2. Even without a thorough understanding of Daniel’s early childhood, it might have been helpful if professionals had developed and worked from a hypothesis that Daniel was highly likely to have attachment issues and therefore did not trust or feel the world was a safe place. Whilst there are many records describing the difficulties professionals faced in trying to engage him, there were far fewer reports analysing why this might be so and how professionals might forward in trying to work with him.  7.7.3. Hard to reach behaviours in adolescents with associated behaviours such as drug misuse, aggression and criminal acting-out are well researched. 34  Some research is found under the heading of                                                       33 See  Z (A Child-DoLS Lack of secure placements [2020] EWHC 1827  34 That Difficult Age: Developing a more effective response to risks in adolescence Research in Practice  (2015)   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   30 adolescent psychopathology and anti-social behaviour, but other studies focus on the strong links between adolescent mental health states and early relational factors and parenting styles. Mental states, beliefs, wishes, feelings and thoughts, whether conscious or unconscious, are known to determine actions and behaviours and Daniel’s determination to acquire status and show people he was in charge and needed no-one, were likely indicators of Daniel’s core beliefs about himself and the unsafe world in which he lived. According to MGM and professionals who knew him, Daniel’s behaviours actually belied a vulnerability that he was careful not to expose. There were however small glimpses of Daniel’s inner turmoil, evidenced by references to him cutting himself and the ways in which he responded to disappointment, challenge, and rejection.  7.7.4. Although professionals struggled to find ways to engage Daniel there is little to indicate, the need to do so was identified as an essential and purposeful intervention in its own right. Work with Daniel was undertaken at a later stage by YOS1 on knife crime, which apparently grasped his attention and led him to produce a PowerPoint presentation on the topic. Whist the appropriateness of the subject matter was questioned, it nevertheless indicated there were ways to communicate with Daniel albeit on his terms, but the need for focused relationship-building opportunities was not well recognised.  7.7.5. The review team was of the view that the continued focus on Daniel’s behavioural symptoms and the view that he needed to ‘understand the risks and the consequence of his behaviour’ was not helpful and a more nuanced approach to his world might have achieved more. The experience of living in an environment of heightened tension, violence or anxiety as Daniel did, seemingly from a relatively young age, would have had a direct impact on his brain development and neurochemical pathways. Alertness and responsiveness to threats and perceived threats were no doubt hard wired into his neurological systems and the primitive flight/fight responses would have left him on continual alert.  7.7.6. This aspect of Daniel’s functioning could have been better explored; it was a fundamental part of who he was. Professionals suggesting that Daniel did not understand the dangers of his world were, it might be argued, naïve, given that Daniel carried weapons and wore a stab vest – he knew the dangers and prepared himself for those risks accordingly. The reality was that professionals could not actually keep Daniel safe and it is likely that Daniel was acutely aware of this even if he had wanted it to be so. There is evidence Daniel believed that being part of a gang was actually a safety measure for Daniel and this was perhaps not fully recognised by professionals, young people often report that the criminal group provides them with relational support, comradery, a family (which may otherwise be absent) and importantly for Daniel, a sense of identity and belonging.  7.7.7. This begs the question of how professionals can be better supported to understand in much greater depth a young person’s experience of gangs and violence and the ‘codes’ and  ‘rules’   they need to adopt in order to survive; how do young people relax and know who they can trust living in a community that is violent and safe and importantly, how can professionals work effectively with young people, when it becomes apparent, as it clearly did with Daniel, that they are excited and hyper- aroused by that violence?  7.7.8. The challenge for professionals was of course the balance between taking critical actions to keep him safe, offering support which he refused to accept and then also taking time to learn more about his life and coping mechanisms. These areas of work were vastly important but they were not fully reflected in the multi-agency plans drawn up for work with Daniel. Research tells us that the highest This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   31 rates of success with young people come from relationship-based practice with long-term support from a worker whose sole purpose is to build that relationship and, if that professional is in a young person’s life for a significant amount of time, they are more likely to drop barriers and begin to trust and that is where true engagement begins.  7.7.9. Some of the challenges in securing Daniel’s engagement were certainly compounded by changes in the allocated social workers (4) and team mangers (2). Daniel appeared to engage more readily with the youth offending service and was particularly interested when completing work with them about gangs and the associated risks, which some professionals thought may have further developed his interest in organised crime. It is far more likely that Daniel took pleasure in talking about his life and demonstrating his knowledge about street life and such engagement was therefore still useful.  Learning Point 6: Early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people as part of their professional role. These professionals need to be well supported to develop specialised skills and the right mind-sets so they can develop relationships with young people that are able to withstand resistance and disengagement, but continue nevertheless to support effective change.  Current Situation: RCCS is working with a Tackling Child Exploitation (TCS) programme to develop a more preventative strategy aimed at early recognition, engagement, and prevention for children who are at risk of exploitation. This is a partnership between Children’s Services, Early Help, the Police, the Community Safety partnership, YOS and Education. Consideration is also being given to recruiting specialist adolescent social workers to work with children and young people who are or are at risk of being exploited.    Learning Point 7: There are critical moments in children’s lives when a decisive response is necessary to make a difference to their long terms outcomes. These ‘critical or reachable moments’ are likely to include, the point at which they are excluded from school, when they are arrested, when they are physically injured. There would be benefit in ensuring that services and systems are in place to ensure that these ‘key’ moments are anticipated and individual practitioners can step in and capitalise on the receptiveness of children at these times. 7.8. KLE4: How well did agencies collaborate and work together 7.8.1. According to agency records, Looked After Child reviews took place in line with required timescales. Care meetings to progress Daniel’s Care Plans took place regularly, although minutes from these meetings suggest they were used more for information-sharing and allocation of tasks than analysing what was working for Daniel and his family and why.  7.8.2. The LAC review held in March 2017 referred to occasions when Daniel had not been returning to his placement after visits home was not engaging with education, and DM was refusing to have him home at that time. The review team could not evidence a support package in place, which recognised that in effect very little had changed for Daniel and the chances of him reverting to his previous behaviours were high. Neither did the LAC review held in June just prior to Daniel going to live with MGM address this issue. The contents of the June LAC review are cut and pasted almost in their entirety from the meeting three months earlier and again there was no challenge by the IRO as might This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   32 be expected as to what measures would be put in place to support Daniel and how would these be measured.  7.8.3. It is difficult to determine how effective multi-agency working was in June 2017 and 2018, although it is clear that professionals communicated with each other during this time. From mid-2018, concerns began to escalate about Daniel’s involvement in stabbings, violent assaults, and aggravated burglaries. Daniel was sentenced to a 12 month Referral Order35 in January 2019 for an offence of robbery but it was not until July 2019, that Daniel was referred to VPG by a social worker newly assigned to work with him to whom Daniel admitted that his observed injuries were a result of him being tied up to a chair and beaten.   7.8.4. Professionals told the review team that knowledge about CCE was only just emerging and prior to that time, the possibility of criminal exploitation had not been considered. Following the referral to VPG, there is evidence that agencies began to work more closely collaborate and share information. Professionals remained vigilant in their attempts to engage and support Daniel but this did not bring about any increase in safety for him.  7.8.5. According to the chronologies provided to the review team, there would appear to have been at the very least, around 45 multi-agency meetings held about Daniel, during the 4-year period under review and about half of these took place between May 2019 and March 2020. Most of these meetings included all or most of the agencies/services referred to in previous sections and most meetings had at least 3 or more professionals, and sometimes as many as 12 – 14 individuals in attendance. Practitioners involved in the review said that supervision sessions generally took place regularly and these were both supportive and challenging.  7.8.6. Risk management meetings took place but it was clear that until late 2019, agencies did not have a comprehensive understanding of the extent of Daniel’s involvement with criminal communities across South Tees and therefore, notwithstanding a lack of cooperation from Daniel, agreed strategies were not effective in keeping him safe.   7.8.7. The Police Agency Learning Report states that Daniel was ‘opened to ‘our’ VEMT team in 2015’ implying that Daniel’s contacts and activities were even then being monitored by police colleagues. However, there is little to suggest that this information was purposefully shared with colleagues. Certainly, by 2017 police were fully aware of Daniel’s involvement with adult criminals who were known to police and suspected of committing violent offences and being involved in the use and supply of illegal drugs. This information, and the extent and nature of Daniel’s contacts with these individuals or the possibility that Daniel could be involved with organised criminal groups (OCGS36) was never shared with partner agencies.  7.8.8. Police told the review team that information they held at the time was highly sensitive and related to ongoing police operations and there were limits to what could be shared. This clearly left other                                                       35 A referral order is an order available for young offenders who plead guilty to an offence whereby the young offender is referred to a panel of two trained community volunteers and a member of the youth offending team. It can be for a minimum of three months and a maximum of twelve months.  36 An OCG is defined as a group which: has at its purpose, or one of its purposes, the carrying on of criminal activities, and. consists of three or more people who agree to act together to further that purpose. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   33 professionals trying to protect Daniel; unaware of the risks he was facing from influences outside of his family and from whom. Significantly, social workers were not informed that Daniel had been involved in a firearms incident three days before he was shot and it was only at the point that Daniel was due for discharge after he had been shot that social workers were made aware that police had issued a ‘threat to life’ notice two week earlier. As Daniel’s corporate parent, the local authority should not only have been informed of the intention to issue this notice, they should have been present when it was delivered and would certainly not have agreed to Daniel being informed when he was still heavily sedated with pain relief.   7.8.9. It was clear to the review team that important information was not shared by police with partner agencies at times when it was necessary and appropriate to do so. Views were expressed that, at that time, the force’s safeguarding arrangements and partnerships were not as robust as they should have been, a view highlighted in the HMICFRS 37  Inspection report following an inspection in December 2018. The review team was informed that information-sharing procedures between agencies have during the past 12 months been reviewed and revised.  Learning Point 8: Agencies need to be able to confidently share information in various ways across force and partnership areas so plans to protect children are based on up to date and relevant information. There is a need to ensure that the revised information-sharing agreement is fit for purpose and is working well, taking into account emerging challenges but remaining focused on the need to safeguarding and protect children and young people.  7.8.10. The use of integrated approaches to respond to sexual exploitation of children through multi-agency cooperation is well recognised and has been for several years.38 During the period of this review, the need to establish similar arrangements for children who were at risk of criminal exploitation was only just emerging and procedures and protocols in South Tees had not yet been formalised at a strategic level and were not yet embedded into operational practice.  Current Practice: Police:  Cleveland Police have now established a Complex Exploitation Team to ensure a wider focus and a more targeted approach to respond to the sexual and criminal exploitation of children and adults, modern slavery and county lines operations. Chairs of VPG across South Tees now attend these meetings where intelligence about OCGs is analysed so implications for children and young people can be better understood from a multi-agency perspective.    7.8.11. The application for a secure order discussed in the December multi-agency risk management meeting was discussed as being the only way in which Daniel’s safety could be secured, but the absence of a bed within the secure estate, or a refusal to accept him, meant this could not be accessed. There were outstanding arrest warrants during December and Daniel seemed to go ‘underground.’ Despite challenges from the VPG chair, there were occasions when police continued to view Daniel through the lens of an offender and tagged him as ‘wanted’ rather than as a missing, looked after child. Referrals reporting Daniel as missing were therefore not always accepted at a local level by police and although this was raised by the VEMT DCI, it appears that the practice continued. There were at                                                       37 Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services   38 Working Effectively to Address Child Sexual Exploitation. Research in Practice Revised 2017.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   34 least 4 missing episodes when police refused to accept the missing reports in relation and the search for Daniel was not therefore prioritised as well as it might have been, leaving him at great risk.  7.8.12. As evidence continued to emerge of Daniel’s violent offences and intimidation of others Daniel was referred to MAPPA in February 2020 and was registered as VERY HIGH RISK and was to be managed under level 2.39  The review team did not have sight of any multi-agency management plan in respect of the risks identified and neither was there any evidence that Daniel’s’ Pathways Plans40 were amended in line with the risks identified.  7.8.13. Despite a high level of multi-agency input, neither VPG nor MAPPA brought about any increase in safety for Daniel, his risk status never reduced and it is unclear what else could have been done, without provision of a bed in a secure setting. The use of DoLs at that time, was thought to be too great a risk for any staff supervising him as attempts to impose the authorised restrictions by staff gave rise to threats and intimidation by Daniel which left them at a loss as to how they could keep him safe. 7.8.14. Whilst, his referral to MAPPA and his assessment of ‘Very High Risk’ had limited impact for the safety and support for Daniel, it did support agencies to make key decisions about what they had to do to keep him safe and how to keep others including staff and the general public as safe as possible from potential harm by harm Daniel. This included making decisions around 2:1 staffing, ensuring NHS and other agencies were aware of the risks should he attend their agencies and ensuring staff had access to safety alerts if needed. The assessment also supported the local authority in taking the very unusual steps of moving a 17 + young person out of area, securing a DoLS and maintaining this until his 18th birthday. Without the assessments, these actions would not have been taken.  7.8.15. Professionals in multi-agency meetings were concerned that Daniel would either seriously injure someone or be injured him. Risk assessments were undertaken in relation to the staff working in the various settings where Daniel was placed, although the possibility of staff being threatened and frightened into ‘overlooking’ Daniel going missing or having prohibited visitors was not understood nor well recognised. There were indicators that he was involved with OCGs but this intelligence was never confirmed and therefore it remained difficult to assess and to militate against these risk factors, especially given Daniel did want the help or services offered.  7.8.16. Tackling violence and exploitation requires a multiple strand approach involving a range of partners across different sectors and communities. Local Community Safety Partnerships (CSP) need to be central to these approaches, so that issues are understood and owned locally and all relevant partners can play their part, this means focusing not only on crime reduction and reducing harms but including also child welfare and perhaps a greater alignment with child protection systems. It can be argued that extra-familial harm cannot be addressed without the involvement of CSPs and the services they oversee.  Current Situation: Links with the community safety partnerships and the neighbourhood policing teams have now been strengthened. Mapping meetings take place which focus on 3P model of peers,                                                       39 Level 2 – A local multi-agency management for offenders where the ongoing involvement of several agencies is needed to manage the offender. Once at level 2 there will be regular multi-agency public protection (MAPPA) meetings about the offender to develop a coordinated plan.  40 The name of ‘Care Plans’ was changed to Pathway Plans sometime in 2019.  This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   35 perpetrators and places and information sharing across particular cohorts of children to deepen understanding of risk, to consider safety planning and ensure that all lead professionals are sufficiently alert to the breadth of concerns about groups of children and perpetrators, as opposed to just the child. These meetings are attended by all relevant partners and include police analysts.  7.8.17. It was not clear to the review team to what extent senior managers were informed about and aware of, the risks that staff working with Daniel were carrying throughout 2019. A discussion did take place between the Director of Children’s Services and the Assistant Chief Constable in December 2019 which highlighted the challenges and frustrations agencies were experiencing in trying to keep Daniel safe.  7.8.18. The independent reviewer was advised that ‘Line of Sight’ meetings do take place in Redcar and Cleveland when complex decisions are needed. It is vitally important that senior leaders have a clear line of sight about the most vulnerable children and young people in addition to a clear understanding of the scale of child exploitation across Redcar and Cleveland so commissioning, policy changes and resource pressures can be addressed. Senior managers also need to be able to review and prioritise resources or specific activities for some individual children at high risk, and of course hold decision-makers to account.  7.8.19. It is important to recognise and acknowledge that the complexities of working with some young people means positive outcomes are not always achievable and some young people do remain at risk, despite the attention of services. The conclusions of Munro (2011) are pertinent here; she argues that what is required ‘is for all to have realistic expectations of how well professionals can protect children and young people [and remember that] this work involves uncertainty.’ Such challenges and uncertainties should not, of course, preclude continued efforts to protect children and young people from harm but the impact on professionals of working directly with complex young people, like Daniel, when the necessary resources are non-existent, should not be underestimated  Transition to Adult services 7.8.20. The VPG members discussed whether Daniel would remain subject to VEMT after turning eighteen. Professionals did not feel they had been able to provide an intervention that effectively safeguarded Daniel. However, the group had remained vigilant; had always acknowledged that Daniel’s case was complex but attempts had continued to be made to offer intervention and support. The VPG members did not feel there was any benefit to keeping Daniel subject to VEMT. Daniel had decided that he was not going to engage with the services offered, it was felt that VEMT has no further service to offer him. Daniel’s case would transfer to the Leaving Care Team, but the primary lead would be MAPPA. It was agreed that VEMT should hand over their role to MAPPA, once Daniel turns eighteen years.  7.8.21. It was noted that there were concerns arising in respect of transfer to adult services given the significant efforts that had been made while Daniel was in hospital and following his discharge to try and secure a smooth transition for him.  Although Daniel was a looked after child with RCCS, he was going to be living with MGM in a neighbouring authority and therefore would access adult services from the LA area in which he was residing. A hand-over meeting between key agencies was convened and it was agreed that an assessment would be undertaken by adult’s services in Redcar and This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   36 Cleveland.  It subsequently transpired that Daniel would not, however, engage in the assessment. Daniel’s Personal Advisor from Leaving Care team continued to try and meet with Daniel but Daniel resisted attempts to make contact.  7.8.22. Although outside of the scoping period, concerns were raised by some professionals about the transition process from children to adult services. Examples were given of a number conversations held with, for example, homeless services and health (around Daniel’s physical rehabilitation) which reflected increased expectations of Daniel now he was an adult. It was queried whether more could have been done by the Leaving Care team to ensure that Daniel’s Pathway Plan addressed his support needs during a crucial and critical point of transition, but it was acknowledged that without Daniel’s cooperation nothing else could have been done at that point.   7.9. KLE5: To what extent were locally agreed pathways effective in providing support and protection to Daniel.  7.9.1. Some of the issues raised in this review are complex and require action from central and local government, police and other agencies, but this review has highlighted the difficulties for Redcar & Cleveland, and other authorities, in trying to safeguard and protect Daniel, as a young adolescent whose needs and vulnerabilities had clearly been exploited.  The child protection system  7.9.2. The child protection framework is clearly set out in Working Together 2018 and is embedded in local practice. The association between abuse/significant harm and parenting and the grounds upon which the local authority should intervene is evident and well known. The framework benefits from independent chairing, clearly set out decision-making responsibilities, regular and timely reviews, and partner agencies that are familiar with and committed to the process. It also has associated statutory data collection, which allows the system to be held to account. Statutory guidance is followed and decision-making responsibilities are clear.  7.9.3. From the point at which Daniel became a looked after child in 2016, professionals recognised that he was beyond the control of his family and that in order to prevent him from ‘placing himself at risk’, he needed to be moved to a safer place. In this respect the child protection system was used effectively and as intended, with social workers trying to work with family members so they would be better able to meet Daniel’s needs and would at a future date protect Daniel from adverse external influences.  7.9.4. Once it became apparent, as it clearly did, that these adverse external influences held far greater sway than family or professionals and Daniel’s involvement in, and exploitation by,  factors outside his family was putting him danger, professionals sought safety through other means.  Placements in regulated and unregulated settings.   7.9.5. There can be no doubt that the local authority was focused on trying to meet Daniel’s needs. Resources were clearly not an issue, the main challenge described by those involved in finding and managing placements for Daniel was finding a specialist resource that could and would hold him and manage his challenging and violent behaviours. Moving Daniel to semi-independent placements brought their own challenges with risks to staff and limited if any oversight of his day to day activities and whereabouts. Daniel went missing from these placements on a regular basis, had taxis pick him This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   37 and drop him off whenever he chose. Seeking a DoLSs at this stage was considered not wise, given the risk involved to others.   7.9.6. Over the last decade, the challenge of providing capacity to care for the most vulnerable children has increasingly fallen to the private sector as the demand for care has grown and local authority provision has not kept pace, or even shrunk in some areas. There were over 11,000 more children in care in 2019 than there were in 2011 – 73% of those additional children were cared for by private organisations. Over the last decade, there has been expansion from both smaller providers (who might own one or two homes) and major private equity investment. Furthermore, there is a clear lack of planning and oversight for the market as a whole, leading to an increasingly fragmented, uncoordinated, and irrational market that ultimately does not meet the needs of children.  7.9.7. Using the additional information set out above, local authorities should make better use of their power as purchasers – through for example greater use of regional commissioning and frameworks – to increase the extent to which they can shape the market and their own provision. In doing so, they would be able to exert more market power, share more risk with other local authorities, and benefit from more of the kinds of economies of scale that have allowed large private providers to grow and succeed.   Application for a Secure Accommodation Order  7.9.8. Professionals consequently sought support from the judicial process. Daniel clearly met the criteria for a Secure Accommodation Order under s 25 of the Children Act which states that such an order can be made if a young person is likely to run away and suffer significant harm or, if secure accommodation is not provided then the young person is likely to injure themselves or others. This order can only be granted if there is already a secure bed available and despite, the review team was told, daily searches, none could be found.  7.9.9. The Department of Education urgently needs to set out a strategy for how it will improve the sufficiency, quality, and costs of residential care in England. The strategy must prioritise ensuring the adequacy of placements, in order to address chronic lack of capacity highlighted by the thousands of children in the care system who are currently experiencing high levels of instability including frequent placement moves.  The Criminal Justice System  7.9.10. Daniel seemed to deliberately go underground when he was aware that there were warrants out for his arrest and actively avoided criminal justice processes; he was often subject to warrants without bail. The evidence available suggests that Daniel had committed a series of serious offences but due to a lack of willingness from victims to make statements, the matters that were put to the Court were often low-level and therefore only invited low-level disposals. Although orders and conditions were imposed, Daniel breached these, seemingly without consequence, so restrictions on his liberty were lessened as opposed to increasing. Agency records indicate that this left Daniel with a view that he was ‘untouchable’.   7.9.11. Professionals told the review team that paradoxically, there were times, when they believed the only way Daniel might have been kept safe was if he had been charged and given a custodial sentence. Under the Bail Act 1976, the courts can also remand a child for their own ‘welfare’, without the young person being convicted or sentenced and, when the criminal charge they face is unlikely to, or will This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   38 not,  result in a prison sentence. This is a significant indictment on our safeguarding system if we have to resort to the most punitive sanction available, imprisonment, to make up for failings in care and child protection systems in the community. Contextual safeguarding  7.9.12. It might be suggested if his Daniel’s childhood experiences had been more nurturing and had there been different professional interventions at key points in Daniel’s life, the outcomes for Daniel might have been more positive. These are important considerations and for many young people they provide some explanation for the difficulties they face in adolescence and provide and often provide the evidence to build safety plans and reduce risk.41  Research reminds us however, that these are not the only routes to harm facing young people, there can be traumatic consequences of victimisation and exploitation through for example peer relationships, grooming online and by criminal groups operating in the community.   7.9.13. Staff who contributed to the review were clearly far more knowledgeable about extra familial harms than they were even in 2020 and the review team were advised of several training programmes which have been delivered to staff in respect of CCE and referrals into the National Referral Mechanism (NRM)42 7.9.14. Local authorities need to respond to the abuse of children in all its forms. According to Firmin, (2020), Contextual Safeguarding offers ‘a lens through which extra familial harms can be recognised as abuse and responded to accordingly. This means not pushing the responsibility for protecting children solely onto parents but recognising that the state also has a duty of care and there are other ways of tackling this issue that vex traditional child protection approaches’.  7.9.15.  It is clear from conversations held within the review team and with practitioners that even prior to this review being concluded, changes have been introduced in Redcar and Cleveland to strengthen and revise responses to adolescent risks and to develop services which offer a different way of safeguarding children abused outside of their homes. These changes are to be welcomed.   Current Situation: Redcar and Cleveland are involved in a pioneering programme to support to young people who are in care, or on the edge of care. No Wrong Door – Strengthening Families Protecting Children programme; which was devised by North Yorkshire County Council, is one of three innovative models selected by the Department for Education as part of an £84 million investment to support eighteen local authorities across the country to improve work with families and safely reduce the number of children entering care.                                                       41 Contextual Safeguarding and Child Protection. Rewriting The Rules Firmin ((2020)  42 The National Referral Mechanism (NRM) is a framework for identifying victims of human trafficking and ensuring they receive the appropriate protection and support. The NRM is also the mechanism through which the Government collects data about victims This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   39  8. Concluding Comments 8.1. Experimentation and impulsive behaviour are part of normal teenage experience and most young people navigate their adolescent years without long-term negative impacts. We now know however, perhaps more so than in the past two decades, how the interaction of individual, family and environmental factors can greatly increase a young person’s vulnerability to risk and the potentially adverse consequences of risk-taking.   8.2. Working with adolescents in harm’s way, requires confident professionals in all agencies. Professionals need to fully understand the complexities of working with children and young people who are vulnerable to the grooming tactics and behaviours of skilled adults, intent on exploiting those vulnerabilities outside their family environment. Whilst our collective response to the challenge must be to recognise and respond to the complexity of these risks and work together to protect children from what are often unimaginably dangerous circumstances, it must also be acknowledged that without increased resources at regional and national levels, children like Daniel will inevitably fall through gaps in provision.   8.3. The significant shortfall in the availability of approved secure accommodation causes considerable problems for local authorities and courts across the country. It continues to be the subject of expressions of judicial concern in a number of cases by judges dealing with cases on a regular basis. Whilst, it cannot be said with any certainty that had there been a secure bed for Daniel, he might never have sustained such injuries, it is possible that he may well have been kept safe for longer and much might have been achieved in that window of opportunity.   8.4. This review found evidence of some good practice by persistent practitioners who worked hard to find a way to engage with Daniel and keep him safe. The review has highlighted the importance of multi-agency working and will hopefully remind professionals working with young people to be aware that the pathways leading to harms that adolescents face are complex, not least because they often involve what appear to be adolescent choices and behaviours which can mask, rather than expose hidden vulnerabilities.   9. Summary of Learning Points:  Learning Point 1: The connection between the past, present and the likelihood of future risk for children is about understanding the patterns of problems and needs in families that require something to change. Unless assessments are robust in exploring a child’s history, their needs may not be as well understood as they could be and this may leave some children vulnerable.   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   40 Learning Point 2: Where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child’s immediate safety or long-term outcomes, should be formally scrutinised by safeguarding partners so that decisions can be taken about the need to re-evaluate any risks to the child and/or escalate concerns.  Learning Point 3: Children’s plans should always include targets/objectives that are SMART, so work with families can be easily monitored and the effectiveness of key interventions and outcomes measured.  Learning Point 4: Unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement and this is likely to limit the effectiveness of any family work.    Learning Point 5:  Unless the lack of secure accommodation is addressed nationally, children like Daniel with complex needs and behaviours will continue to fall through the gaps that exist between secure accommodation, regulated accommodation and detention under the mental health legislation. Learning Point 6: Early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people as part of their professional role. These professionals need to be well supported to develop specialised skills and the right mind-sets so they can develop relationships with young people that are able to withstand resistance and disengagement, but continue nevertheless to support effective change.  Learning Point 7: There are critical moments in children’s lives when a decisive response is necessary to make a difference to their long terms outcomes. These ‘critical or reachable moments’ are likely to include, the point at which they are excluded from school, when they are arrested, when they are physically injured. There would be benefit in ensuring that services and systems are in place to ensure that these ‘key’ moments are anticipated and individual practitioners can step in and capitalise on the receptiveness of children at these times. Learning Point 8: Agencies need to be able to confidently share information in various ways across force and partnership areas so plans to protect children are based on up to date and relevant information. There is a need to ensure that the revised information-sharing agreement is fit for purpose and is working well, taking into account emerging challenges but remaining focused on the need to safeguarding and protect children and young people.   10. Recommendations   Recommendation 1: (Learning Point 5)  South Tees Safeguarding Partnership (STSCP) should urge the Department of Education to urgently to set out a strategy for how it intends to improve residential care for looked after children in England. This strategy needs to show how the DoE will ensure the adequacy of placements for children, to address the chronic shortage of placements, including those, which provide secure accommodation. STSCP should also press the DoE to respond to the recommendations regarding This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   41 residential care made recently by the National Audit Office; the Housing, Communities and Local Government Select Committee; the Public Accounts Committee and the Children’s Commissioner.  Recommendation 2: (All Learning Points)  STSCP should use the findings from this review to support the development of a multi-agency, strategy aimed at addressing the risks faced by vulnerable adolescents susceptible to abuse and exploitation in South Tees.   STSCP should ensure that the strategy, whether it is named ‘Vulnerable Adolescents ‘or Adolescents at Risk’ should include:   Partnership aspirations and overarching goals for effective and ongoing work with vulnerable adolescents   A roadmap for how agencies across South Tees will work together to:  prevent vulnerable adolescent abuse and exploitation   identify vulnerable adolescent abuse and exploitation  engage and support vulnerable adolescents   disrupt vulnerable adolescent abuse and exploitation   enforce/ prosecute vulnerable adolescent abuse and exploitation   The means by which professionals will be supported to develop and refine specialised skills to build and maintain relationships with adolescents and especially with those for whom contact with statutory services is not working  The process for ensuring there is improved connectivity between key multi- agency risk assessments, for example VPG, MAPPA and MARAC there are systems in place to ensure these are used to inform a child’s Pathway Plan  Recommendation 3: (Learning Points 2)  STSCP should explore, with key stakeholders, how schools and academies can be supported   and challenged, but also held to account, by partner -agencies when there is evidence that school exclusions or non –attendance is placing, or would place, a vulnerable child at greater risk.   Recommendation 4: (Learning Points 3)  The use of tools, such as chronologies, varied assessments, children’s plans etc, to aid professional judgment and decision-making is well researched. The review team was of the view, however, that more could be done to educate and support practitioners know what tools are available, how best to use them and when, tools such as:   better use of chronologies to support multi-agency decision-making   assessments which purposefully explore early childhood experiences  assessment tools  which measure parental capacity to change (as opposed to quality of care) production of plans  which include SMART targets so progress, or the lack of, can be measured   This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission   CSPR/Daniel/FINAL REPORT /MAY 2021/LR   42  Recommendation 5 (Learning Point 8) STSCP should seek assurance from partner agencies that the revised information-sharing protocol between police and key agencies is working well and that professionals in all agencies are kept well-informed and regularly updated as to what information can be shared, with whom and when. This is especially important when concerns about child criminal exploitation arise.    Recommendation 6 Whilst, STSCP should seek assurance that the learning from this review will be widely disseminated by partners agencies, the partnership should also consider how it can be confident, and evidence, that learning from this and other similar reviews make a difference to professionals practice and contributes to improved outcomes for children, young people and their families.   END/  