Near-fatal knife injury to a 17-year-old boy in December 2020. Child V had been subject to a child protection plan until March 2020. Learning includes: the need to view children who are not in school, especially those with Education, Health and Care Plans (EHCP), as high risk and requiring a safety network of agencies to work together; there is a need for professionals to improve their understanding of the impact of cumulative harm on an adolescent who is struggling to find a safe transition into adulthood; there is a need to ensure that the work already undertaken to develop a contextual safeguarding approach is strengthened to include a wider range of agencies; ensure that the child's voice is heard. Recommendations include: EHCP reviews must involve health and social care to ensure that there is a multi-agency approach to addressing the educational needs of the children; ensure that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extrafamilial harm by applying contextual safeguarding principles; ensure that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved; ensure that children who are out of school are given opportunities to voice their views of their situation.
      
 Title:  Child V: child safeguarding practice review. LSCB: Sutton Local Safeguarding Children Partnership Author: Nicola Brownjohn 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.                                                        Child V   Child Safeguarding Practice Review       August 2021                                       Author: Nicola Brownjohn                    2  1 CONTENTS 2 Introduction by Independent Author ................................................................................ 3 3 Executive summary ........................................................................................................... 4 4 Reason for commissioning the Local Child Safeguarding Practice Review ....................... 6 5 Purpose and scope of review ............................................................................................ 6 6 Involvement of Child V and his mother ............................................................................. 7  Child V ........................................................................................................................ 7  Child V’s Mother ........................................................................................................ 8 7 History and key circumstances of the case ....................................................................... 9  History ....................................................................................................................... 9  Key circumstances of the case ................................................................................. 11 8 Questions raised regarding how agencies worked together........................................... 13  Did agencies consider that Child V at risk of exploitation? ..................................... 13  What could have been done earlier in Child V’s life to change the outcome? ....... 14  How was the EHCP for Child V managed by the Multi-Agency Network? .............. 15  What significance did professionals place on the role of Child V’s access to male role models? ........................................................................................................................ 16 9 Analysis of practice .......................................................................................................... 17  Theme 1: Individual needs of the young person ..................................................... 17  Theme 2: Family history and dynamics ................................................................... 20  Theme 3: Quality of practice ................................................................................... 21  Theme 4: Impact of non-engagement on relationships? ........................................ 24 9.5  Theme 5: Disconnected Systems and Insufficient evidence of harm ........................... 25 10 Learning points ............................................................................................................ 26  School as a place of safety ....................................................................................... 27  Cumulative harm ..................................................................................................... 28  Contextual safeguarding: applying thinking to practice .......................................... 29  Relationship-based practice .................................................................................... 30  Hearing the child’s voice ......................................................................................... 31  Managing organisational or partnership risk .......................................................... 32 11 Key Practice Issues ....................................................................................................... 33 12 Conclusion ................................................................................................................... 34 13 Recommendations for LSCP Statutory Partners and relevant agencies ..................... 34 14 Appendices .................................................................................................................. 36  Methodology ........................................................................................................... 36  Action Plan ............................................................................................................... 38 3   2 INTRODUCTION BY INDEPENDENT AUTHOR I was commissioned to undertake this review in February 2021 by the Local Safeguarding Children Partnership (LSCP).  The review focused on the circumstances prior to the incident resulting in a near fatal stabbing of a young person. For Sutton, this was the first incident of this nature to occur in the borough and the LSCP were keen to ensure that learning could be identified to prevent future incidents.  As with any learning review, it is crucial that the subject, if still alive, and families are invited to contribute to the review. Unfortunately, both Child V, who is now an adult, and his mother have not responded to the offer to speak to me. Therefore, it is difficult to gain their perspective of what happened, and despite the despite the best efforts of agencies, the full details of the incident have not been discovered. In my view there are three potential reasons for the incident: 1. Child V was in the wrong place at the wrong time: Little is known about how Child V spent his days during that period of time. 2. Child V was involved in violent street crime: He was known to police and the youth justice system 3. This was a dispute between the family and other, unknown, individuals: Following the incident there was a fear of retaliation raised by mother and son. From my research I would consider 2 or 3 as holding the most likely underlying indicators of the risks faced by Child V. Additionally, he was reported to have been taken to the outside of the hospital by the perpetrators.  This incident should not have happened. It could have been prevented had the systems of child protection, exploitation, youth offending, and education been able to find a way to work with Child V to facilitate him finding a safe pathway into adulthood. Nevertheless, my conclusion is that practitioners made immense efforts to try to find a way but were impeded by the influence of difficult historical involvement with the family.  The National Panel recognise that adolescent reviews tend to focus on the recent past when it is seen to be difficult to make any positive change for the young person1. The Panel note that the major decisions that could have prevented the harm would have been in the adolescent’s early childhood years, but these periods are not considered within the learning of these reviews. 2  Therefore, I have                                                            1 Dickens, J. et al. (2021) Annual Review of LCSPRs and Rapid Reviews. The Child Safeguarding Practice Review Panel. p.21.  2 ibid 4  attempted to pull into the learning ways in which the LSCP can ensure that other high risk adolescents are identified and that there is preventative work undertaken to improve the outcomes for younger children experiencing abuse or neglect.   The report provides some contextual background of Child V’s life and then sets out a summary of the key periods within the timeframe of November 2019 and December 2020. Within the conduct of the review, questions were identified to follow through within conversations which then lead into the full analysis of practice. The core practice issues were explored in terms of how they relate to wider practice within Sutton, beyond this case. The report concludes with recommendations for improvement arising from the learning identified.  This was a focused review using a brief chronology, documents showing key decisions within Child Protection Conferences and Missing and Child Exploitation Panel (MACE), plus conversations with practitioners, managers, and multi-agency groups.  I would like to thank the services and individuals who contributed to the review in a candid and honest way.   I know this case has made a significant impact on those involved with the family and there is an ambition to learn from it to improve outcomes for others in similar circumstances.  3 EXECUTIVE SUMMARY Child V was 17 years old when, in December 2020, he was sustained a near fatal knife injury. During the previous year, he had been subject to a Child Protection Plan until March 2020 and on the review list of the MACE until November 2020.   Child V was dropped off at the hospital, possibly by the perpetrators, and walked into the Emergency Department alone. He was transferred to a trauma centre for a lifesaving operation. He is reported to have sustained long term damage to his lungs, limiting his work choices due to his breathing being impaired.  He is now 18 years old.  Prior to the incident, agencies attempted to address Child V’s needs but would be blocked through disengagement, and at times aggression, by the child or mother.  Efforts were made to offer support to the mother for her own emotional and mental wellbeing, but she would only engage with the GP.  Advocacy was offered for the child protection process, but she refused, assessments for both mother and child were offered but not taken up. This meant that professionals were unable to gain a deep understanding of Child V’s life or to develop stable relationships with him to promote positive outcomes.  5  This review has identified areas of good practice in how agencies recognised how the family could not work with statutory services. There was recognition that a few professionals were able to reach the family. It was agreed within the multi-agency network, at practice and management levels, that these workers could lead the work with the family.  However, this was limited and only lasted for the time that the family would engage. Once that stopped then Child V was left again in an unknown world, within the home and outside.  The review has identified key areas of learning for practice.  Firstly, the need to view children who are not in school, especially those with Education, Health and Care Plans (EHCP), as high risk and requiring a safety network of agencies, not solely education, to work together. Considerable attention has been given to the importance of schools during the Covid-19 Pandemic in the extent to which schools provide a safe place for children3.  For Child V, he lived much of his childhood without that safe place, not just a few months of lockdown.   Secondly, there is a need for professionals to improve their understanding of the impact of cumulative harm on an adolescent who is struggling to find a safe transition into adulthood.   Thirdly, the LSCP needs to ensure that the work already undertaken to develop a Contextual Safeguarding approach is strengthened to include a wider range of agencies. This will support the partnership to fully embed the approach into the safeguarding of children in the borough and embrace a culture of constant vigilance of the most high-risk children.  Fourthly, and aligned to the Contextual Safeguarding approach, is the need to strengthen relationship-based practice throughout the multi-agency partnership. This requires all services working with children and families to reflect and review how they adapt their offer to facilitate the engagement of those who need their support, rather than closing the doors to them.   Fifthly, as so often in children’s reviews, there is a need to ensure that the child’s voice is heard. For Child V, agencies could not reach him, but the challenge is for professionals to be supported, with time and resources, to persevere in their efforts to reach such young people.  Finally, it was evident from this review that there was an ambition by senior managers to support their teams to work in different ways to reach a successful outcome. However, this can be a high risk for organisations and the partnership to manage.  Nevertheless, it is important that the systems enable flexible working                                                            3 The Child Safeguarding Practice Review Panel (2020) Supporting Vulnerable Children and Families during Covid-19: Practice Briefing.  6  when professionals are faced with blocks that cannot be broken down by the customary procedures.  Child V survived a life-threatening assault. The learning for the LSCP is crucial in preventing this type of incident happening for other adolescents in Sutton.  4 REASON FOR COMMISSIONING THE LOCAL CHILD SAFEGUARDING PRACTICE REVIEW  The Local Authority submitted a notification of serious child safeguarding notification, in relation to a knife stabbing, to the national Child Safeguarding Practice Review Panel within the statutory timescale after Child V’s assault was reported.  On 08 January 2021, a statutory Local Safeguarding Children Partnership (LSCP) Rapid Review meeting was held to consider whether the criteria for undertaking a Local Child Safeguarding Practice Review (LCSPR) had been met based on the initial chronologies. The grounds for the decision to recommend a LCSPR at this point was that the initial chronologies and analysis of agency involvement by those organisations who had been involved in the case:  a) Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified. b) Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children. c) Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. d) Where the safeguarding partners have cause for concern about the actions of a single agency. On 02 February 2021, the National Panel confirmed the decision that the case met the threshold for undertaking a LCSPR and the LSCP was advised that the learning could be through a local review.  5 PURPOSE AND SCOPE OF REVIEW The purpose of this LCSPR is to independently review the circumstances that led to the serious incident, in order to identify learning for individual agencies and the partnership. The LSCP must also seek assurance that children’s safeguarding needs are effectively responded to by local services and the wider partnership to prevent further serious incidents of this nature.  7  The scope of this Local Child Safeguarding Review is based on the requirements and quality standards set out in the Safeguarding Practice Review Panel: Practice Guidance (2019) and Working Together 2018 and includes: a) To review the circumstances and analyse critical incidents in the care of Child V during the period of November 2019 until 20 December 2020 and provide any other significant relevant information prior to this time. b) To review the professional involvement during Child V and the family’s involvement with services, specifically special educational needs, drug use and offending behaviour. c) To frame questions to explore and seek clarification on whether anything could have been done differently to prevent the serious youth violence incident from occurring. d) To engage directly with the Child V and the mother to explore their experience and perception of the effectiveness and impact of services and professionals.  e) To engage directly with frontline practitioners and their managers to examine standards of practice and compliance with procedures and protocols with a view of identifying if there is future learning to improve practice and services. 6 INVOLVEMENT OF CHILD V AND HIS MOTHER  Both Child V and his mother were contacted by letter offering them the opportunity to contribute to the review. However, neither responded. Given their relationship with statutory services, perhaps this is not surprising. Nevertheless, it means that the review has a significant gap in not being able to tell Child V’s story from his perspective.  Therefore, this section will try to pull together a little of Child V’s life and consider this from his, and his mother’s perspective, by trying to be in their shoes.   CHILD V Little is known of Child V’s lived experience, from his own voice.  When he was 14, the EHCP noted his views: “I have conduct disorder and emotional and behavioural and social needs and I don’t like speaking to strangers. I don’t like meeting with strangers as I get panicky. I like going out with my friends on my bike. I enjoy playing football. My dream is to be a carpenter or work for Playstation. I think I am good at playstation, technology and fixing things like building my bike. I do not like going to school as it is really far. I find it hard when I have to speak to strangers. I find it hard to sit still and focus on work” 8  Child V is of mixed heritage, unlike his half siblings. Child V witnessed violence in the home at a young age. He has not been in school for four years.  He is reported not to mix with peers of his own age but those who are already adults, but some previously known to the care system.  One of his half siblings has a job which Child V has shown interest in.  As part of the assessment for the initial child protection conference in 2019 there was a home visit by social workers. Child V was reported to be: “Initially frustrated with the social workers and said that he and his mum have been unsupported all this time. However, towards the end of the visit (Child V) indicated he wouldn’t mind working with Integrated Youth Services again. He ended the meeting in a polite manner telling the worker it was nice to meet them” The YOT worker managed to engage him on limited occasions and noted that Child V had aspirations for work and was happy to work with the YOT worker on his cannabis use.  “Child V looked and sounded well. He was clean and tidy and made good eye contact with me. This was a massive turnaround from when I last tried to work with him about 18 months ago. At that time, he barely spoke to me and would sit at the top of the stairs, give ‘yes’ or ‘no’ answers and then quickly retreat into his bedroom” However, 3 days later, when Child V attended the centre to meet the YOT worker he did not engage well and did not turn up for the following session.   CHILD V’S MOTHER Child V’s mother told the YOT worker that she could not relate to the social worker assigned to Child V for the Child Protection Plan in 2020 due to the social worker:           “Being too young, no life experience and not a parent of teenagers”  A mother’s perception of a professional at the start of the relationship means that the possibility of any productive work to be undertaken is highly unlikely and sets both up to fail.  Child V’s mother did have, apparent, trusting relationships with some services, namely the YOT worker, NEET (Not in Education, Employment or Training) worker and, for a period of over 8 years, the GP practice.  She was proactive in seeking help from these services and would contact them about Child V.   There was evidence noted within the Child Protection minutes that Child V’s mother wanted him to get a career and employment and she would report to the police if he went missing. Therefore, she did demonstrate that she wanted a positive future for her son. Nevertheless, she did not have the ability to help her 9  son, or the capacity to fully understand the way professional support could only be effective with the family as active participants.  In 2019, the social worker noted that: “From my observations and speaking with (Child V) it is clear that he has a strong bond with his mother. I observed her speak to (Child V) in a warm tone. She enquired about his mood, encouraged him to engage with me and paid attention to what (Child V) was saying. (Child v) also appears to worry about his mum and has been observed wanting to support her. (Mother) shared that (Child V) at times offered her money for electric and is able to manage his finances” 7 HISTORY AND KEY CIRCUMSTANCES OF THE CASE  HISTORY Child V was the youngest child of a white British mother. His father was black Caribbean, unlike his half-siblings’ fathers. From an early age Child V was known to Children’s Services, in fact the local authority had been working with the family since 1997 in relation to the older children, with Child Protection (CP) Plans in place between 2004 and 2007, and 2008 to 2012.  During this time, the focus was on the behaviour of one of Child V’s siblings who was viewed as being beyond parental control, as well as the mother’s parenting style, domestic violence, and alcohol misuse. A series of child protection and court proceedings ended in relation to the older children in July 2012, however concern regarding Child V’s schooling coupled with the lack of CAMHS involvement meant that the court proceedings for Child V continued until October 2012. Since 2011, an Education, Health and Care Plan (EHCP)4 (previously known as Statement of Educational Needs) had been in place for Child V.    In June 2016, a referral was received via the National Society for the Prevention of Cruelty to Children (NSPCC). The concerns raised related to, unsubstantiated physical abuse, neglect, emotional abuse, and alcohol & substance misuse. Child V’s mother refused to cooperate with services.  However, during this time Child V came to the notice of the Police for anti-social behaviour and assault on a peer. His mother informed the Police that Child V had learning difficulties with a mental age of seven. Child V was 13 years old at the time. Child V was given a youth caution and preventative work was offered by the YOT team however, the family did not engage. Later in 2016, Child V’s mother had an altercation with the Headteacher of his school which led to the mother being banned from the school premises and seems to have been the final issue that led                                                            4 Statutory assessment under Children and Families Act 2014 10  to Child V’s school attendance declining to a point of no return.  Child V’s mother refused support and alternative placements.  Before November 2016, Child V had deteriorated to a school attendance level of 32.97%. By the end of 2018 he was off roll of any mainstream school.  From 2017 until 2021, when he reached 18, he was provided with alternative placements, none of which proved successful. In 2016, it was recognised how vulnerable he would be in not attending school. However, his mother refused to engage with any services and refused entry into the home.  In 2016 Police reported that there had been a long history of violence within the family, Child V was involved with a group of youngsters with disturbed behaviour and exposure to violent episodes both at home and outside.  It was during this time that Child V was subject of a CP plan for neglect, but his mother refused to engage, and it was not possible for assessments to be completed. Nevertheless, the professional network recognised the risks that had the potential to have a negative impact on Child V’s development, including witnessing violence, non-school attendance, lack of mental health assessment and living in a household where he could be influenced by the behaviour of siblings.  It was known that Child V was at high risk, not just from non-attendance at school, but also the violence and possible criminal behaviour of members of his family. However, care proceedings were unsuccessful in achieving his removal from the home. All options had been tried and were unsuccessful. There is a sense that the professional network had to withdraw due to insufficient evidence of harm.  In 2018, there was an EHCP review for Child V held at the school where he had remained on roll.  Child V was identified as having severe social, emotional, and mental health problems and ADHD.  Child V’s mother attended and stated that she “didn’t want everyone to waste any more money on V as this money could be better used with pupils that will use it, as V is not going to”.   She reported that Child V would be violent if forced to do something he did not want to do. She also reported her own mental health difficulties and ill-health.   The outcome of the review was for a referral to NEET and work with the careers’ adviser rather than taking immediate legal action regarding non-attendance.  Child V’s mother reported that he would be able to do some work experience with a family member once he reached 16 years.  That was the final review held for Child V. In 2019, he was no longer on roll at the school and was not in a further education setting. Both he and his mother refused to engage. The NEET worker undertook the liaison between the SEND service and the family. In 2020, a review was not held due to waiting for an Educational 11  Psychology Assessment to be undertaken, which was refused by Child V and his mother.    KEY CIRCUMSTANCES OF THE CASE There are four key episodes identified during the period in focus for the review.   Key Episode 1: November 2019: Safeguarding Referrals During 2019, there were safeguarding referrals and concerns raised with Children’s Services. These culminated in a strategy discussion being held, in November 2019, which concluded that the concerns met the threshold to convene an Initial Child Protection Conference. The concerns included an anonymous referral was received by Children’s Services via the NSPCC. The concerns related to physical abuse, neglect, emotional abuse, alcohol, and substance misuse.   The absence of an education placement was noted, and the education officer was tasked with finding one that would be agreeable to Child V.   Key Episode 2: December 2019 – March 2020: Child Protection Plan In December 2019, Child V was made subject to a Child Protection Plan (CPP) under the category of emotional abuse. At the Initial Child Protection Conference, mother and Child V were present. Child V’s mother was angry at the conference. The decision was that the YOT social worker would liaise with the family as he was one professional who seemed able to engage the family. However, this was on a voluntary basis and the engagement was not sustained between the initial and review conference.  The local authority reported that they had taken the case to the MACE panel which suggested a police welfare check. This was done however the police were unable to get into the family home as the mother would not give them access and Child V was not in the home.  The mother did send a picture of Child V to the YOT worker to prove that he was alive.  There was recognition by the Conference that Child V had a poor experience of childhood and that there had been a theme throughout his life, and his siblings’ lives, of a lack of boundaries and neglect.  Consideration was given to Care Proceedings, however it was deemed unrealistic due to the outcome of previous proceedings in 2012 and 2016. It was acknowledged that both Children’s Services and IYS had made significant attempts to work with the family. However, due to their non-engagement, it was very difficult to decide how best to support the family.  Child V’s age was deemed, alongside his childhood experiences, to limit his ability to change. He needed to be able to engage with services to move forward. He was considered to be old enough to advocate for himself and, without the evidence to back up the concerns that professionals had regarding Child V’s welfare, it was 12  decided that he did not meet the threshold for a CPP but needed early help services to continue to try to engage the family.    Key Episode 3: March 2020 – October 2020: MACE Panel monitoring Child V was monitored through the MACE Panel from March 2020 due to the indications that he was involved in criminal activity, some of it in association with adults.   The incidents included an aggravated vehicle taking and robbery charge, suspected aggravated burglary and several other burglaries, for which there was insufficient evidence of Child V being involved.  He was also found in possession of cannabis and, during an unrelated search of the home, was found to have scales and snap bags in his bedroom along with knives and a baseball bat in the home, which the family denied were his.   In March 2020, Child V was risk assessed as having low vulnerability to child exploitation, although it was recognised that this was likely to be higher but there were numerous unknown factors about his life.  Nevertheless, in March Child V had been arrested, due to robbery charges, which led to a period of being on an electronically monitored curfew between the hours of 7.00pm and 7.00am. He complied with the curfew which allayed concerns slightly and his mother reported that he was easier to manage.  He had weekly contact with the Integrated Youth Service (IYS) and was seen to be more engaging than when they had worked with him in 2018. There was limited information regarding his peer group but there seems to have been the suspicion that some of his peers were also known to the Youth Offending Team (YOT). In October 2020, Child V was assessed as being low risk. There was no evidence of current child exploitation concerns, with little being known about what was happening in his life. He was considered as being potentially vulnerable due to:  Poor relationship with parents  Parents own vulnerabilities  History of abuse  Poor school attendance  Learning Disabilities/ communication problems  Alcohol/drug misuse  Mental health issues  Low self esteem  Change in engagement with professionals  Engaging in anti-social behaviour 13   Additionally, there was evidence of potential grooming as he had been found in possession of unaccounted for items.  The assessment score was 18 and this led to Child V being removed from the list, with no further action.5   Key episode 4:  December 2020: Stabbing On 20 December 2020, the Police were called to the Emergency Department, at 1707hours, following a report from the hospital of Child V having walked in with a stab wound to the back, and was in a life-threatening condition and was deteriorating.  Child V was transferred, by ambulance, to a trauma unit where he had a lifesaving operation.  A strategy discussion was held on 21 December 2020, following which Child V’s mother agreed to her son being voluntarily accommodated under s20 of the Children Act 1989. Although she rescinded this agreement on 23 December 2020 and Child V was discharged home.  8 QUESTIONS RAISED REGARDING HOW AGENCIES WORKED TOGETHER Several questions were identified from the review of the chronology, documents, and discussions with staff. The purpose was to establish whether the incident could have been prevented, and what difference the agencies, either together or alone, could have made.   DID AGENCIES CONSIDER THAT CHILD V AT RISK OF EXPLOITATION?  It was reported that there was no evidence to show that Child V was being exploited. Nevertheless, he was reviewed at the MACE panels due the assessment that he was at a high risk of being exploited. He was believed to mix with older young people, who had poor life experiences, rather than peers.   The understanding of the level of risks that Child V faced was difficult to assimilate with the actions of the MACE to remove him from the panel list. It seemed obvious that the outcomes for Child V would not be positive. Although he was clearly known to services, he was the ‘invisible young person’ as professionals could not reach him to gain his trust and facilitate any possibility of a positive outcome for him.                                                              5 Sutton Exploitation Screening tool: 0-20 = low risk: No evidence of current Child Exploitation concerns. A child is potentially vulnerable to exploitation, but no current concern they are being targeted or groomed. Multi Agency Early Help responses to be considered.  14  The professional networks tried various ways to connect with Child V but ran out of options available to them. It was deemed that there was insufficient evidence to suggest that he was being exploited.   Ultimately, although the assessment of risk was scored as low, the ‘gut feeling’ of those professionals who knew Child V, recognized that his risk was higher. The evidence of a ‘checklist’ was given more status than professional opinion. From the perspective of the MACE panel, there needed to be more evidence of the risks faced by Child V.    WHAT COULD HAVE BEEN DONE EARLIER IN CHILD V’S LIFE TO CHANGE THE OUTCOME?  Child V spent his childhood being neglected in some way. His needs were not prioritized within his family when younger, as he witnessed violence in the home; his education requirements within a school setting were not prioritized by his mother or schools. This led to him being out of the school system for 4 years, although he did have education support.   This was a child who was known to have a conduct disorder and had an Education, Health and Care Plan in place. However, there was no therapeutic intervention for the conduct disorder as Child V’s mother had not taken him for the CAMHS assessment. The EHCP included the need for an Educational Psychology assessment which was not achieved due to both mother and child not agreeing to take part.   Child V had been subject to a CPP earlier in his life and had been known by Children’s Services throughout his life. However, relationships between professionals and Child V’s mother failed, leading to her pushing services away.  Child V was left to grow up with his mother, without the safe space of a school placement.    At the end of 2019, when there had been an anonymous referral to the NSPCC regarding neglect of Child V, full consideration was given to the need to protect him.  He was made subject of a Child Protection Plan, but the idea of progressing to Care Proceedings was not taken forward due to his age and that previous Proceedings had not achieved the safety that professionals desired for Child V.   It is difficult to see a child, aged 16 or 17, left in a potentially unsafe situation due to his age. However, when this was discussed with various professionals, as part of the review, it was very clear that they felt all options had been fully considered. There was a consensus that to have progressed with Care Proceedings would not 15  have helped Child V. If he had been removed from his mother there was an extreme likelihood that he would abscond, return to his mother and his associates in the community.  There was a definite sense that the connection between Child V and his mother was strong.  There was also evidence that his mother wanted to protect him from the outside world but found it all but impossible to trust professionals to help her to do this.  The impact of decisions earlier in Child V’s life had left professionals making assumptions about their ability to progress with meaningful relationships with the family that would make a positive difference his life.   HOW WAS THE EHCP FOR CHILD V MANAGED BY THE MULTI-AGENCY NETWORK?  It was striking that Child V was reported not to have been in school for 3 or 4 years. This gives the impression that he had no access to education during that time but had an EHCP. However, the Special Educational Needs and Disability (SEND) team explained that he did have access to education during that time and there were immense efforts to provide bespoke packages. It was reported that he was provided with Social, emotional and Mental Health Need (SEMH) placements but the family did not engage with these provisions. Then, once he had reached 16, his mother said her son would not engage, and a home online package was provided, but again was unsuccessful. It needed commitment from the family to follow through with the work. There were other placements offered and Child V did engage for short periods in the Life Centre work, but he did not receive a consistent secondary education, i.e., 2015-2021. However, this was a child who had an Education, Health and Care Plan (Statement of Educational Needs) from 2011.  Child V was known to the Not in Education, Employment or Training (NEET) worker who was able to connect with Child V and his mother, intermittently.  Efforts, currently, continue to be made to try to engage Child V in education or work experience to enable him to move forward into a positive adult life.  At the start of 2020, Child V was subject to a Child Protection Plan. Within the documentation, of the CP conference, seen there was evidence that it was recognised that NEET needed to be involved with Child V. However, there was no representation from education at the conferences.  From the evidence found, there was a misunderstanding between social workers and education regarding the process of invites. This meant that the vital contribution of the SEND team was missed. Subsequently, there was a lack of understanding about Child V’s educational needs, the fact that he did have an EHCP, and the reasons behind him not being in a school placement.   16  At this point neither mother nor child were actively engaging in the education opportunities offered. Indeed, there is sparce evidence of how Child V spent his day. It was reported that the mother had told workers that she felt let down by the education system for not providing her son with the right placement. This contradicts what she had told the EHCP review in 2018 that her son would not accept anything.  Workers did try to see Child V at home, with little success. His mother warned professionals that Child V would be aggressive if they visited. Meanwhile, there were offers for him to meet workers at outside venues, but this required a commitment from him or his mother to get there.  There seemed to be a significant expectation on his mother to address the needs of a child with a conduct disorder who was limited, without intervention, in being able to function within society.   WHAT SIGNIFICANCE DID PROFESSIONALS PLACE ON THE ROLE OF CHILD V’S ACCESS TO MALE ROLE MODELS?  It is not clear what involvement Child V’s father had in his life. The impression is that he did not feature after the family were moved due to him being violent. Child V’s mother raised concerns at the Initial CP Conference in December 2019 that the father’s details were recorded on the documentation. She informed the professionals that her ex-partner was not permitted to know the family’s location. However, there were suggestions that Child V had been bought an expensive coat by his father. This was not explored by professionals because they could not reach a point of a trusting relationship to discuss this with the family.   This highlights the invisibility of a father to professionals and the poor understanding of the impact that of that parent on a child’s life.  This has been identified extensively within other reviews, as professionals fail to ask about fathers and men in the lives of the child6. Thus, the need of a child to have positive male role models in their life is missed.   Child V had half-brothers who were, at times, involved in Child V’s life. Indeed, Child V reported being interested in the work that one of his brothers did. However, there were varying professional views as to who was living in the home.  The male professionals involved during the period reviewed seemed to have the most success, albeit limited, in reaching Child V. This was recognized within the CP Conference with the plan for the YOT worker to engage with him.                                                             6 Dickens, J. et al. (2021) Annual Review of LCSPRs and Rapid Reviews. The Child Safeguarding Practice Review Panel.  17  9 ANALYSIS OF PRACTICE  The terms of reference identified three key themes for exploration: Individual needs of the young person; family history and dynamics; Quality of practice. Two further themes were identified during the review.   THEME 1: INDIVIDUAL NEEDS OF THE YOUNG PERSON   Child V was viewed through his needs and behaviours:  Conduct Disorder / Oppositional Defiance Disorder (ODD)/Unsocialised Conduct Disorder  Long term absence from school and Learning difficulties  Trauma from childhood experiences  Offending behaviour Additionally, there is a theme of how  his unique identity and ethnicity were not visible within the documents reviewed.   Conduct disorder  It was noted that Child V had a conduct disorder but there were varying accounts of what actual diagnosis he had. The GP was able to confirm that, in 2013, he was seen by CAMHS and had a diagnosis of Unsocialised Conduct Disorder.  However, due to his mother not taking him for appointments, CAMHS closed his case and, therefore, ended the opportunity for a coordinated approach to provide Child V with the high-quality care as defined by NICE.7 This review did not explore what options were offered by CAMHS as their involvement had ended many years ago. However, within the CPP it was recognised that he had a conduct disorder, but any assessment had been refused by his mother. There did not appear to be any consultation with CAMHS to aid the decision making. It was just seen as one of those too difficult things to address because it would have needed mother’s engagement. Given that Child V’s mother had a good relationship with the GP practice, this could have been a route in for agencies to encourage her to take her son to CAMHS appointments.  Between the CP Conference and the EHCP reviews there should have been the opportunity for workers to discuss with Child V and his mother the need for assessment and treatment of his disorder to enable him to function safely and transition into adulthood.  Although, the EHCP included an educational psychology assessment, this was incomplete due to workers not being able to engage Child V and his mother.                                                              7 https://www.nice.org.uk/guidance/cg158 : accessed 31 May 2021.  18  There remains insufficient knowledge of Child V’s life experience and his insight into how the conduct disorder affects him. Nevertheless, there is sufficient evidence that Child V did not receive the intervention he needed to support his mental and emotional needs. This is deemed to be due the negative response from Child V and his mother to voluntary interventions and assessments. However, there was evidence that mother reported that Child V could become aggressive when asked to do something he did not want to do. This showed that his mother had difficulty in managing him. Therefore, the expectations placed on the mother to get Child V to appointments were unrealistic.  It is of note that Child V did access hospital services, when necessary, and the YOT/IYS, when required. Therefore, the potential for a different approach to attempt to reach Child V was available but not addressed by the multi-agency network.   School absence and learning difficulties  For the scope of this review, Child V was not at school and had not been for years. In fact, in 2016 when he had previously been subject of a CPP and Care Proceedings, the main problem was seen as him not attending school. At that time, he was 12 or 13 years of age. More should have been done at this point, or earlier in primary school, to ensure that he was in a school placement that could meet his needs. The view held within the EHCP was that education was not the main problem for him, yet it was the SEND service that was having to continue to find a solution.  Education provision was offered during those years, but this seems to have been isolated from the wider professional network. This diminished the opportunities for a holistic solution focus within MACE, Child Protection Conferences, EHCP meetings and youth offending discussions.   There was an incomplete picture of the extent of his learning difficulties. This with the unmanaged conduct disorder meant that Child V did not receive the assessment and treatment set out in the NICE guidance. There was no consultation for professionals with CAMHS or Educational Psychology. There needed to be a collaborative approach to ‘wrap around’ a family to prevent the misdirection of professionals.  Child V had a severely limited education. From a history of moving schools, exclusions, and non-attendance at alternative placements. He missed out on the safety of a school, positive role modelling, learning opportunities, management of his conduct disorder, all that would be needed to enable him to function well within society.  19  Given Child V’s emotional behavioural issues and communication difficulties, his needs should have been considered in collaboration between education, child protection and youth justice rather than in isolation of each other, to give him constructive support. There were assumptions made of the authority of each system to enforce change.   There were reports of him being interested in a job done by one of his brothers which seemed positive, but this needed Child V to take part in educational activity at a time when he had been out of school for too long and struggled with the concept of a college course.  There was also an indication that a male relative was going to get him some work experience, but this was when he was 16, and there was no knowledge of whether that came to fruition.   Childhood trauma This family reflected high levels of harm towards the children due to witnessing violence or being subjected to physical harm. In Child V’s early years, his mother was viewed as being able to manage him, although there was evidence of her not managing the older sibling.   In 2019, there was another opportunity to address the harm Child V had been subject to during his life, but the professional network was incapacitated from making any impact to improve his life chances. He was about to transition into adulthood on an unsafe pathway. There was a dearth of legal options available to professionals due to his age and these would not have kept Child V any safer than he was with his family.  For Child V, he needed a ‘reachable, teachable moment’ which was unlikely to be found until he was within the criminal justice system. Although, he had been seen during 2019-20 within hospital settings, it was not until after the stabbing, that he was seen a trauma centre where he would have had access to youth workers to talk to him. Had he had an opportunity for that moment when he might listen to trusted adults, within the local hospital or urgent care setting, he might have been ‘reached’ before the incident.  9.1.4 Offending behaviour Child V was known to take risks. He was known to Police and to YOT.  Over a period of five years, he came to the notice of the Police 175 times.  Yet, he managed to keep on the edge of criminal activity and risk taking, thus avoiding any intensive agency intervention, until he became the victim of a violent assault. It is possible that he could have just as easily have been a perpetrator rather than a victim.  More should have been done to view him as a child, at risk of exploitation. If this had been done, in alignment with the child protection work and knowledge of his 20  learning difficulties, it might have been possible to find a way to work with him to reduce his risk taking.  9.1.5 Identity and ethnicity  It is not known how Child V has found his identity within his family and difficult to make a judgement without speaking to him and his mother. Nevertheless, there was a view from some professionals that Child V’s mother struggled with him being a person of colour.  Although this was not found to have been explored by professionals.  In the documents reviewed, there was evidence of recording of his ethnicity, but this was not used in any context for the work being undertaken. For example, it was noted in the MACE risk assessment but there was no mention of ethnicity as a factor in the risks of exploitation faced by Child V.  In fact, in terms of youth violence, he did not fit the Sutton profile that shows that the majority of victims of knife crime in Sutton are male, over 18 years of age and of White European ethnicity, indeed there has been a substantial reduction in the number of knife crime victims under the age of 258.   THEME 2: FAMILY HISTORY AND DYNAMICS   This is a family known to services for over 20 years, yet there was limited knowledge of Child V’s life during his teenage years.  According to the genogram, Child V has four half-sisters and two half-brothers. The two brothers and one sister seem to have been part of Child V’s home life, although one of the brothers had been in care and in 2016 continued to have a different address. It is not known where the sister is but there were reports of the other brother returning to the home. There have been varying views from professionals as to who else is currently living in the home.  This shows that there was information available about Child V which was only reviewed by individual agencies rather than within a multi-agency context. Had it been there would have been the opportunities for more questioning by professionals about how this young person could achieve his full potential and how they could work together to facilitate this.  This theme is subdivided into:  Dysfunctional families  Mother’s influence                                                             8  Sutton Serious Youth Violence Strategy.  21   Dysfunctional families   So little is known about the family, although they have been known to services for the whole of Child V’s life, and earlier.  Agencies made numerous attempts to get into the home whilst Child V was subject to a CPP during the first part of 2020, but both Child V and his mother blocked this. This meant that there was limited understanding about Child V’s experience in the home and the adults who have been part of his life.   Professionals recognised that this was a dysfunctional family over long period of time, through consistently withdrawing from services after short periods, historical violence within the home, difficulties in parenting and boundary setting, indicators of substance misuse and criminal activity.  Child V appears to have spent his childhood learning to live in isolation from positive social experiences and professional contact. He has learned to live in a transactional world with others, like him, who struggle to function within mainstream society.   Mother’s influence  The dominating figure in making decisions about Child V’s life is his mother. From her arguments with schools, mistrust of social workers, refusal to let workers into the home and not taking Child V to appointments, she appears to have dictated the path that Child V has led and continues to lead. Services report that mother has her own, long term, mental health issues, possible, substance misuse, and aggressive responses to professionals. Although she has managed to remain a patient at the same GP Practice for many years. She has a working relationship with the team there, to the extent that, when agencies had not seen Child V, the social worker asked the GP Practice to check with mother. The Practice Manager phoned the mother and she obliged by passing the phone to Child V.  This shows that there were ways of working with the mother which could deliver successful responses, even though small.    THEME 3: QUALITY OF PRACTICE  The initial finding, in relation to the quality of practice, is that Child V was ‘unreachable’ by services. There were numerous proactive attempts to accommodate both his, and his mother’s, wishes. However, when systems were put in place to help Child V, either he would not follow through with taking part in the work, or his mother refused the involvement of the professionals.   The impression is that services were not able to move forward with supporting, and protecting, Child V. The focus moved onto him as an offender, but this seems to have been mainly due to the YOT worker being the main person with any chance 22  of engaging Child V.  The consequence was that the necessary assessments were not completed as these required other professionals and services to be involved. The systems did not support the individual professionals and services to make a positive difference to Child V’s life chances due to the need for families to ‘engage’ with services. Although there was supervision in place for workers, and line managers were focused on supporting their staff, e.g., at the CP conference, there needed to be more opportunities for bringing together the key agencies to find a solution and to be able to formalise the agreed approach. This needs to be set within a statutory framework to ensure that plans do not drift, due to informal arrangements. In the case of Child V, the CP Plan was the appropriate mechanism to hold the work together, rather than stepping down to early help at the point at which the YOT worker was no longer able to commit to the efforts made to reach the young person.  There are three key areas of practice to be considered:  Assumptions about historical decision-making  Quality of multi-agency meetings: CP Conference and MACE Panel  Responding to Risk 9.3.1 The assumptions that professionals make regarding historical decisions and the influence this has on their current concerns    In 2012 and 2016 there had been care proceedings which resulted in supervision orders which the mother ignored. There was a sense from the social work team that they had been failed by the judge and guardian ad litem as the request had been for removal of Child V from the care of his mother. However, when this was checked with the legal team, it was found that Children’s Services, certainly in 2016, had not asked for removal. Nevertheless, this seems to have been the view that led to the thinking at the Child Protection Conferences in 2019 and 2020, i.e., not to go for care proceedings.  It was clear from the conversations held with the professionals that Care Proceedings would not have worked for Child V due to his age and his strong bond with his mother. Child V was seen to be able to advocate for himself.  However, there was no consideration of alternative options which created a mindset of if something did not work then the risks to the child must be low.  9.3.2 Quality of multi-agency meetings: CP Conference and MACE Panel Child V’s mother would not engage with the CPP 2019-2020.  Within the initial conference it was clear that she would not work with Children’s Services.  As Child V had been engaged with YOT/IYS, it was decided that the worker would lead the interventions with Child V and his mother.  This was agreed at senior management 23  level. It was positive in recognising that Child V’s mother was difficult to engage but had a good relationship with the YOT worker.  The expectation was that the YOT worker would be the key practitioner if the family would agree to engage. However, Child V chose not to continue to work with the YOT worker who was unable to influence this as there had been no formal arrangement for Child V to be on his caseload.  Although it was included within the CP Plan that this would be the way forward, there was no consideration of the potential outcomes.  Meanwhile, the MACE panel continued to monitor Child V, but could not establish the evidence of high risk for him, despite the intuition of the IYS worker who was another professional able to have some, limited, engagement with Child V. Subsequently, MACE monitoring came to an end before the incident as well.  There was consideration of the risks at the Child Protection Conferences and MACE panels. This was supported by managers who attended the meetings regarding Child V as they recognised the risk to their teams.  However, both professional networks did not find the tools to support them to address the risks. Decisions were based on incomplete assessments due to being unable to reach the family.  There needed to be formalised work on behalf of the systems. Targeted intervention, using mentoring, needs to be intensive and consistent to enable trusting relationships to be established9. This could have supported Child V, and his mother, to start to trust other workers and agree to further intervention and assessments. However, for this to have been successful it needed to be embedded within the CP Plan, EHCP and MACE plan.   Responding to risk  Child V was part of a cohort of high-risk adolescents who seem to be ‘unreachable’ by statutory services.  Child V met the profile for a wide range of risk factors for both perpetrator and victim of serious violence as set out in the national youth strategy10. It is extremely difficult to manage the risks for this cohort without a coordinated, consistent approach. Otherwise, as in Child V’s case, there can be a tendency for workers and organisations to feel powerless to change the young person’s life chances.                                                             9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/498493/what-works-in-managing-young-people-who-offend.pdf   : accessed 19 June 2021.  10 Home Office (2018) serious Youth Violence Strategy pp32-43 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/698009/serious-violence-strategy.pdf : accessed 19 June 2021. 24  For Child V, during 2019-2020, there were growing indicators of the risks he posed for himself and others, whilst his mother continued to be unable to effectively interact with the professionals who could assist her in keeping her son safe.  There were three, somewhat disconnected, systems in place: Child Protection, MACE, and EHCP. These did not work together to pool their information regarding the risks Child V faced. Additionally, there was no inclusion of specific services such as GP and A&E which could have been points for reaching Child V and his mother more effectively.    THEME 4: IMPACT OF NON-ENGAGEMENT ON RELATIONSHIPS This family did not engage with services over most of Child V’s lifetime. There was evidence of limited engagement with some services, but actions would not be completed by the family. The lack of ‘engagement’ can be divided into different themes:  Not taking a child to appointments leading to a service closing the door to the family  Aggressive attitude by a parent leading to a service withdrawing from the family  Family members needing to undertake activity to help themselves but not doing so, leading to no improvement and the service withdrawing from the family In Child V’s case, his mother had several poor experiences with professionals over the years of being a parent. Meanwhile, there is no knowledge of her own childhood experience. Child V had a poor experience of school and saw his mother’s difficult relationships with most professionals.    Child V lived in a household where the avoidance of statutory agencies was normalised. His mother avoided any service where there were expectations made of her to act, i.e., Children’s Services, CAMHS and education. This meant that Child V was aware that it was possible to avoid any perceived interference. However, this also meant that he had little exposure to potential trusted adults who could help him, and when they did appear he dropped them if he needed to be an active participant in the relationship. Child V connected with the IYS/YOT but only when he chose to, e.g., he attended the centre to meet with the YOT social worker in relation to his use of cannabis. He appeared, initially, to take an interest in the activities to understand the impact of substance misuse but then disengaged. This does not appear to have been an issue of the service not being flexible enough but, rather, that Child V realised that it was voluntary, and he made the choice to not attend.  25  There is a definite sense that the family know how to use services, specifically health services. Child V’s mother used the GP practice and had remained a patient there for many years. The reason for this was that the staff there had also been in place for years and understood Child V’s mother and responded to her needs. Interestingly, Child V was not proactive in using the GP practice. His mother would contact the GP on his behalf. Meanwhile, if Child V needed health care, he would take himself to A&E, and this remains the case.  However, what Child V needed was education services and CAMHS intervention to address his conduct disorder and learning difficulties.  Yet neither he, or his mother, recognised these in the same way as they did general or urgent health services. The difference being that the latter are available whenever an individual decides they need support, whereas education and CAMHS require active participation and are not immediately available.  Non-engagement cannot be a reason to stop statutory work to safeguard a child. There needs to be a united front by professionals with an agreed plan, single lead practitioner, shared purpose and agreed outcomes for change. The impact of non-engagement for the future management of Child V’s disorder and learning difficulties needed to be addressed by the agencies.  9.5  THEME 5: DISCONNECTED SYSTEMS AND INSUFFICIENT EVIDENCE OF HARM  At the Initial CP Conference in December 2019, the threshold was considered, unanimously, to have been met. However, at the Review CP Conference in 2020, it was concluded that there was insufficient evidence of harm. Only months later, the MACE concluded that there was insufficient evidence of exploitation.  From November 2019 until December 2020 when Child V arrived at the hospital having been stabbed in the chest, there were concerns about Child V but never sufficient for immediate action.  There should have been a clear agreement, between the CP Conference members and the MACE panel, on the expected outcomes for him to ensure that he was not left without the safety net of either11.  Individual workers, and managers, were concerned for the safety of Child V. Managers attended Child Protection Conferences and decisions were discussed with senior managers. Yet, there was still a mindset of professional powerlessness when Child V or his mother would not engage with services sufficiently to enable evidence to be gathered to fully understand the risks Child V faced.                                                             11 Sheffield Safeguarding Children Board (2020) Serious Case Review: Archie.  26  This has been raised in other reviews of various safeguarding work, under the auspices of professional curiosity. This can be viewed as a ‘cliché’ as a way of not fully exploring the underlying reasons why adolescents might be seen as ‘troublesome’.12   For Child V, professionals knew a great deal about his history, they felt blocked by his mother in their efforts to initiate any up-to-date enquiry into Child V’s behaviour and thought processes. This left him isolated.   10 LEARNING POINTS  The criteria for this review included: a) Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified. In this case, the practice systems for child protection, criminal exploitation and special educational needs did not support practitioners in coming together to find a way of safeguarding Child V and enabling him to have a successful transition into adulthood.  The review shows that improvements are needed in the way the multi-agency networks communicate with each other and in how adolescents are safeguarded within Sutton.   b) Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children. The review suggests that there is a recurring theme of how agencies support children who are not in education but have complex needs in relation to their social and emotional wellbeing.   c) Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. The review highlights that there is a disconnect between education services and the child protection system. There are concerns about the absence of CAMHS within the EHCP and child protection systems when families have disengaged with the service. d) Where the safeguarding partners have cause for concern about the actions of a single agency.                                                            12 Dickens, J. et al. (2021) Annual Review of LCSPRs and Rapid Reviews. The Child Safeguarding Practice Review Panel. 27  The focus of this review has been on how agencies have worked together rather than any cause for concern about a single agency. Nevertheless, there does need to be more understanding and consideration of the role of the Police in working with partners to address how to find evidence of criminal exploitation when professionals intuitively know that a child is at risk of harm.  Additionally, although not asked to contribute to the review, there should be discussion about how CAMHS can contribute to CP Conferences and EHCP reviews, in a consultative manner, for children who should be under their care.  This case shines a light on the Sutton systems in six specific areas:  School as a place of safety  Cumulative harm  Contextual safeguarding  Relationship-based practice  Hearing the child’s voice  Managing organisational risk   SCHOOL AS A PLACE OF SAFETY The Covid-19 Pandemic has highlighted the risks to children when they have long term absences from school, as for so many during the first lockdown in spring 202013. However, there were already a cohort of children without access to regular school time, either through parents not taking them to school, children absenting themselves, or schools using permanent exclusions. These children can be invisible to services and wider society. These children have limited ways of making their voices heard. These children are at high risk of exploitation due to their invisibility and exclusion is a definitive indicator for being at risk of significant harm14. The pandemic has emphasised the extent to which a school is a place of safety for children.  Taking the Covid-19 lockdown as a benchmark, those who have not been in school for four to six months are at highest risk. Some will remain on the school roll, but this might be placed out of borough. Therefore, there needs to be tighter monitoring of these children to ensure that there is joint working with neighbouring boroughs to find a way of sharing information, thoroughly and timely, for children who are not attending school, particularly those who have behavioural disorders.                                                            13 The Child Safeguarding Practice Review Panel (2020) Supporting vulnerable children and families during COVID-19: Practice Briefing. DFE.  14 The Child Safeguarding Practice Review Panel (2020) It was hard to escape: Safeguarding children at risk from criminal exploitation. DFE. 28  The second aspect of school safety is that of providing special educational needs support, which, again, is a serious problem when a child has been excluded or does not have access to a placement that can meet their needs. This lack of access can be through insufficient supply or parental refusal. This was raised in a previous Sutton review15.  It has been shown that much work has been done to improve the SEND offer16 in Sutton, including the development of the ‘Graduated Response to Preventing Exclusions’.17 Nevertheless, there continues to be a need for more, multi-agency, analysis regarding those highest risk children with complex behavioural needs who sit outside of the school system.   CUMULATIVE HARM A child growing up in a household where the dominating issues are those of the parents, such as violence or mental health problems, can lead to the child not having their needs adequately addressed.  When the child has been diagnosed with a behavioural disorder, any lack of supervision or affection by the parents can exacerbate the child’s risky behaviour. Alongside this, there can be a lack of effective professional intervention due to the parental dynamics, just when robust, creative interventions are needed to enable this child to reach their full potential18.  Brandon et al. (2020) highlighted the long-term harm caused to a child when there are parental and environmental risk factors present19. They noted that  ‘When there is a focus on parental illness (mental and/or physical) and other difficulties, the voice and lived experience of the child can easily be overlooked’20.  Within Sutton, for Child V, there was plenty of historical information available. Within formal networks, the agencies worked together well in their ambition to make a positive difference to the child. However, Brandon et al (2020) suggest that the amount of information held, and the nature of complex families such as Child V’s, can block the sight of the professionals attempts to identify the risks face by the child and opportunities to understand the lived experience of the child.21 Brandon et al (2020) found that:                                                            15 Sutton LSCP (2020) Child Safeguarding Practice Review: Child T. 16 DFE (2015) Special Educational Needs and Disability Code of Practice: 0-25 years; Sutton Local Offer www.sutton.gov.uk : accessed 31 May 2021. 17 Sutton Schools Graduated Response - Preventing Exclusion. https://www.sutton.gov.uk/downloads/file/4260/sutton_schools_graduated_response_-_preventing_exclusion: accessed 31 May 2021. 18 Okuda M et al. (2018). Do parenting behaviors modify the way sensation seeking influences antisocial behaviors? Journal of Child Psychology and Psychiatry, 60, 169-177. doi: 10.1111/jcpp.12954 19 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE. p14. 20 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p16. 21 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p66. 29  ‘Adolescents were living in situations of neglect may be particularly vulnerable to having their needs, and the risks they face, overlooked. Clear pathways for transition to adult services are important to ensure young people receive the care and support they need.’22 Therefore, the Sutton LSCP needs to gain assurance that adolescents are not left at high risk due to the family living in isolation of societal support.  During one of the workshops held as part of this review, there was a decision that the partnership needed to monitor the ‘top 10’ children at risk to find ways of intervening to help them to achieve their full potential. This should be done for those at different, crucial, transition periods of childhood such as ages 4-5, 10-11, 15-16.   This was raised at a workshop on 20 May 2021, which led to a discussion as to how the Sutton Vulnerable Pupil Panels could be utilised to initiate multi-agency problem solving work in relation to those children who are deemed to be at highest risk of long-term harm but appear to be ‘unreachable’.   CONTEXTUAL SAFEGUARDING: APPLYING THINKING TO PRACTICE   The Contextual Safeguarding work underway in Sutton could be used to strengthen the approach towards this age group, in enabling practitioners to be more enquiring about the ‘capacity of contexts to create safety around young people and open-up safer choices.’ 23  This could build on the work done by Children’s Social Care through their restorative practice model.  Firmin (2018) found that 33% of young people involved in a study of nine peer on peer cases, had experience of harmful behaviour within their families.24 However, the expectations of programmes to reduce community antisocial behaviour by young people, usually rests with the need for parents to supervise their children25. Yet, for a young person such as Child V, this a way of setting the family up to fail as the parenting capacity is not at a level to provide the supervision he needed.  Sutton is currently doing work in the upscaling of Contextual Safeguarding, with a project lead who is facilitating the discussions into whether the concerns are about the individual young person or the community. The workshop held, as part of this review on 20 May 2021, discussed the need to find ways of working with young people whose behaviour is entrenched. Workers need to have the tools to engage                                                            22 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p66. 23 Owens, R. et al. (2020) Relationship-based Practice and Contextual Safeguarding: Key messages for practice. p.9.  https://www.csnetwork.org.uk/en/resources/briefings/practice-briefings : accessed 19 June 2021.  24 Firmin, C. (2018) Abuse between Young People: A contextual account. Routledge. Oxon.  25 Featherstone, B. et al. (2020) The Social Model and Contextual Safeguarding Key Messages for Practice. The International Centre.   30  with the young people, and their families, without becoming overwhelmed by the complexity of their lives.    At the May 2021, workshop it was suggested that young people are asked to name a key person who has made a difference in their life. Anecdotally, where a young person can name a key adult then that young person has managed to find the right path into adulthood. Therefore, the ambition should be that all children and young people are able to identify one adult who has been a protective factor for them.   Of note, the local hospital Emergency Department (ED) does not have youth worker provision, due to it not being a trauma centre. Considering the frequency of use by Child V of the ED, it seems to have been a missed opportunity for him to be reached by professionals. The Contextual Safeguarding work provides the opportunity for the LSCP to think about the wider possibilities to reach young people and what measures can be put in place as they transition into adulthood.   RELATIONSHIP-BASED PRACTICE  This case demonstrates the difficulties that professionals face when parents refuse to engage with the service, be it voluntary or a statutory requirement such as schools or CPPs. The children in these families do not learn how to have a trusting relationship with services designed to help them. The professionals can view these families as not engaging and reduce the level of activity to attempt interventions.  Within this case, the ‘non-engagement’ took place throughout Child V’s life, and this had a severe negative impact on his ability to reach adulthood safely and with a positive purpose for life.  The term ‘non-engagement’ is used frequently for families who do not attend appointments, because a parent has not taken the child; for parents who refuse to work with social workers, and others, to change their behaviour to enable them to meet the needs of their children; constant changes of individual practitioners mean that parents can lose the willingness to work with professionals. However, this maintains the focus on the adult relationships and allows the child to be lost without a voice.   Brandon et al. (2020) placed a vital importance on the need for professionals to develop good relationships with families to enable good understanding of the family context and effectively manage the complex risks over a period of time, which are not impeded by staff changes. 26 This includes the need to have a workforce capable of developing an empathetic relationship with parents.                                                             26 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p18. 31  There needs to be clear understanding of the reasons for a family to ‘non-engage’ and what the resulting risks are for the child. Additionally, organisations need to challenge themselves about the level of flexibility their service provides, to ensure that avoids promoting a ‘one size fits all’ approach but recognises the personalised needs of those they are trying to reach. The National Panel (2021) found that a key theme of reviews was that some parents were overwhelmed by the number of professionals they needed to work with.27 The emphasises the need for a single practitioner to take the lead. This does  not necessarily need to be a social worker, as in the efforts made within the CP plan within the case of Child V, but this role must be recognised, given the resources and authority to act.  Within Contextual Safeguarding, there is a significant focus on the importance of relationships for interventions with children and young people at risk of exploitation. These relationships are seen as having five key features, consistency, reliability, stability, continuity, and authenticity28.   This case review shows the need for adolescents to have consistent relationships with professionals, which can set clear expectations. The case demonstrated that not all services did what they said they would do, throughout the child’s life, e.g., following through with options for activities. There needs to be strengthening of how workers gain a good understanding of the impact of a child’s experience of professionals.   HEARING THE CHILD’S VOICE Consider how to gain the trust of a child to enable them to be able to disclose, when they are ready. There can be challenges regarding children disclosing abuse or neglect but then there is no improvement in their situation. Professionals need to recognise the strength of relationships between children and their parents even when professionals can see neglect. If a child is in school, there are more opportunities to hear their voice than if they are never in school. Therefore, the voice of the child should be a high priority for professionals trying to work with families where a child has been permanently excluded or absent from school. Additionally, for children with special educational needs, they can be excluded from having their voice heard from an early age, due to the reliance of services on the parents to engage with the interventions.                                                             27 The Child safeguarding Practice Review Panel (2021) Annual report 2020: Patterns in Practice, Key Messages and 2021 work programme. 28 Owens, R. et al. (2020) Relationship-based Practice and Contextual Safeguarding: Key messages for practice. https://www.csnetwork.org.uk/en/resources/briefings/practice-briefings : accessed 19 June 2021.  32   MANAGING ORGANISATIONAL OR PARTNERSHIP RISK Working with adolescents who have complex needs can be challenging for organisations and partnerships to manage. The role of the parents can become a conflict with the growing independence of the young person. This makes it challenging for professionals when undertaking assessments and planning interventions. Under 18 is still a child under the Children’s Act 1989, yet it can be extremely difficult for professionals to take forward legal protective actions due to either the parental obstruction or that of the young person themselves.  There is evidence of an approach akin to that of a social model that promotes a way of working that diminishes ‘them and us’ professional to family conversations and encourages thinking about the wider inequalities for a child and family.29 In this case, Sutton made use of the fact that the mother could not work with social workers due to her previous experience. Therefore, the plan was made to utilise a professional who was known to connect with the mother.  This posed a high level of risk for Children’s Services to step down from the Child Protection model. However, it was a risk that was held by the senior leaders and is something to build on.  If that way of working had been tried at earlier and had the resource and provided the worker with the ‘permission to act’ rather than being seen as an informal approach, this might have helped the young person more.  The Contextual Safeguarding scale up work being undertaken in Sutton could be used to strengthen this approach, through a partnership commitment to fund workers who can undertake the intensive interventions with the children and young people most at risk of exploitation30.  The Sutton approach to the use of the Vulnerable Pupils Panel (VPP) and Graduated Response provides a good framework for managing the risk for these children and young people. However, within the framework it requires referrals to other services, thus the LSCP needs to be able to gain assurance that all referral pathways enable a quick response to referrals from the VPP.  This needs to include a collaborative approach from the three statutory partners: the police need to strengthen their engagement with the Contextual Safeguarding work through sharing data and critically planning how to disrupt the serious  youth violence that meets the needs of the distinct Sutton profile; the CCG needs to ensure that CAMHS services are commissioned in a way that enables intervention  for those at risk of serious youth violence or isolation from a school community,  and to review the profile of under 18s attending local A&E or Urgent Care settings which could provide vital points of diverting the young people;  education need to reflect on                                                            29 Featherstone, B., Gupta, A., Morris, K.M. et al. (2016) Let’s stop feeding the risk monster: towards a social model of ‘child protection’. Families, Relationships and Societies. https://doi.org/10.1332/204674316X14552878034622 : accessed 11 May 2021. 30 Owens, R. et al. (2020) Relationship-based Practice and Contextual Safeguarding: Key messages for practice. https://www.csnetwork.org.uk/en/resources/briefings/practice-briefings : accessed 19 June 2021. 33  the impact of no school or home learning on the risks to a child or young person at risk of serious youth violence31.  11 KEY PRACTICE ISSUES From the learning points, there is evidence of the key practice issues that need improvement within Sutton.  These will be expanded on within the recommendations, but it is important that these are acknowledged throughout the local safeguarding partners, relevant agencies, and other strategic networks with a role to play in preventing serious youth violence. This table can be used, alongside the recommendations, to promote joint conversations within multi-agency groups.  Practice Issue Areas for improvement  Role of education within the wider professional network  The impact of a child not being in school and having a limited education due to:   SEMH needs not met  Historical poor attendance at school for a child with an EHCP  Education provision not achieved through working together across agencies Professional responses to cumulative harm over a child’s life    Repeated child protection plans without progress  Multi-agency systems not enabling working together to reduce harm  Responding to adolescents in the high-risk cohort Commitment to adopting a Contextual Safeguarding approach   Chairs of MACE and CP Conference need to join up to develop safety plans for young people  Contextual safeguarding needs to be embedded throughout the partnership  Professionals need to come together to apply their knowledge of an individual and community to assess the risks to children Finding out about the adolescent’s identity   Practitioners need to find ways of talking to a child to hear their voice                                                            31 Home Office (2021) Serious Violence Duty: Preventing and reducing serious violence. Draft guidance for responsible authorities. pp24-34 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/986086/Draft_Guidance_-_Serious_Violence_Duty.pdf : accessed 19 June 2021.   34   Be more proactive in asking about fathers or male role models  Across professional networks, formalise the role of the worker who can act as the key contact to the child, with perseverance and support from others across the agencies Relationship -Based Practice   Professionals need to reflect on how they address refusal of assessments by parents  Need for multiagency reflective practice, not isolated within single agencies   12 CONCLUSION  The case of Child V shows some good relationships across the professional network, at senior levels.  Nonetheless, there is a need to strengthen how systems come together to ensure that assumptions are not made that a child is being safeguarded, and their needs met, by another system.  The findings from this review correspond to the wider learning, for independent scrutiny, from the London Safeguarding Children Board set out in a workshop in April 2021.32 The findings from the review and the wider London work should be taken forward by the LSCP to take forward to improve practice across all agencies and strategic networks. The LSCP should use these recommendations to seek assurance about the effectiveness of safeguarding for the children resident in Sutton and enable the joint working in the borough to be strengthened. 13 RECOMMENDATIONS FOR LSCP STATUTORY PARTNERS AND RELEVANT AGENCIES Review Finding Recommendations There are risks to children who have social, mental, and emotional health needs whose needs are not met in mainstream schools.  1. EHCP reviews must involve health and social care to ensure that there is a multi-agency approach to addressing the educational needs of the children. Where there are limited options or barriers in place, there should be a multi-agency review of the safeguarding risks to the child.  2. For the LSCP to seek assurance that the SEND Coordinator is routinely included in the invites                                                            32 Ibbotson, K. (2021) Selected learning from reviews of deaths and serious injury due to serious youth violence: Questions for independent scrutiny. London Safeguarding Children Partnership.  35  and attends Child Protection Conferences, as required. Contextual safeguarding is an approach that would help the system in developing more constructive ways of working with those at risk of criminal exploitation and adolescents who have had a neglected childhood.  3. For the LSCP to seek assurance that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extra-familial harm by applying Contextual Safeguarding principles. 4. For the LSCP to seek assurance that there is a clear framework that underpins the rationale for the decision making about removing children and young people from the risk list.  5. For the LSCP to seek assurance that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved.  E.g., If there are expectations on Early Help services to work with the family, EHCP or MACE, then this needs to be risk assessed if these do not make sufficient progress. 6. For the LSCP to seek assurance through an independent scrutiny exercise that there are effective problem solving mechanisms in place to address complex adolescent child protection concerns. The Serious Youth Violence Duty will require Sutton partners to review how they address the changing needs of young people in the borough.  7. The LSCP to seek assurance that the Police effectively share data and plans within the multi-agency system that have an impact on disrupting the potential for serious youth violence.  8. The CCG should review the commissioning of CAMHS to ensure that there are arrangements for the service to support those at risk of criminal exploitation. 9. The CCG should review the profile of under 18s attending A&E or Urgent Care settings. Managing organisational and partnership risk: focus on seeing schools as places of safety 10. The LSCP should undertake annual scrutiny of the top 10 children of concern who are approaching transitions e.g., those due to start school, those in year 6 and those approaching 16.  11. For the LSCP to seek assurance that there are effective systems within the Local Authority for sharing data, plans and risks in relation to those children, who are resident in Sutton, who are excluded or missing school for more than four months. This needs to include those children on roll out of borough. Relationship based practice needs to be 12. For the LSCP to seek assurance about how the Local Authority work with parents and 36  strengthened to prevent families withdrawing from the help of services.  adolescents who have found it difficult to relate to professionals to find gather their views on what would hinders and what can improve engagement.  Partners need to ensure that there are opportunities for all children to have their voice heard by agencies without this being reliant on parental engagement. 13. The LSCP to seek assurance from the Local Authority about how children who are out of school are given opportunities to voice their views of their situation.  14. This should include looking at the options for a youth worker to be placed within the hospital setting to work with adolescents who attend particularly those who are at risk from violence, mental health problems or substance misuse.  Contextual Safeguarding needs to be utilised within   Child Protection Plans 15. The LSCP should undertake development sessions for those involved in child protection plans for adolescents to: a. Strengthen the use of contextual safeguarding within the plans b. Establish an agreed protocol with the MACE to ensure that there is a discussion between the two systems prior to an adolescent being removed from either’s safety plan.  Sutton need a framework for developing transitional safeguarding within the borough to ensure that the work to meet the needs of children does not end when they reach  adulthood.  16. The LSCP should arrange to share the learning from this review with the Safeguarding Adult Board to ensure that the needs of those who are 18-25 who have been at risk of being exploited are provided with constructive opportunities for support.  17. For the LSCP and Safeguarding Adult Board to work together to use this case to evaluate the transitional safeguarding work in place within Sutton. This includes ensuring that Child V’s case has been discussed with Adult Social Care, Adult Mental Health, Education, Primary Care, IYS and Police to develop a joint plan for offering support to the young person to keep him safe.   14 APPENDICES  METHODOLOGY This methodology was blended with the SCIE ‘systems’ model to observe how much Child V’s case provided a ‘window on the system’ beyond the specific 37  case33.   This provided the basis for the learning points but also enabled the acknowledgement of the work already achieved by the agencies in Sutton.  The recommendations were suggested by the independent author and then developed in consultation with the Case Review Group to ensure LSCP ownership of the actions to be taken forward from the learning in the case.                                                             33 Social Care Institute for Excellence (2012) Learning together to safeguard children: a ‘systems’ model for case reviews  38     ACTION PLAN No. Recommendation Rationale Action Lead By When Intended Impact 1. EHCP reviews must involve health and social care to ensure that there is a multi-agency approach to addressing the educational needs of the children. Where there are limited options or barriers in place, there should be a multi-agency review of the safeguarding risks to the child. To mobilise the multi-agency network to meet the special education needs to reduce the risk of children being abused and exploited.  To develop or update existing multi-agency adolescent safeguarding protocols and children social care practice directive.  LSCP 31/01/2022 To ensure that all staff are aware how to utilised SEN specialists to review safeguarding risks.  To ensure that special education needs form part of child safeguarding planning.  To undertake a multi-agency audit into safeguarding children in education.  LSCP 31/01/2022 To ensure that multi-agency planning processes to meet the needs of the child are joined up.  2 For the LSCP to seek assurance that the SEND Coordinator is routinely included in the invites and attends Child Protection Conferences, as required. To ensure that EHC needs are considered alongside child protection planning processes from the perspective that schools protect. To follow up with children’s social care, systems are in place to routinely invite the SEND co-ordinator to a CPC and/or MACE panel  for any  child who is subject to an EHCP. LSCP 31/01/2022 To ensure that SEND specialism is utilised in safety planning.  3 For the LSCP to seek assurance that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extra-familial harm by applying Contextual Safeguarding principles. Multi-agency planning meetings are informed by a contextual safeguarding approach.  To hold a multi-agency learning event and roll out contextual safeguarding training across the multi-agency professional network.  LSCP 31/03/2022 To improve responses and safety planning for children who are at risk of extra familial harm.  4 For the LSCP to seek assurance that there is a clear framework that underpins the rationale for the decision making about removing children and young people from the risk list. Children are removed from the MACE risk list because of evidence of reduced risk.  To ask the MACE panel to explore whether a decision making criteria for removing children from the MACE risk register can be developed.  LSCP 31/01/2022 To ensure that there is a safe rationale for removing children from the MACE panel.  39  No. Recommendation Rationale Action Lead By When Intended Impact 5 For the LSCP to seek assurance that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved.  E.g., If there are expectations on Early Help services to work with the family, EHCP or MACE, then this needs to be risk assessed if these do not make sufficient progress. Contextual safeguarding principles refer to services being flexible to respond to the needs of the child; and to take a relationship based approach to ensure that children with complex safeguarding needs are protected.  To undertake an audit of children removed from child protection plans and whether the outcomes were met, and if not what action was taken.  LSCP 31/01/2022 To ensure that children with complex safeguarding needs are not excluded from services.  6 For the LSCP to seek assurance through an independent scrutiny exercise that there are effective problem solving mechanisms in place to address complex adolescent child protection concerns. To ensure that there are effective multi-agency arrangements to address complex adolescent safeguarding needs.  To include problem solving approaches in the multi-agency deep dive audit of safeguarding children  who have special education needs. LSCP 31/03/2022 The learning  to  be used within supervision and training for those working with younger children within the child protection system. 7 The LSCP to seek assurance that the Police effectively share data and plans within the multi-agency system that have an impact on disrupting the potential for serious youth violence. Children who are not in school do not have the same access to professionals who can identify safeguarding risks.    To request that the police undertake a review of the intelligence gathering for children who are known to MACE and not in school.   LSCP 31/01/2022 To ensure that community risks to children are fully considered for those who are not in school.    8 The CCG should review the commissioning of CAMHS to ensure that there are arrangements for the service to support those at risk of criminal exploitation. To support emotional well being needs and trauma informed responses for children who are at risk of criminal exploitation.  To review whether the current commissioning arrangement with CAMHS includes providing professional expertise to the MACE panel and CP Conferences; and to provide services as part of multi-agency safety planning.  CCG 31/01/2022 To improve responses and safety planning for children who are at risk of extra familial harm.  40  No. Recommendation Rationale Action Lead By When Intended Impact 9 The CCG should review the profile of under 18s attending A&E or Urgent Care settings. To influence intervention opportunities with the children and young people, without reliance on parents to engage. The CCG to review the profile of under 18s attending A&E or Urgent Care settings and make appropriate recommendations CCG 31/01/2022  To improve responses to children accessing A&E and Urgent Care settings 10 The LSCP should undertake annual scrutiny of the top 10 children of concern who are approaching transitions e.g., those due to start school, those in year 6 and those approaching 16.  This work should provide greater understanding of the issues the children are facing and to ensure that interventions are implemented to safeguard these children. The LSCP to undertake annual scrutiny of the top 10 children of concern who are approaching transitions LSCP  31/03/2022 To have an improved understanding of the issues children are facing and to ensure that interventions implemented to safeguard are effective. 11 For the LSCP to seek assurance that there are effective systems within the Local Authority for sharing data, plans and risks in relation to those children, who are resident in Sutton, who are excluded or missing school for more than four months. This needs to include those children on roll out of borough. To ensure that children who are hidden from services due to being out of school are risk assessed and provided with services, as needed. To set up arrangements to provide the data and any other information to assess risks of exploitation and going missing  LSCP 31/01/2022 To ensure that children out of school are risk assessed as any other child who attends school, and that plans are put in place to address safeguarding needs.  12 For the LSCP to seek assurance about how the Local Authority work with parents and adolescents who have found it difficult to relate to professionals to find gather their views on what would hinders and what can improve engagement. To listen to those with lived experiences of services to find ways to more effectively engage with young people and their families.  To gather the views of  people with lived experience  who have found it difficult to relate to professionals in the past, but have found a way to progress, to gather their views on what worked for them, or did not. LSCP  31/03/2022  To have an improved understanding of the issues children are facing and to ensure that interventions implemented to safeguard are effective. 13 The LSCP to seek assurance from the Local Authority about how children who are out of school To ensure that the lived experiences of children and their wishes and feelings are recognised. To gather the views of  people with lived experience  who are out of school. LSCP 31/03/2022 To have an improved understanding of the issues children are facing and to ensure that interventions 41  No. Recommendation Rationale Action Lead By When Intended Impact are given opportunities to voice their views of their situation. implemented to safeguard are effective. 14 This should include looking at the options for a youth worker to be placed within the hospital setting to work with adolescents who attend particularly those who are at risk from violence, mental health problems or substance misuse. To ensure that young people are supported by appropriate services, and to reduce the need to access A&E services.   To review A&E attendance of adolescents at risk and the outcome of responses.  LSCP 31/03/2022 To improve responses to children accessing A&E and Urgent Care settings 15 The LSCP should undertake development sessions for those involved in child protection plans for adolescents to: a. Strengthen the use of contextual safeguarding within the plans b. Establish an agreed protocol with the MACE to ensure that there is a discussion between the two systems prior to an adolescent being removed from either’s safety plan. To ensure that safety planning processes are joined up across systems (CPC, MACE, EHCP reviews). To revise the multi-agency adolescent safeguarding protocol to reflect the findings from this review. LSCP 31/03/2022 Joined up multi-agency approaches to safeguard children with complex needs. 16 The LSCP should arrange to share the learning from this review with the Safeguarding Adult Board to ensure that the needs of those who are 18-25 who have been at risk of being exploited are provided with constructive opportunities for support. To ensure that the Safeguarding Adult Board is aware of the risks faced by those who are transitioning to adulthood. To present the Child V LCSPR overview report and findings to the Safeguarding Adult Board. LSCP 31/01/2022  To ensure that the Safeguarding Adult Board is aware of the risks faced by those who are transitioning to adulthood. 42  No. Recommendation Rationale Action Lead By When Intended Impact 17 For the LSCP and Safeguarding Adult Board to work together to use this case to evaluate the transitional safeguarding work in place within Sutton. This includes ensuring that Child V’s case has been discussed with Adult Social Care, Adult Mental Health, Education, Primary Care, IYS and Police to develop a joint plan for offering support to the young person to keep him safe. To ensure joined up processes for young people transitioning to adult services. To develop a joint multi-agency transitional safeguarding protocol. LSCP 31/03/2022 Joined up multi-agency approaches to safeguard young people transitioning to adulthood with complex needs.  