Fatal stabbing of a 16-year-old boy in June 2021. In the preceding months there were other assaults and multiple exclusions from school; gang associations and conflicts were also known about. Learning considers: multi-agency response to risk, including sensitivity when working in a diverse population and understanding subtleties associated with gang networks; the background and profile of the young people, including effective early intervention, recognising that complex cultural and relational dynamics require insight from those with lived experience, the importance of early identification of additional educational need and/or learning disability, and balancing the use of exclusions from school; and frameworks for assessing risk, threshold decisions and interventions, including acknowledging the cultural role of extended family and providing support for young people when taking a case to prosecution. Recommendations include: to map and evaluate arrangements for identifying and responding to contextual safeguarding and safeguarding children at risk of violence and criminal exploitation, and examine whether there are differences in how some children might receive a safeguarding response versus those that may receive a criminal justice response; to understand whether there are other young people with unassessed or undiagnosed learning difficulties who are not having their needs met; to ensure that all key agencies are fully informed about core child protection processes; to refer children to the MASH who are on the cusp of being permanently excluded from education and where there are contextual safeguarding concerns; to improve the offer of mediation with young people and their families that are at high risk of harm through culturally competent service providers; and to ensure that processes are followed within educational settings where there are known risks to pupils from gang associations.
      
 Title:  Child safeguarding practice review report: thematic review: which examines the multi-agency response in the Luton area, to keeping young people safe from risks related to exploitation, violent youth crime and gang associations. LSCB: Luton Safeguarding Children Partnership Author: Kevin Ball Date of publication: 2023  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1    1. Brief outline of circumstances resulting in the review   1.1. In 2021 a 16-year-old male tragically died as a result of stab wounds. Information gathered by agencies after the stabbing identified that there had been conflict between the victim and other young people in the preceding months, which included a recent assault, resulting in multiple permanent exclusions from school; gang associations and conflicts were also known about.  1.2. As well as the victim of the attack, the review examines the contact and involvement of agencies with three other young people, all of whom had some associations with the victim. Three of the four young people considered were known to agencies and services to varying degrees. In July 2020 a school raised concerns about a large number of young people at the school in respect of criminal activity, drugs, weapons, gangs and county lines; all young people were referred to the MAGPAN (Multi-Agency Gang Panel1).   1.3. In September 2020, the School resumed following the holiday and easing of Covid-19 restrictions; one of the young people’s father’s expressed concerns to school about his son’s safety and wellbeing following concerns that had developed during lockdown. A risk assessment and plan were put in place in school to manage his safety. His father asked about a possible managed move to another school. The Pupil Placement Panel considered this request and refused a move on the grounds he was in Year 11 and it was not the best time to be moving schools. The Issues of concern were discussed, including the risk assessment and perceived threat but the decision stood despite the identified risks.  In October 2020, this particular young person refused to follow the risk assessment arrangements at school by deviating from the agreed route between lessons and was subsequently assaulted by four students –                                                            1 In 2014, the Community Safety Partnership Tackling Serious Youth Violence Group has commissioned the introduction of the Multi-Agency Gang Panel to co-ordinate appropriate, intelligence-led and evidence based multi-agency partnership interventions with individuals who are involved in, at risk of involvement in or directly affected by serious violence and gang related activity across Luton but most notably North and West Luton. The over-arching purpose of the MAGPAN is to safeguard the communities of the town from this type of serious criminal behaviour by identifying lead agencies and monitoring interventions to individuals and families that ideally prevent association with/involvement in gang behaviour, disrupt criminal behaviour and provide support and exit strategies where appropriate. Child Safeguarding Practice Review Report Luton Safeguarding Children Partnership Thematic Review which examines The multi-agency response in the Luton area, to keeping young people safe from risks related to exploitation, violent youth crime and gang associations. Independent Reviewer: Kevin Ball Date: April 2023 2  two of which are subjects of interest for this review. Alternative educational placements were sought, and secured, for two of the young people following their permanent exclusions.  1.4. In November 2020, the victim of the later fatal assault was brought to hospital by ambulance with injuries to his arm, from a stabbing by one of the other young people; he was accompanied by another young person, who was described as his ‘cousin-brother’ (who also had minor injuries but did not require treatment).   1.5. Through a managed move, the young person for whom his father had expressed concerns, transitioned to another school. This young person was arrested for the role he played in the November 2020 assault. The victim of the fatal assault was discussed at MAGPAN by education professionals following the earlier stabbing incident. Bedfordshire Police referred him to the next MAGPAN meeting in December 2020 which resulted in him receiving support services; he was believed to be involved with a local gang. The Single Assessment conducted by Children’s Services commented ‘… the seriousness of Child X being stabbed and the Social Worker appropriately identifies that the incident could have led to Child X losing his life …’. The Social Worker ‘… hypothesises about the possibility of Child X becoming part of a gang to protect himself … he denied any gang affiliation and this is accepted with some scepticism …’. The case was closed with ‘no identified role for statutory social work intervention or early help’.   1.6. In January 2021 another of the four young people, was chased by 3 – 4 males and sustained a stab wound. . The Police issued a Memorandum of Understanding to his mother and the young person. The father of one of the young people, continued to express concerns about the safety of his son. The specialist worker from the Amber Unit (Specialist Police Unit2) continued to try to engage this young person in individual sessions. In May 2021 concerns were expressed by the specialist worker from the Amber Unit that there was a serious risk of someone being harmed. In early June 2021, the young person for whom his father had expressed concerns, was arrested for possession of a bladed article; no further action was taken. Four days later the victim, was brought to hospital with wounds from a stabbing, which caused his death. Two other young people were injured in the incident. An immediate Strategy meeting was convened.  1.7. This report provides a summary account of a thematic Child Safeguarding Practice Review (CSPR) conducted by Luton Safeguarding Children Partnership (the Partnership) in accordance with statutory guidance (Working Together to Safeguard Children, HM Government, 2018).   1.8. By examining the circumstances of agency and professional involvement with all the young people involved in this tragic event, this thematic review has focused on exploring the multi-agency response in the Luton area to keeping young people safe from risks related to exploitation, violent youth crime and gang associations. Its intention is to promote learning, reflection and improvement in the way the multi-agency partnership might respond.    2. Practice & organisational learning   2.1. Through review and analysis of information submitted, plus two separate reflective sessions with practitioners that had contact with the four young people concerned, but also agency leads responsible for safeguarding, a number of points have been captured. These have been distilled into three key areas, and are:  - The multi-agency response to risk: working together to reduce risk. - Background and profile of the young people. - Frameworks for assessing risk, threshold decisions & interventions.                                                             2 Amber Unit - The Amber Unit is led by the Youth Offending Service with representatives from other agencies, including the Police. The role of the Unit is to work alongside MAGPAN to scan, identify and proactively target those young people who are not yet chronic or entrenched in serious violence or gang activity, but are showing signs of moving toward it i.e., gang activity by their associations, concerning activity within education, and low-level offending that is indicative of transition toward gang activity. The work offered by the Unit is usually voluntary, with either 1:1 work, or group work at education establishments. 3  2.2. It is important to note that this review does not offer a view about whether, had different actions been taken, it would have predicted or prevented the fatal and tragic stabbing that resulted in one young person losing his life. To attempt to answer this question would require a comprehensive understanding about the individual circumstances of each person involved, and an understanding about the complexities of the immediate motivations and dynamics at the time. This review has not been commissioned to undertake such a detailed task and indeed is not the purpose of the review. Instead, the review – in examining the multi-agency response in the Luton area to keeping young people safe from risks related to exploitation, violent youth crime and gang associations – has sought to place the findings in context of the Partnership wanting to reflect, learn and improve arrangements.  The multi-agency response to risk: working together to reduce risk – what can we learn from this?  2.3. The Local Safeguarding Children Board (LSCB) Annual Report (2020 – 2021) provides data about the local context and profile of the Luton area. It states that 27% of its residents are below 18 years making it one of the youngest populations in the country, yet with 39.4% of children in the area growing up in relative poverty in 2019/2020. It is the sixth most deprived area in the East of England by indices of multiple deprivation, and 67% of 16 to 64-year-olds are educated to level 2 or above compared to 78% nationally. The close proximity to London may account for a 50% population churn (since 2011), which is likely to impact negatively on stability for children and young people, but increase their networking opportunities.   2.4. From a crime perspective, data (data provided by Police.uk, and accessed on 08/02/20223) indicates that violence and sexual offences, and anti-social behaviour were the most prevalent crimes reported in the preceding 12 months with a 31.5% and 21% prevalence rate respectively; the possession of weapons accounted for 1% in the preceding 12 months. The Pan Bedfordshire Violence & Exploitation Reduction Unit (VERU) strategic needs assessment (March 2020), whilst advising caution about the data sources, suggest that the number of recorded violent crimes appears to be increasing across the county.  2.5. The headline data shown above somewhat reflects the level of adversity and vulnerability that many agencies and professionals work with on a day-to-day basis – often working to disentangle and assess the complex interplay between adversity, actual risk to young people, or exposure to risk but with limited danger; the reality being that this is complex and demanding work. Positively, data from the Youth Offending Service (Luton Strategic Youth Justice Board, Quarter 3 performance report, February 2022) suggests that arrangements in Luton continue to exceed the performance of all comparative groups (nationally, regional and within the cluster of statistically similar authorities), with rates being lower in terms of first-time entrants and custody. This may be an indicator that current arrangements, such as MAGPAN, successfully intervene and address early intervention and prevention of risk and exploitation. It may also indicate the need for further support and investment in this earlier intervention approach.   2.6. From information submitted, as well as discussions held with agency representatives and practitioners, it is evident that there are significant efforts to reduce, disrupt and tackle knife crime, violence and exploitation in the Luton area. Initiatives such as Operation Sceptre week of action, Bin your Blade campaign, the work of Bedfordshire Police BOSON4 team tackling gun crime and gangs, the work of the Violence & Exploitation Reduction Unit (VERU) and the contributions of the Youth Interventions Specialist Team. Positively, the recognition that a multi-agency response is needed to tackle these matters is strong and is articulated in the Bedfordshire - Violence and Exploitation Reduction Strategic Response 2020-2025 plan. There is also recognition that adopting an approach that spans both the criminal justice and child welfare domain is critical5; this was recently and helpfully expressed by Bedfordshire Police ‘… our whole system is focussed on prevention, early intervention and diverting young people away from the drivers of knife crime, as we realised some time ago that we cannot simply arrest our way out of this problem …’                                                            3 Data provided by Police.uk, and accessed on 08/02/2022, Note – data reflects both violence and sexual offences, and is not separated; Police.uk - Luton South & East crime levels overview  4 BOSON – A specialist unit operated by Bedfordshire Police dealing with gun and gang crime.  5 Blurring boundaries: young people, safeguarding and the criminal justice system, Bedfordshire University, Research in Practice, and The Children’s Society, 18/12/2020.  4  (statement issued by Bedfordshire Police, , 30/11/2021). Despite these strong efforts, recent data6 indicates an increase of 34% in knife crimes in the Bedfordshire Police area. Whilst recognising that data collection methods have altered over a 10-year reporting period, and Covid-19 restrictions are likely to have had an impact on crime rates, this data also highlights, more or less, a steady national rise in knife crime.  2.7. Agencies and services that have participated in this review have clearly expressed – on the whole – a very positive, well regarded, but evolving picture of the multi-agency response to young people drawn into violent youth crime, exploitation and gang associations. This finding is especially positive given the relative infancy of the local area having to respond to what appears to be an increasingly worrying issue. In this case however, there are examples where the very best multi-agency response, through the timely sharing of information, was not as effective as it might have been.   2.8. A striking finding is the number of multi-agency forums, meetings or panels that have been named as contributing to the overall response in the local area; some of these are meetings convened by one agency i.e., Youth Offending Service or Children’s Services, but which include representation from other agencies, and some are fully multi-agency in nature and composition.  2.9. Through reflective sessions some comments have arisen highlighting the importance of developing and maintaining trusting relationships across professional boundaries, particularly those that bridge statutory and voluntary organisations (and especially those voluntary sector services that can represent community and local networks as highlighted above). Issues included comments about; a) partial trust about the confident sharing of sensitive information and local information but also intelligence (and by implication the sharing or handover of risk and safety management), b) perceptions about the relative value attached to those who have previous lived experiences of gang associations, exploitation, criminality and harm and which are now being used to help others, and c) the differing layers of bureaucracy statutory agencies may need to deal with versus those in some voluntary sectors organisation and how this may impact their respective responses to young people.  2.10. Some very useful mapping has taken place by the VERU illustrating the number and range of meetings held across the pan Bedfordshire region (comprising Central Bedfordshire, Bedford Borough, Luton Borough); the mapping neatly shows some of the strategic, tactical and operational forums/groups established by statutory agencies, that meet to tackle a range of issues within each authority area. The next stage of work, it is argued is to further develop and collectively reflect on their inter-connections and where opportunities may arise for synthesising information and risk management; this should also include community-based groups where there may be some reliance to provide intervention or prevention activities but which may be viewed more favourably by local residents than statutory services. Building good partnership arrangements between statutory and non-statutory services is important to effective interventions. Information provided has highlighted the following non statutory services providing support and interventions to young people involved in gang associations, who may be offending or at risk of exploitation: Action Guidance Plus, Directional (Inspiring the next generation), Dynamic Decisions, One Stop Advice Centre, Gangs Line, VERY YIS Team, Att10tive Social Enterprise, Youturn Futures, Tree Project, Link to Change, Greenhouse Mentoring, Chance to Change, St Giles Trust, and the Avenue Centre for Education. When these are considered alongside the meetings/forums, the need for mapping and encouraging effective working arrangements becomes more pronounced.  Learning points:  - Professional awareness, sensitivity and competence when working in a diverse population is important to gaining insights and understanding about relational dynamics, particularly when trying to appreciate the changing subtleties associated with gang networks. Drawing on different perspectives may be useful when trying to problem solve, mediate or reduce risk.  - Rigorously assessing both pre-disposing and situational risks is fundamental to understanding what type of support children might need in order to help and guide them to pursue a protective pathway through childhood and transition into adulthood. A multi-disciplinary approach is likely to be most helpful.                                                            6 Knife Crime in England and Wales, p. 30 table A4a, House of Common Library, Grahame Allen & Megan Harding 30th September 2021. 5   - If the multi-agency approach to managing risk, once identified, is agreed as the most effective way to keep some children and young people safe, investment is needed to ensure planning and interventions are the best they can be; leaving it to chance that agencies, forums and different groups will communicate with one another and synthesise information will limit effectiveness.  Background & profile of the young people – what can we learn from this?  2.11. Those that knew each of these four young people have described them as not being the young people that they were worried about the most; whilst there were some behavioural issues to manage these were never considered extreme.   2.12. All of the young people were of British Asian ethnicity, with three being of Pakistani heritage. All were males aged between 16 – 17 years. Research by the National Child Safeguarding Panel (Child Safeguarding Practice Review Panel; It was hard to escape: Safeguarding children at risk from criminal exploitation, 2020) in respect of children at risk of exploitation highlights that in the cohort of children examined, the risk of death or serious harm was greater with children from black or minority ethnic background. Ethnicity of victims is not a conclusive factor although research and work by the Youth Justice Board7 does highlight that black or minority ethnic children are disproportionately represented across a number of areas analysed. From a brief examination, other case reviews8 and studies9 do exist which highlight family vulnerability, parental substance use, and neglect as being factors that stand out for young people associated with gangs. Additionally, young people associated with gangs and who experience violence are more likely to be educated in alternative provision, rather than mainstream schooling, and more likely to have experienced educational instability and have had poor school attendance. Males appear to be disproportionately represented as being victims of violence.    2.13. Whilst the above findings may highlight some commonalities – in terms of background, ethnicity, vulnerability and risk factors – these cannot necessarily be considered predictive factors for young people being exploited, being drawn into violent crime or gang associations. Any child, of either gender and from any ethnic background, that has faced a multiplicity of adversity during their childhood will likely experience further challenges and disadvantage as they grow and transition. The findings do however reflect a number of important learning points, which whilst well-rehearsed and familiar from any number of other case reviews conducted and researched10, reinforce the need for the professional network and agencies to be receptive to, and respond well, to children’s needs.  Learning points:  - Early identification of indicators of harm, early assessment and sustained, effective early intervention prior to children entering secondary school education is likely to be critical to a successful and positive transition into adolescence.                                                              7 Exploring racial disparity How it affects children in their early years and within the youth justice system, Youth Justice Board, August 2020.  8 a) A Thematic Review of Serious Youth Violence for Bedford Borough Safeguarding Children Board, Dr Julie Harris, University of Bedfordshire, 2021. b) Serious Youth Violence: Thematic Serious Case Review, Buckinghamshire Safeguarding Children Partnership, Keith Ibbetson, 2020. c)  Vulnerable Adolescents Thematic Review, Croydon Safeguarding Children Board, Charlie Spencer, Bridget Griffin & Maureen Floyd, February 2019.  9 a) Child Safeguarding Practice Review Panel, It was hard to escape: Safeguarding children at risk from criminal exploitation, 2020. b) The characteristics of gang-associated children and young people, The Children’s Commissioner, February 2019. c) Analysis of statutory reviews of homicides and violent incidents; A report commissioned by the Mayor of London’s Violence Reduction Unit, SCIE, 2020, d) Violence and Vulnerability, Crest Advisory, February 2021.  10 a) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews, 2011 to 2014, May 2016, University of Warwick & University of East Anglia, HM Government, b) Complexity and challenge: a triennial analysis of SCRs 2014-2017, March 2020, University of Warwick & University of East Anglia, HM Government, c) Serious violence in context: Understanding the scale and nature of serious violence A report by Crest Advisory Authors: Sarah Kincaid, Sophie du Mont, Callum Tipple & Callyane Desroches, Crest Advisory, September 2019  6  - Recognising and disentangling complex cultural and relational dynamics, alongside ethnicity, may require a level of competence and insight that is best gained from those who have personally lived with these experiences.  - Identifying and assessing additional educational need and/or learning disability needs to happen at the earliest opportunity; this allows the child the greatest opportunity to maximise their formal educational career and receive the right support at the right time, thereby improving the likelihood of better outcomes.  - Consideration needs to be given to balancing the use of exclusions from school for those children that present as a risk, alongside protecting the needs and safety of other pupils, whilst remaining mindful of placing a child on a potentially harmful pathway by them attending alternative educational provision.  Frameworks for assessing risk, threshold decisions & interventions - what can we learn from this?  2.14. Review of the Bedford Borough, Central Bedfordshire and Luton Safeguarding Children Boards Procedures highlights that the framework for assessing risk to children and young people vulnerable to gang activity follows the standard route, with an expectation that concerns should be referred via either the Police and/or Children’s Social Care. This is similarly the case for children who are risk of all forms of exploitation. This then allows for a Single assessment to be conducted by Children’s Services in order to determine whether, and what level of, support or protective measures are needed. In this case, it is evident that the victim of the fatal stabbing and his family were known to the Police and Children’s Services due to the previous concerns. One other young person was also well known, and had been through a similar process of assessment, planning and intervention in order to achieve a Child Protection Plan, and then a Child in Need Plan for a period of time. Based on the information provided some assurance can be gained in as much as the identification and assessment of risk to these two young people was timely.  2.15. However, learning has been captured in respect of agency contact and involvement with other young people, particular in respect of thresholds, decisions, the quality of assessment undertaken, and risk management, as follows.   2.16. Information submitted by agencies has confirmed that referrals were made using the National Referral Mechanism (NRM) – a procedure used for identifying potential victims of modern slavery to ensure they receive support. Two were made by the Youth Offending Service in August 2020 and March 2021 in respect of one young person; other records submitted by agencies indicate additional referrals were made however records are not sufficiently clear to confirm when these were made, and by which agency. Regardless, through discussion, the review has highlighted uncertainty about the usefulness of the procedure, what it can achieve and whether it does offer any support to those individual’s identified as potential victims. Whilst the referrals in respect of one of the young people may have helped the Youth Offending Service shape a narrative about him that meant that some of his offences were dealt with more sympathetically, there appears to be no certainty that potential victimisation and exploitation will be taken into account if an individual is also committing offences. Similar findings about the NRM have been made by the Child Safeguarding Practice Review Panel11 and the children’s rights organisation, Every Child Protected Against Trafficking (ECPAT UK) and the Independent Slavery Commissioner12.  2.17. The provision of early intervention support has been cited as a critical feature to strengthen so as to catch and prevent negative pathways for some children and young people. Whilst it is impossible to argue with the importance of early intervention being available for all children that may be in need of support, there can be a challenge to consistently identifying early enough, those particular children or young people that may be at risk of exploitation, committing youth crime or becoming involved in gang associations. This is particularly so when trying to avoid having to respond to families when in crisis – a situation that the MAGPAN routinely finds itself faced with. Assessing the context in which children or young people live i.e., thinking beyond issues from within the immediate family but outside of the family home into the neighbourhood and community, will be important in achieving a better                                                            11 Child Safeguarding Practice Review Panel, It was hard to escape: Safeguarding children at risk from criminal exploitation, 2020.  12 Every Child Protected Against Trafficking (ECPAT UK) & the Independent Slavery Commissioner, A review of what works in multi-agency decision making and the implications for child victims of trafficking, August 2020.   7  understanding about to identify and intervene at an even earlier stage.  It may also require a revised approach to helping decision makers categorise individual cases against threshold criteria13; standard case management routes for managing such circumstances may be less effective14. For example, the use of the traditional and family-based approach to Child in Need or a Child Protection Plan may not be as effective as imagined, but nonetheless the role of a lead professional (the local authority Children’s Services by current statute) will have significant value. Other recent case reviews15 have raised questions about whether the use of a Child Protection Plan, and its associated Core Group processes, is the best approach when dealing with youth crime and gang associations; especially given that nationally, many areas seem to adopt different approaches to responding to such issues.  2.18. The late identification, response and diagnosis of one young person’s learning disability meant that he went without the appropriate levels of support for the majority of his school career; this is a significant factor and will have had a major impact on his life chances and development. The findings of this aspect of the review need to be placed in context of the overall architecture of the arrangements at the time. In December 2018 Ofsted conducted a joint local area SEND inspection in Luton. This inspection highlighted a number of far reaching and systemic weaknesses in the local area’s practice ‘… Professionals and families in Luton are left frustrated by long waiting times and slow identification of children and young people’s needs. For many families, even once they have a diagnosis for their children, there is often little support and guidance available to them about how to meet their children’s needs … The co-production of EHC plans and services with children and young people, and their families, is too limited in its scope and breadth …’16. The findings from this focused inspection also need to be considered in the overall scheme of Luton Borough Council being on an improvement journey since 2016 (at which point the young person would have been 12 years), at which point the Borough was judged as requiring improvement. The identification and response to this young person’s learning disability (in 2019 at 15 years) may, not unreasonably, be placed in the context that there were significant systemic failings during the period when he really needed considerable additional support to access an educational curriculum to meet his needs. It is recognised that considerable improvement activity has been undertaken, and remains ongoing, in order to strengthen the local area response.  2.19. The use of Memorandums of Understanding (Police) and Statements of Expectations (Children’s Social Care) have been noted when working with the family of one of the young people. These have been described as ‘contracts’ that are developed by an agency that is designed to convey expectations about behaviour or conduct but has no formal or legal footing. Research17 highlights the limitations and deficiencies of written agreements, and although they may have a place, further work is needed in the context of the issues faced by young people experiencing exploitation or having gang associations to better understand whether they have any effectiveness at-all given the risks originate from outside of the family home, and therefore may be outside of the control of the individuals the expectations are targeting. In any case, the ability to read and comprehend what is contained in such agreements is fundamental; given the known learning disability as well as speech and language difficulties experienced by this young person, the use of such memorandums or statements has to be challenged as a poorly conceived intervention.  2.20. The victim’s father has raised important points about the level of support available to young people when taking cases to Court to try to gain a prosecution. The support to the victim from the Police was questioned, with him feeling like he could not trust or rely on the Police to help deal with the pressures he faced (face to face or via                                                            13 Effective Support for Children and Young People in Luton: A Shared Guidance to help all practitioners working with children, young people, families and carers to provide additional and early help, intensive and specialist support, Final Version October 2021, Luton.  14 Contextual Safeguarding: Applying thresholds to extra-familial harm, podcast, 18/10/2019.  15 a) Islington Safeguarding Children Board: Serious Case Review: Child P and services provided to reduce serious youth violence Independent Chair - Islington Safeguarding Children Partnership, Alan Caton & Independent Lead Reviewer Keith Ibbetson, undated; b) Serious Case Review: Child K and services to reduce serious  youth violence, Convenor - Brent Safeguarding Children Forum, Keith Ibbetson, undated; c) Oxfordshire Safeguarding Children Board - “Untouchable Worlds”: Protecting Children who are criminally exploited and harmed Child Safeguarding Practice Review: Jacob, Sarah Holtom, 19/01/2021; d) Child Safeguarding Practice Review Panel, It was hard to escape: Safeguarding children at risk from criminal exploitation, 2020.  16 Ofsted & CQC, December 2018, Joint local area SEND inspection report.  17 Complexity and challenge: a triennial analysis of SCRs 2014-2017, March 2020, p. 152, Brandon, M., Sidebotham, P., Belderson, P., Cleaver, H., Dickens, J., Garstang, J., Harris, J., Sorensen, P., and Wate, R., HM Government. 8  social media) in following through with a prosecution. In examining these issues, the following findings have been made;  - Given the complex dynamics we know exist with gang associations, which are often exacerbated by the influence of social media fuelling emotions, the support offered to young victims to help them feel safe and empowered to follow through with a prosecution is inconsistent and limited. There was no consideration of offering a victimless prosecution. - Similarly, the offers of support to parents of victims are also inconsistent and limited; in this case, the family were viewed as protective, and therefore could have been seen as part of the safety plan. - Crime investigation officers and specialist units such as Boson/Gangs team might not necessarily communicate with one another, resulting in parallel processes taking place, and this impacting the support offered. - Crime investigation officers are less likely to be aware of other professionals working with a young person/their family.  - Special measures used to support young people through the criminal prosecution process may not be effective in these types of circumstances - The code on the street for these young people is likely to be more influential and powerful than any support offered. - When a victim is also an offender, it challenges the system in how to assess and prioritise actions and address needs.  Learning points:  -  The inclusion of grandparents and extended family members, especially in communities where culturally, great value may be placed on these people having a caring and supportive role should be viewed with equal priority as when assessing those with direct parental responsibility.   - Child Protection Conferences are – fundamentally – an opportunity to bring the multi-agency network together – to examine risks that children face. One of the single most important factors to get right, is the communication, participation and engagement of all relevant services that might be involved in a child’s life at this moment in time. Failing to achieve this, undermines the very purpose of the child protection process.   - Decisions about the level of need and subsequent offers of support should be based on a thorough and timely multi-agency assessment which includes examining the history of the child/family, pre-disposing as well as situational risk factors, and listening to the voices of all family members. Statutory guidance reminds us about what a high-quality assessment will comprise of, and that ‘… every assessment should reflect the unique characteristics of the child within their family and community context …’.   - The consistent interpretation of threshold criteria across all agencies, but particularly those with a lead role and responsibility is critical to timely and effective decision making. Assessing risk and forming judgements about risks from outside of the family and within the community may be departure from routine practice, and require a different approach to decision making.   - Support for young people who are victims, and their families, when taking a case to prosecution is important to consider. Situational risks and influencing factors, such as social media, can generate an interplay of complex dynamics that impact on victim’s decision making and need to be assessed on a multi-agency basis. Such dynamics are unlikely to easily lend themselves to processing assessment work or working towards a case to prosecute. Recognising that this complexity may challenge routine procedural routes, it is critical that systems and procedures are in place to respond to such factors.     9   3. Improving systems and practice   In addition to the individual learning and actions captured by each single service or agency, the following recommendations are made for the Partnership:  1. The Partnership should take a lead on mapping and evaluating the current arrangements for identifying and responding to contextual safeguarding and safeguarding children at risk of violence and criminal exploitation. It should especially map and evaluate the inter-relationships between the existing plethora of forums, meetings and panels at a tactical and operational level, but also relevant community groups. The contributions of Pan Bedfordshire meetings/forum, and Community Safety Partnership should also be evaluated. Consideration of a dedicated operational coordinating role should be assessed, in order to strengthen these inter-relationships.   2. Collectively, in achieving the recommendation above, the Partnership should explore ways to strengthen information mapping/collation which supports a) the coordination and efficacy of risk management, b) a better understanding of the cohort and demographics of young people that are being presented and discussed by the various multi-agency meetings, and those that are pushed into gang associations and criminality, and c) the levels of support given to young people (and their families) who are victims of crime. In doing so, examine whether there are differences in how some children might receive a ‘safeguarding’ response versus those that may receive a ‘criminal justice’ response, and what the underlying contributory factors might be in any variation of response.   3. Ensure the Partnership has a sound understanding of whether there are other young people, similar to the profile of one of the young people with unassessed, late or undiagnosed (yet significant) learning difficulties, who remain in the education, health or care system and are not having their educational, health or care needs met. On identification, consideration should be given to whether urgent steps need to be taken to resolve any residual or situational risks that these young people may be experiencing. This may be achieved via an audit.  4. Children’s Social Care to ensure that all key agencies are fully informed, and able to contribute to, core child protection processes starting at the point a Strategy discussion may be convened, through to holding Child Protection Conferences.   5. All children, regardless of age, that are on the imminent cusp of being permanently excluded from their educational setting, and where there are contextual safeguarding concerns, should be referred to the MASH, by schools having gained parental consent. Where parental consent to refer is not given, consideration should be given to consulting with the MASH duty line around whether a referral without consent is justified. Referral should result in a full, prompt and multi-agency assessment of the child/young person’s circumstances. Consideration should also be given to the feasibility of re-referring all children to the MASH that disengage with any alternative educational provider/setting, and the need for a re-assessment.  6. Explore opportunities to strengthen the offer of mediation with young people and their families that are at high risk of harm, through trusted and culturally competent service providers. This may well rest with the Youth Partnership Service.   7. Partners within education settings/services should continue to ensure and encourage that processes are followed where there are known risks to pupils from gang associations, this may include the submission of multi-agency intelligence forms to the police and/or appropriate referrals and communication with agencies. This expectation should be reinforced through training, briefings, and the current regular partnership forums.     10   4. Statement by independence by the Independent Reviewer: Kevin Ball  I make the following statement that prior to my involvement with this case review:  - I have not been directly concerned with the children or families involved, and have not given professional advice on any case management. - I have no line management responsibilities of the practitioners involved. - I have the appropriate qualifications, knowledge, experience and training to undertake the review. - A full and thorough review was conducted and was rigorous in its analysis and evaluation of the issues set out in the lines of enquiry and terms of reference. The review included a thorough and systematic quality assurance and validation process involving all relevant agencies involved from within the Luton Borough area.  Appendix 1: Terms of Reference & methodology for the review 1. Following the fatal stabbing in 2021 the Partnership conducted an initial information gathering exercise as part of the Rapid Review process. A decision to conduct a thematic CSPR was confirmed by the Partnership in July 2021. This decision was subsequently ratified by the National Panel.  The following steps were then taken; - Kevin Ball was confirmed as the Independent Reviewer in August 2021. - An initial Panel meeting of agency representatives was convened in September 2021 to further consider the scope and terms of reference for the review; key lines of enquiry were established. Further Panel meetings were held as necessary throughout the review process. - Gathering additional information from relevant agencies and services to complement the information already submitted by agencies was considered necessary. As such, a request for single agency reports was made to the relevant agencies listed below in September 2021. This process provided each relevant agency with the opportunity to reflect on their involvement with each young person. Practitioners were interviewed as part of the single agency reporting and were able to offer their insight and contributions to the review. As a result, agencies have been able to consider actions required of themselves in order to make improvements. - A request for information was also made in September 2021 to relevant multi-agency groups, forums or initiatives in the Luton area, with a view to examining their effectiveness. These are also listed below. - The views of practitioners and designated leads were captured in November 2021 and January 2022. - The approach taken has complied with the principles as set out in statutory guidance and as such, the process been able to capture and identify opportunities for professionals and organisations to learn and improve safeguarding practices from a whole safeguarding system perspective. - Due to protracted legal processes, there was a delay in finalising the review, which could not happen until early 2023. 2. The following services, agencies and forums have contributed to this Review: Luton Borough Children’s Services Luton Borough Special Educational Needs Service Luton Borough Early Help Services Luton Borough Safeguarding in Education Service Cambridgeshire Community Service NHS Trust Luton & Dunstable University Hospital  The Clinical Commissioning Group (for the GP) Bedfordshire Police Alternative Provision 1   Luton Youth Offending & Targeted Youth Service School A School B East London NHS Foundation Trust Bedfordshire Hospitals (Luton) Luton Multi-Agency Gang Panel (MAGPAN) Alternative Provision 2 Bedfordshire Violence & Exploitation Reduction Unit -  3. The role of the Review Panel was to assist with the smooth and timely completion of the review.  11  4. Lines of enquiry were agreed as needing to explore: - The identification, assessment, planning and intervention against identified need and risks. - The timeliness of work, against agreed policy & procedure, & timeliness of response by other agencies. - Any issues or challenges in relation to ethnicity, gender, culture and religious persuasion. - Any critical moments that particularly stand out, from either the child’s perspective or with decision making. - Engaging with the child, and parents and building relationships. - Multi-agency collaboration, information sharing, barriers or challenges to working well together. 5. Through review and analysis of information submitted, plus two separate reflective sessions with practitioners that had contact with the four young people concerned, but also agency leads responsible for safeguarding, a number of points have been captured. These have been distilled into three key areas, and are: - The multi-agency response to risk: working together to reduce risk. - Background and profile of the young people. - Frameworks for assessing risk, threshold decisions & interventions. 6. The timeframe under review was set to focus on the most recent events from July 2019 to June 2021, however the review was interested in any relevant history prior to this. Family contribution to the review: 7. Seeking the contributions of family members has been an important consideration for this thematic review. Due to Police investigations and legal processes, there was a delay in the Independent Reviewer being able to make contact and speak with family members.  8. The father of the victim was spoken with, and has offered some valuable insights into circumstances, but also areas for learning. His contributions have been welcomed, especially at a time when he continues to grieve the death of his son and, quite understandably, feels strong emotion about what happened. He has been offered the opportunity to comment on this report and is satisfied with the content, findings and recommendations. He spoke about the steady build-up of concerns over a 2 – 3 year period, his son expressing deep concern to him about getting involved with certain other young people, not knowing how to distance himself from them and feeling trapped by the circumstances he found himself in.  He spoke about his son feeling under pressure about not being able to walk away from these young people so as to not lose respect, and feeling overwhelmed by the pressure of following through with a potential prosecution following the assault in November 2020. Four areas that the victim’s father expressed the most concern, and greatest frustration about, were in his view: - Not enough being done by School or the Police to respond to other young people, particularly, one young person, hanging around outside the school gates in a threatening and provoking way with weapons. Having CCTV cameras, he feels, would have been a huge help as it might have acted as a deterrent.  - The level of pressure his son felt under to pursue a prosecution following the November 2020 assault was overwhelming for his son. He feels his son was not given enough support to help him follow through with a prosecution; this was not helped by not being able to develop a trusting relationship with the Police to the point where he lost confidence in them. His son also felt under considerable pressure at the time due to social media postings, which ultimately prompted him to withdraw his statement and not follow through with the prosecution. He was recovering from the injury and it seemed that the greater pressure was on the victim to take the prosecution forward, with less pressure on the offender. - The level of support provided to him by the Police, as a parent of a young person that was trying to do the right thing in following through the prosecution, was not enough given the challenging ongoing circumstances. 9. The families of the other young people involved in these incidents, and those young people who were subjects of the review were all offered several opportunities to contribute and hear about the findings of the review. No one came forward to accept the offer within the agreed timescales.12  Appendix 2: Concise summary timeline under review of key episode  2020 2021 Agency July Aug Sept Oct Nov Dec January Feb March April May June  Schools & Education providers School raises concerns about gangs & referral to MAGPAN  Schools return. Father of one young person raises concerns Assault in school resulting in permanent exclusions and transfers        FATAL STABBING OF ONE YOUNG PERSON  Hospital     Victim of fatal incident brought to hospital with injury from assault        Police & allied specialist units     Police arrest young person for the assault  Young person chased & assaulted. Attempts to engage young person by specialist unit    Concerns expressed by specialist worker about safety of young person Children’s Services       Single Assessment completed on one young person – case closed          Covid-19 pandemic   