Serious knife assault by one young person, aged 17-years-old, against another, aged 15-years-old in April 2020. Learning includes: early assessment, early help and intervention are critical to avoiding later problems for children who live with a daily adversity in their home lives and where there are multiple children living in the same household; parental disengagement in early help offers should be viewed as a potential risk indicator rather than an informed and consensual decision made by the parents; timely and targeted intervention needs to follow assessment activity, especially in respect of educational provision which can be a significant stabilising factor in a child's life, and particularly for those children that have experienced trauma and persisting levels of adversity; children who have complex histories, and struggle to regulate their emotions and behaviours are more vulnerable to abuse, exploitation and exposure to drugs, alcohol and criminality unless diverted away; having adequate local resource and local capability to sufficiently manage or track the risk in communities for individual children is a significant challenge for all professionals and agencies; and stability of care placements and forming meaningful and lasting relationships with young people can be influential, protective and ultimately make a lasting difference. Recommendations include: seek assurance, through regular focused review and audit activity, that new initiatives become embedded into day-to-day practice; and ensure that the learning identified through this review is disseminated using a variety of mechanisms and routes and in a timely and effective way.
      
 Title:  Jordan and Prada: child safeguarding practice review report. LSCB: Warwickshire Safeguarding Partnership Author: Kevin Ball Date of publication: 2022  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.                                   Jordan & Prada  Child Safeguarding Practice Review Report  Author: Kevin Ball Published: 23rd March 2022                               Contents Report section   Page 1. Introduction & synopsis of the review   1 2. Method for conducting the review   1 3. Family structure & contribution to the review   2 4. Concise summary of relevant case history   3 5. Findings & analysis  - Using information about both pre-disposing and situational risks, to aid safety planning  - Educational provision and attendance being a key protective factor  - The importance of trusting relationships when working with young people and assessing risk  - The sufficiency of alternative care placements to provide support and stability   5 6. Conclusion   16 7. Recommendations   17     Page 1 of 20 1. Introduction & synopsis of the review 1.1. This report provides a summary account of a Child Safeguarding Practice Review (CSPR) completed by Warwickshire Safeguarding Children Partnership (the Partnership) in accordance with statutory guidance1. The review was triggered by a serious knife assault by one young person, aged 17 years, against another, aged 15 years in April 2020. Both young people had a significant history of involvement with statutory services and both were formally under the care of Warwickshire County Council. For the purpose of this report the 17-year-old young person will be known as Prada (name chosen by young person) and the 15-year-old known as Jordan; these are pseudonyms in order to protect their identities. 1.3. Although the consideration of a CSPR was triggered by a serious assault, early information gathering by the Partnership highlighted a number of similar features about both young people and how agencies had been working with each of them. The Partnership determined that although the circumstances surrounding the assault may be interesting to examine, the CSPR would likely add greater value by undertaking a review that explored the effectiveness of local procedure and practice in identifying and responding to adolescents with complex backgrounds and whose vulnerabilities put them at increased risk of abuse and exploitation. By undertaking a proportionate review of these issues, it has allowed learning to be captured that can be used by the Partnership to strengthen arrangements.   1.4. By way of a summary, the following headline learning has been captured as a result of this review; - Early assessment, early help and intervention are critical to avoiding later problems for children who live with a daily adversity in their home lives and where there are multiple children living in the same household. Parental disengagement in early help offers should be viewed as a potential risk indicator rather than an informed and consensual decision made by the parents. - Timely and targeted intervention needs to follow assessment activity, especially in respect of educational provision which can be a significant stabilising factor in a child’s life; and particularly for those children that have experienced trauma and persisting levels of adversity.  - Children who have complex histories, and struggle to regulate their emotions and behaviours are more vulnerable to abuse, exploitation and exposure to drugs, alcohol and criminality unless diverted away; the professional network that surrounds such children needs to think, and work, as a collective and dynamic strategic unit in order to remain alert to shifting risks and dangers.  - Having adequate local resource and local capability to sufficiently manage or track the risk in communities for individual children is a significant challenge for all professionals and agencies.  - Stability of care placements and forming meaningful and lasting relationships with young people can be influential, protective and ultimately make a lasting difference.   2. Method for conducting the review 2.1. Following the assault in April 2020 the Partnership conducted an initial information gathering exercise as part of the Rapid Review process2; this mostly concluded in June 2020 however further enquiries were judged necessary in order to allow the Partnership, the Independent Chair and the National Panel3 agree a final course of action.  These further enquiries mostly related to whether a CSPR was best conducted on one, or both, young people. Once a final decision to conduct a CSPR on both young people had been agreed by all parties the following steps were taken; - Kevin Ball was confirmed as the Independent Reviewer4 in November 2020.  1 Working Together to safeguard children, HM Government, 2018.  2 Working Together to safeguard children, HM Government, 2018.  3 Child Safeguarding Practice Review Panel – an independent Panel with responsibilities under the Children & Social Work Act 2017.  4 Kevin Ball is an experienced independent safeguarding consultant, with specific experience of chairing and authoring case reviews.    Page 2 of 20 - An initial Panel meeting of agency representatives was convened in December 2020 to agree the scope and terms of reference for the review; key lines of enquiry were also established. - A short briefing for single agency report authors was provided in early December 2020, at which point the request for single agency reports was made to the relevant agencies listed below. This process provided each relevant agency with the opportunity to reflect on their involvement with both young people. 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 begin the process of making improvements. - A multi-agency practitioner workshop was held in April 2021 involving practitioners for both young people.  - The review was accepted by the Case Review Group in September 2021 and the Executive in October 2021.  - The approach taken has complied with the principles as set out in statutory guidance5 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.  2.2. The following agencies have contributed to this Review: - Warwickshire County Council Children’s Services             - Warwickshire Police - CAFCASS       - George Eliot Hospital - Warwickshire County Council Flexible Learning Team  - Youth Justice service - University Hospital Coventry and Warwickshire   - Compass: School Nursing - South Warwickshire NHS Foundation Trust   - GP Practice 5  - Supported Accommodation A        - Nuneaton and Bedworth Borough Council - Coventry and Warwickshire Partnership NHS Trust  - Primary School 1  - School 2        - Medical Centre 1 - Medical Practice 2        - GP Surgery 3  - GP Surgery 4       - Multi Agency Missing & CSE Team  2.3. The timeframe under review was agreed as March 2019 to April 2020. Relevant background information was considered as necessary. 3. Family structure & contribution to the review 3.1. At the time of the assault Jordan was accommodated in foster care. She, and her five younger siblings, had been removed from the care of her parents eight months earlier due to abuse and neglect.  3.2. At the time of the assault Prada was living in support accommodation having been placed there by Warwickshire Local Authority Children’s Services and being subject to section 20 (Children Act 1989) accommodation status. Her relationship with her mother had broken down some months earlier and she was unable to remain the family home with her three younger siblings. 3.3. The Independent Reviewer, in discussion with professionals involved with Jordan, made the decision that it was not sensible or helpful to approach Jordan to seek her contributions given the ongoing crisis situation she faced. Given her care arrangements, it was considered not appropriate to seek any contributions from Jordan’s parents. 3.4. The Independent Reviewer had a video call with Prada, who was serving a prison sentence at the time, and now an adult. Prada spoke about finding the majority of professionals and agencies that she came into contact with unhelpful, either due to them not really listening to what she might have to say and making assumptions, her believing they were scared to enter the family home, placing her outside of her local area which caused her additional problems, not responding to some of the things that were happening to her in a timely way, or asking too many questions. She did find the Inclusion Mentor helpful in encouraging her to engage with opportunities, and also found the Manager of  5 Working Together to safeguard children, HM Government, 2018.   Page 3 of 20 the Alternative Education Provider helpful because of the support he gave her (up until he formed and disclosed a relationship with Prada’s mother). Prada reflected on two points which stood out for her, and which really changed things for her; firstly, being placed outside of her area prompted her to engage in behaviours and alcohol use, that she thinks would not have happened had she remained in her local area. Secondly, at the point that she was no longer able to attend the Alternative Education Provider she found this damaging and upsetting. Her final reflection was that being detained in prison has been a lucky break for her; she is aware of friends and associates that have continued to have very difficult lives, and she has the view that being removed from that network has been a helpful intervention. Given her age, and the circumstances, it was not considered appropriate to seek the contributions of Prada’s parents. 4. Concise summary of relevant case history 1. On one day in April 2020 Jordan went missing from her foster placement but was picked up by an unknown person. Later that day Jordan was assaulted and stabbed by Prada. This assault appears to have been prompted as a result of Jordan assaulting one of Prada’s friends towards the end of 2019 and there being ongoing feuds between the friend’s family and others associates in the local area.  2. Review of information from a number of agencies that had contact with both Jordan and Prada reveal an extensive history of involvement with each of the young people and their respective families. Although it was known by some professionals there were family rivalries in general, it appears that it is only with the benefit of hindsight, as a result of the above incident, that connections were made between Jordan and Prada’s families. Information set out below provides a brief chronological profile of each young person, thereby providing context for the issues to be examined.   4.1. Relevant case history regarding Jordan 4.1.1. The incident between Jordan and Prada occurred when Jordan was 15 years old. Prior to this, agency records show a history of involvement with Warwickshire Children’s Services beginning in 2008. The more worrying aspects of Jordan’s childhood experiences included; multiple school exclusions and educational instability, witnessing parental domestic abuse, inadequate parental supervision and neglectful care, living with parents that were known to be misusing alcohol and using illicit drugs such as cocaine and cannabis, and alleged physical and sexual abuse from her parents.  4.1.2. From February 2018 through to July 2019 a number of NSPCC referrals were received about Jordan’s parent’s alcohol and substance misuse, lack of parental supervision of the children, domestic abuse incidents as well as referrals about physical and sexual abuse of the children. These referrals were deemed malicious and no further action was taken. During this time, the parent’s non-engagement with professionals was a feature. In September 2018 Jordan began attending an Alternative Education provider whilst a more permanent specialist school setting was considered. In October 2018 an Education, Health Care Plan was issued. 4.1.3. From March 2019 Warwickshire Police responded to a number of incidents involving Jordan, and include: Jordan being arrested to prevent a breach of the peace and being under the influence of alcohol, multiple episodes of harassment and assault between Jordan and another young person from a family where there were disputes, Jordan being arrested for criminal damage to her family home. A number of these incidents did not result in further action given either a lack of evidence or no complainant or witnesses. However, the Youth Offending Team were involved and after a series of events it culminated in Jordan being charged with harassment in 2020.  In March 2019 Jordan disclosed an assault by an 18-year-old male whilst at his house but did not want to make a complaint to the Police.  4.1.4. In April 2019 an investigation by Warwickshire Police following a referral from the NSPCC raised concerns for Jordan and her younger sibling about allegations of sexual and physical abuse. The allegations also included parental use of cocaine and cannabis. Due to the numerous previous referrals to the NSPCC being judged as malicious, this resulted in a single agency investigation by Children’s Services; no disclosures were made by the children. A further similar referral by the NSPCC was made soon after this (June 2019); again, no action was taken by Warwickshire  Police given the involvement of Children’s Services.  As a result of further parental non-engagement and developing concerns throughout this period, Jordan, and her five siblings were made subjects of a Child Protection Plan for neglect in June 2019. In July 2019 there was a serious domestic assault in the family home resulting in the father being arrested and   Page 4 of 20 given a 28-day Domestic Abuse Exclusion Order. This was breached several times. Following on from this there were ongoing disputes between Jordan, her mother and father which included; the mother reported that Jordan ‘was in foster care but staying at her friends and she was banned from visiting the property after she kept coming and being abusive and kicking off’, Jordan being assaulted by her father following an altercation which was witnessed by all of her siblings. This resulted in a Child Protection medical during which the Doctor recorded seven non-accidental injuries which were consistent with Jordan’s account of the incident. The Police interviewed both parents on a voluntary basis but the offences were denied; this resulted in the crime being filed due to insufficient evidence to proceed.  4.1.5. In September 2019 Jordan was accommodated into the care of the local authority under section 20 and continued attending the Alternative Education provider three days a week. Shortly after this, all of her siblings were removed from their parents care via Police Protection after the father threatened to burn the house with the family inside it as well as making threats to Children’s Services staff. This episode culminated in Interim Care Orders being granted by the Family Court in October 2019.  There were numerous incidents of Jordan being reported missing from September 2019 onwards for varying lengths of time, often refusing to say where she had been or who she had been with. In one such incident she was taken to hospital by a friend, having gone missing from her foster placement for over a day, heavily intoxicated and reporting feeling suicidal, and then assaulting a Police officer whilst at the Hospital. This incident was reported to Children’s Services by the Hospital but not by the Police.  4.1.6. In March 2020, and as a result of Covid-19, school closures were confirmed. Following a risk assessment by the Designated Safeguarding Lead Jordan was judged as high risk requiring frequent monitoring by agencies given the changing situation. During March 2020, the foster placement Jordan was staying at, broke down. Her contact with Children’s Services, including the Independent Reviewing Officer Team, and the Children in Care Team was maintained. Her contact with other agencies, such as the Youth Justice Service, the Police, and Cafcass also continued throughout this timeframe. 4.2. Relevant case history regarding Prada 4.2.1. The incident between Prada and Jordan occurred when Prada was 17 years old. Prior to this, agency records show a history of involvement with Warwickshire Children’s Services since 2012 due to concerns about her behaviour, violent episodes in the home, school and community, substance misuse and absconding. Positively, Prada had consistent attendance at one primary school from 2006 to 2014 before then moving to secondary school; however, in her final year of primary school she was excluded four times for refusing to follow instructions and absconding. Concerns about Prada’s younger siblings, also attending the same primary school emerged during this period. 4.2.2. In April 2014 an assessment noted ‘Prada’s behaviour at home is becoming unmanageable, she is aggressive and violent towards mum, swears and displays angry behaviour – damaging the house. She shows risky behaviour, little of concern for her own safety …’. 4.2.3. Early assessment activity conducted by the Youth Justice Service in December 2015 identified that Prada had experienced early trauma by exposure to domestic abuse, had an absent father serving a prison sentence, frequently used multiple forms of drugs, stole to fund her drug use, plus had a family network with extensive criminality.  4.2.4. CAMHS had frequent involvement with Prada due to her behaviour; one notable letter in December 2015 stated that she had described ‘having a hit list of children she wanted to assault in education’.  4.2.5. Prada and her siblings became subject to a Child Protection Plan in February 2016 under the category of emotional harm and physical harm; this plan ended after nine months in November 2016, but concerns were noted about Prada being at risk of child sexual exploitation as well as concerns about her mental health. 4.2.6. In November 2016 information was shared to the Police by Children’s Services that Prada was in possession of a bag containing a large metal meat cleaver; given she had carried out a number of other threats, this was removed from her as she claimed that she wanted to stab someone.   4.2.7. As the Child Protection Plan ended, case management was stepped down to Child in Need, being managed initially by a locality Team and then by the Children with Disabilities Team. At this point she was also having contact   Page 5 of 20 with CAMHS. In April 2017 Prada had a formal diagnosis of ASD (Autistic Spectrum Disorder) and began a prescription of medication in order to help reduce her aggressive behaviour. 4.2.8. Attempts to provide Prada with a secondary school education were unsuccessful, resulting in her being excluded from a secondary school 16 times. In November 2017 an Alternative Education provider was found which seemed to meet Prada’s needs and she made good progress in attending and committing to this placement. This had been the first time that Prada had engaged positively in any form of education since leaving primary school. However, concerns remained about her parents limited engagement with the Child in Need Plan, about risk posed to her by adults, accessing alcohol, drugs and absconding. 4.2.9. In July 2019 Prada caused significant damage to the family home, and was aggressive and violent; this happened whilst a younger sibling was in the home with the mother. This eventually resulted in Prada being accommodated under section 20 of the Children Act 1989 and her placement at the Alternative Education provider being terminated; at which point circumstances significantly deteriorated for her. The extent and severity of Prada’s behaviours then began to emerge, often unbeknown to others during the initial stages, because significant and relevant information had not been shared by the Alternative Education provider. Concerns included gang associations, greater drug and alcohol misuse and drug debts, continued violence and hostility, sexual exploitation and criminality.  In February 2020 Prada was accommodated in Supported Accommodation A. During the timeframe under review (March 2019 to April 2020) Prada continued to have significant contact with CAMHS, the Youth Justice Service, Children’s Services (including the Independent Reviewing Officer Team), the Police, a specialist Child Exploitation & Missing Team, and Barnardo’s; as well as the Children in Care Team providing Initial Health Assessments. 5. Findings & analysis 1. The emphasis of this review has been to undertake a proportionate examination of the effectiveness of local policy, procedure and practice in identifying and responding to adolescents with complex backgrounds who as a result may be at an increased risk of harm. It has examined the circumstances of two young people that, although having different origins to their complex histories, have manifested in similar high-risk situations. 2. Agencies were asked to submit information about their involvement with each young person considering the following four core practice areas, common to working with all children and families:  - Assessing need and assessing risk. - Agency response and/or intervention, based on identified need and risks. - Practice around information sharing to inform risk and safety management. - Gaining children’s views & experiences, and using this information to help with risk & safety management.  3. Through review of documentation about these core practice areas and further discussion with practitioners that were working with Jordan and Prada it has been possible to establish four themes which connect their circumstances;  - Using information about both pre-disposing and situational risks, to aid safety planning. - Educational provision and attendance being a key protective factor. - The importance of trusting relationships when working with young people and assessing risk. - The sufficiency of alternative care placements to provide support and stability.  4. The findings of this review strongly resonate with a previous Serious Case Review completed in 2018 by the Partnership, Sophie, but also the findings of a Challenge & Learning session facilitated in June 2019.   Page 6 of 20 5.1. Using information about both pre-disposing and situational risks, to aid safety planning 5.1.1. The review has been able to highlight the importance of information about risk being shared in a timely and intelligent way with partner agencies. The review has captured many good practice examples where information was shared in a timely and effective manner e.g., some return home interviews following episodes of going missing, and the work of a number of individual practitioners working with both Prada and Jordan. However, it has also highlighted areas for improvement which, had information been used and shared, in may have aided safety planning.  5.1.2. When assessing risk from a safeguarding and child protection perspective, it can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e., situational risks, and those where there is less likelihood of effecting change and which are more historical and may be biographical in nature i.e., pre-disposing risks6. For both Jordan and Prada there were some considerable and known pre-disposing risk factors, prior to the timeframe under review, that formed part of the family history. 5.1.3. For Jordan, and her siblings, pre-disposing risks included; - Contact and involvement with Children’s Services from 2008 due to absconding behaviour. - Parental non-engagement with services. - Multiple school exclusions followed by educational instability. - Witnessing and living with parental domestic abuse and violence. - Inadequate parental supervision and neglectful care. - Living with parents that were known to be misusing alcohol and using illicit drugs such as cocaine and cannabis. - Alleged physical and sexual abuse from her parents.   5.1.4. For Prada, and her siblings, pre-disposing risks included; - Contact and involvement with Children’s Services since 2012 due to concerns about Prada’s behaviour, which included violent episodes in the home, school and community. - Substance misuse by Prada and her absconding. - Prada and her siblings being subject to a Child Protection Plan in 2016 having experienced significant harm due to emotional abuse. - Prada receiving four school exclusions in her final year at primary school for refusing to follow instructions, absconding from the school site and safety concerns.  - A formal, yet later, diagnosis of Autistic Spectrum Disorder for Prada in April 2017, aged 14 years, and beginning a prescription of medication in order to help reduce her aggressive behaviour. Concerns were apparent about profound needs and what this meant for her social and communication abilities and being equipped to manage the complexities of the world.   5.1.5. Whilst the origins of these pre-disposing risk factors will be different for each child it is evident that both young people experienced a significant number of adverse childhood experiences. Research7 helps us appreciate the  6 A model for risk assessment as proposed by Brearley in 1982, as cited in Risk in Child Protection, Calder, M., 2016, Jessica Kingsley.  7 a) Beyond adversity: addressing the mental health needs of young people who face complexity and adversity in their lives, 2016, Young Minds, b) Children living with domestic violence: Towards a framework for assessment and intervention, 2006, Calder, M., Russell House Publishing, c) Youth crime, 2004, Muncie, J., Sage publishing.  Working Together (2018) states ‘… No system can fully eliminate risk. Understanding risk involves judgement and balance … assessment is a dynamic and continuous process that should build upon the history of every individual case, responding to the impact of any previous services and analysing what further action might be needed … revised throughout the process and takes account of family history and the child’s experience of cumulative abuse …’ (p.29).    Page 7 of 20 considerable impact of such adverse experiences and the importance for professionals to recognise this history when faced with assessing, planning and intervening in fresh concerns. 5.1.6. Against a backdrop of significant pre-disposing risk factors, situational risks became heightened for both Jordan and Prada completely independently of one another. There are a number of factors which contributed to this, and include; each child having reduced levels of resilience and therefore limited internal resource to counter factors that might pull them into greater harm, a limited or unreliable peer support networks on which to rely upon, a loss of control or agency over their own lives, challenges with managing and regulating emotions associated with previous trauma as well as situational events, and limited trust or confidence in the numerous professionals surrounding each of them.  5.1.7. It can be reasonably argued that the cumulative impact of life events and combined situational factors encountered by each young person resulted in them each being on a pathway that would cause harm8. Given the extensive history of pre-disposing risk factors outlined above, it provides strong evidence highlighting the need for the early identification of support, and the sustained and assertive involvement of professionals; especially in those families where the oldest child (or one of the older children) is exhibiting problematic behaviours, yet there are a number of younger siblings that are also living in the same conditions and are likely to experience the same adverse conditions and harmful care. The inability of the Early Help Service to engage with both of these families due to parental non-engagement, at precisely the time that the children needed input, presents a conundrum; this being how to intervene earlier using a consent driven service offer and knowing that a service such as Early Help can provide much needed scaffolding9 to the parent at a critical time of their child’s development, yet concerns not being at such a level that warrant a more interventionist approach. In both cases, Prada and Jordan’s parents did not engage with the Early Help Service. Given the information captured about neighbourhood disputes, unhealthy local relationships, and gang affiliations it seems that there are wider community issues in play which are highly likely to impact on a much larger population of children beyond the two that are the focus of this review. The Early Help Foundation have cited a case study10 about an attempt at a whole system approach that aims to adapt strategies and practice to reduce parental conflict and improve outcomes for children with a ‘relationship revolution’; the review is aware that Warwickshire has adopted this model and the Partnership may wish to monitor how effectively this is being embedded.  5.1.8. Similarly, and in Prada’s case, the early identification and assessment of special educational needs or disorders which may impact learning and care needs is important to acknowledge which, if left unassessed, may go on to create greater risk and heighten vulnerability especially during adolescence and transitioning into adulthood. The late identification and long delays of diagnosis of ASD for Prada did not help. This is an issue that has been acknowledged by the relevant local services with a lead for assessing and diagnosing such conditions and has been subject to improvement activity.  5.1.9. The above issues and risks, mostly originating from within each young person’s family and which were known about and were critical to assess and respond to, became complicated when additional external risk factors, from a contextual perspective were added. Key agencies involved with both Jordan and Prada recognise that profiling and disentangling contextual risks – those risks from outside of the family environment - could have been much stronger. This finding has resonance with the findings set out in SCR Sophie (2018).  Contextual situational risks for both Prada and Jordan included; - Fractured relationships with family members; parents and siblings.  8 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, May 2016, Department for Education, HM Government.   9 Scaffolding is a term often used to help those in a learning situation build on prior knowledge and internalise new information. The scaffolds facilitate a student achieve greater autonomy through competent assistance and can readily be applied to helping parents acquire new skills.   10 Early Intervention Foundation, 26th March 2021, Rochdale: Starting a 'relationship revolution' to improve the quality of relationships for everyone    Page 8 of 20 - Being placed in alternative care arrangements that were unstable and that at differing times were more or less risky, dependent on whether the arrangements were in, or out of, the child’s local home area. - Episodes of missing from care. - Exploitation and potential exposure to criminal networks capable of exploitation. - Feudal tensions between families and rival groups. - Drug and alcohol misuse including drug debts and associating with drug users and dealers. - For Prada, the inconsistent use of prescribed medication.  5.1.10. The situational and contextual risks experienced by both young people has exposed fault lines that span a number of agencies involved which concern the effective and timely sharing of information and intelligence for the purposes of safeguarding. These fault lines have especially become apparent due to the complexity of the number of agencies and services that were in place and this particularly relates to the Police, Youth Justice and Children’s Services (including the local Children’s Services Team, the Children with Disabilities Team and the Child Exploitation & Missing Team) and Barnardo’s. Whilst it has not been possible to determine with any certainty whether, had intelligence been shared at an earlier stage, it would have prevented the assault on Jordan by Prada, it is clear that there was one particular line of enquiry that, had it been shared and examined, it would have opened up further potential avenues for professionals to have caused some diversion. The application of a complex abuse meeting approach would have been valuable in this instance. The agreement of a recently revised information sharing guidance document Warwickshire County Council (WCC) Information Sharing agreement, is hoped to reduce the likelihood of information being lost or not provided particularly in regard to Local Authority Education and Social Services, Early Years Providers, Schools, Colleges and Academies. 5.1.11. The contextual concerns identified were significant in nature, involved a number of other vulnerable young people in their associations, and importantly provided intelligence that, when untangled, directly exposed a family feud and linked Prada to the individual that Jordan was originally accused of assaulting. It is only as a result of this review being commissioned that the impact of the links, networks and associations were understood upon the young person. Working in isolation from other key agencies, rather than as a strategic unit resulted in information, tactics and strategy not being shared with multi-agency partners and there being no coordinated approach to tackle the family feud. Another example where a strategic and coordinated approach might have been beneficial to Prada is through the use of the Autism Learning Disability at Risk Register (ALDARR)11. This is a local register of individuals with autism and/or a learning disability that have been identified as requiring additional support, either because of increasingly challenging behaviour or due to a deterioration in their mental health.  It is held by the relevant Clinical Commissioning Group (CCG) and is designed to ensure that there is a coordinated and integrated approach across education, health and social care to providing any additional support required to keep the individual in their home. However, it is important to note that this would only have been beneficial to Prada if conducted and applied in an integrated way with the other plans and activities taking place; in effect strengthening the need for a strategic effort rather than a set of fragmented interventions by a range of agencies.  Learning point: Complexity – based on considerable pre-disposing and situational risk factors for each child - makes it harder for professionals to understand cause and effect, predict events and exercise control. To manage this complexity, it is important that the professional network operates strategically rather than a collective effort of isolated interventions. Using and maintaining tools such as chronologies will enable sharing and mapping intelligence in a timely way across the professional network.  The use of supervision will also aide more effective networking Learning point: Engaging parents at an early stage when concerns are identified is critical to identifying, assessing and targeting support. It is more effective to provide early help when problems are first noticed than to intervene later. When parents resist engagement with available support for an adolescent child, yet concerns do not diminish but simmer, and there are multiple other younger children in a household, there is value in assessing risk from a holistic  11 The Autism & Learning Disabilities Admission Avoidance Programme Information Leaflet for Arden Transforming Care Partnership (TCP),    Page 9 of 20 and multi-agency perspective. The use of combined multi-agency chronologies to identify patterns is a useful tool to begin mapping and assessing risk. Learning point: Parents are a child’s first and most enduring educators for all aspects of life and development. Exploring the conundrum that is presented to the professional network when parents resist professional engagement at an Early Help level, yet there are clear indicators of a harmful pathway, however concerns do not reach or persist at a threshold to warrant a more interventionist approach, will be beneficial – at an individual case management level but also as a strategic partnership. 5.2. Educational provision and attendance being a key protective factor 5.2.1. The review has captured information which confirms considerable instability and gaps in both Jordan and Prada’s educational careers; this instability, caused by the limitations of assessment, delays in processing and then finding appropriate resourcing resulted in both young people being exposed to additional risk.  5.2.2. Jordan had experienced a permanent exclusion from one secondary school in 2017 resulting in an alternative interim provision then being provided. From this, she went on to another secondary school (School 2) starting in January 2018 however it was recognised by school staff that a mainstream setting was not the most appropriate provision to meet Jordan’s needs. School 2 have reported that they did not receive details about the permanent exclusion from the previous school nor the family history prior to Jordan starting with them. Combined, the issues of exclusion, seeking an interim solution, starting at a new provision that was acknowledged not to be the best option, and a lack of information sharing, did not maximise the chances of success for either teaching staff or Jordan. 5.2.3. Despite considerable efforts to provide support School 2 have reported that Jordan displayed high levels of disengagement, poor emotional regulation and often refused to follow instructions – which prompted the involvement of an Educational Psychologist to assess Jordan for an Education, Health & Care Plan. Attempts to engage the parents in this process, alongside the involvement of other agencies such as the Early Help Service, resulted in considerable delays; all the time with Jordan refusing to attend lessons and having a reduced timetable. Alternative provision was provided during these delays and there was recognition by the Educational Psychologist and Special Educational Needs Coordinator in March 2019 that the current arrangements, as well as the delays for Jordan’s educational needs, were not sufficient despite the arrangements providing well for her emotional needs. This prompted them to organise a professionals meeting to raise the profile of concern about the unfolding situation. It appears that there was a difference of opinion; one set of school professionals recognised the current arrangements were not adequate, and the Special Educational Needs & Disabilities Annual Review (SENDAR) Service believing that the situation needed longer to settle and for learning routines to be established. It did however prompt an annual review of Jordan’s Education, Health & Care Plan in May 2019, resulting in further assessment of her needs. This suggests that the current local arrangements for reviewing and re-evaluating children’s changing educational needs at the time were not child focused in order to be sufficiently responsive to children’s changing circumstances. The review is aware that new arrangements have been introduced in April 2021 as part of the local SEND & Inclusion Strategy, which will mean that regular Panels will meet to review new or existing EHCP’s.   5.2.4. Positively, Prada had maintained her place as a pupil at her primary school up until her final year; however, during her final year (up to July 2014) was excluded four times. Prada then experienced a period of nearly three years (up to November 2017) of considerable disruption to her educational career with various provisions being tried but none of which met her needs. Prada was formally diagnosed with ASD in April 2017 aged 14 years. This highlights that an earlier assessment and diagnosis might have offered considerable insight into how her needs might have been met, and reduced the number of attempts at sourcing an appropriate educational provision for her, but which ultimately The Children’s Commissioner has stated ‘… Stability can be the difference between children flourishing in their environment, or having the difficulties they have already had to endure further compounded. Instability makes it harder for a child to form positive trusting relationships with their carers, teachers and social workers, and makes them feel less safe ...’. Stability Index 2018 report.    Page 10 of 20 ended in failure for her. As noted above, the late diagnosis of girls with autism is an issue that Warwickshire Special Education Needs Service is aware of, with this case not being an isolated case; a wider review into those issues has been underway. 5.2.5. Following the diagnosis in June 2017 the SEND Assessment & Review Service concluded that her current specialist school was not meeting her needs noting that they were ‘… not convinced that we are necessarily looking at a school but could be a very personalised programme. Prada’s views and engagement will need to be sought as otherwise I fear another placement will be sourced that she also does not attend …’. The Flexible Learning Team, which took responsibility for coordinating Prada’s educational needs and recruited an Inclusion Mentor, noted in an assessment in April 2018 completed by an Occupational Therapist that Prada ‘… is a vulnerable young person who has difficulty processing sensory input. She displays definite differences in her behaviour to sensory input especially oral and tactile sensations. She displays seeking, avoiding and sensitivity to sensory input. Prada does have complex social and communication, behavioural and mental health needs and therefore this is impossible to deal with her sensory needs in isolation without considering all other aspects of her behaviour and presentation. Any sensory processing difficulties will not explain or account for all of Prada’s past or present difficulties. As her mood and psychotic symptoms are being managed, I understand that the extreme responses to sensory input have become more evident. For example, dealing with her periods has become significantly more challenging to cope with for her…Prada is at a significant point in her development, she is going through puberty and has limited insight into her own difficulties. She participates in risk taking and in the past criminal behaviour. On a day-to-day basis this means she is vulnerable and safety is a concern as she gets older and seeks more independence …’.  This evaluation is helpful in being able to offer some level of prediction for the management of future needs but also risks and vulnerability.  5.2.6. From November 2017 Prada accessed an Alternative Educational placement which provided outdoor and practical based learning opportunities. Funding was also provided to provide Prada with a bespoke package of opportunities with dedicated workers to support Prada; this proved ideal for her and whilst it was not without complications was successful for nearly two years. In March 2019, for example, Prada was well settled with the Alternative Education placement and making good progress. For the first time in her life, Prada was engaging positively with education and saw the vocational learning opportunities she was engaged with as her potential career pathway. There was little engagement from her family despite being on a Child in Need plan and there were some concerns about Prada being at risk of harm from adults, accessing alcohol and substances and absconding; however, her commitment to the education provision helped to reduce the level of risk. 5.2.7. Following the incident in July 2019 whereby Prada was not accepted back to the home by her mother, the risks increased. Furthermore, the education placement was terminated in September 2019 due to the stated risks she posed to staff and other students, and that she appeared sometimes to be under the influence of drugs. This proved to be a considerable loss, both emotionally but also as it being a factor that held her back from being at risk of harm. Clearly Prada had a number of issues impacting her life at this time such as managing her medication, the push and pull of different factors and individuals who could harm Prada, and the trauma associated with family tensions and dynamics. However, the ending of her placement at the Alternative Education provider has to be viewed as a significant episode which had a seriously adverse impact on her emotional wellbeing and stability.  5.2.8. One likely, and significant, contributing factor which may shed some light on why the wider professional network was not fully aware of the extent of the risks Prada faced has been identified. It has emerged that Prada’s mother had been in a relationship with the Manager of the Alternative Education resource. Information about significant risk factors held by the Manager of this provision was withheld from other agencies in the belief that it may compromise the trusting relationship that had been formed between Prada and the Manager; information included knowledge about Prada being at risk due to exposure to another criminal network, being aware that Prada had been regularly climbing out of the window of a family friend’s house with whom she had been staying at, using drugs, and knowing about numerous drug debts. The explanation for withholding this information and of it potentially compromising what was perceived by Prada as a positive relationship, has to be balanced with the knowledge that the Manager was in a relationship with Prada’s mother for nearly nine months and at one point he had suggested Prada ‘needing to be sectioned’; there was a clear conflict of interest which demonstrate lost professional boundaries, and not being clear   Page 11 of 20 about safeguarding responsibilities. The delays in reporting this information left Prada at risk of further harm or exploitation, which was something the Local Authority wished to protect her from. Ultimately, this did result in her placement at the Alternative Education provider being terminated causing her to feel betrayed. The circumstances of this relationship – which raised questions about suitability to work with vulnerable children - have been investigated separately from this case review via the appropriate procedures.  Learning point: Background information should always be provided from one school to another, or sought if not provided, about a child prior to a child being admitted on to the school roll. Learning point: If parents are resistant to professional contact which is intended to support a child’s needs (health, physical, intellectual, emotional, social or behavioural) the matter should be escalated or referred to the next level, with a follow up seeking an outcome.  Learning point: When a number of professionals have a collective view that a child’s educational needs are not being met, especially when the child has a complex constellation of factors in their lives, there needs to be robust and timely challenge in the form of a formal escalation to the relevant agency. This challenge should include when local policy and procedure do not appear to be working in a child focused way. Learning point: There are training needs between the Flexible Learning Team and Alternative Education providers that might be commissioned to offer care, support or educational opportunities to children, in respect of safeguarding and child protection practice; in particular, the need to be additionally curious about what information is being shared by the Alternative Education provider, how it is being shared and whether issues are being minimised as part of the ongoing training programme.  5.3. The importance of trusting relationships when working with young people and assessing risk 5.3.1. The review has been able to highlight a mixed picture about the quality and effectiveness of professional relationships formed with both Jordan and Prada. Some positive and very effective professional relationships were formed and were able to influence and shape each of their lives. However, the review has shown the need for professional continuity and targeted relationship-based interventions that benefit from having local intelligence about actual or potential risk factors shared as a means to supporting safety planning activity.  5.3.2. Jordan had experienced considerable loss at the point she was removed from her parent’s care, which included the further breakdown of her relationship with her parents, as well as the loss of living with her siblings. Invariably, it resulted in conflicting feelings. Jordan had not built a network of positive peers, in part because of her not experiencing stability in her educational placements and also not engaging in peer-based activities which would allow her the opportunity to build relationships. She had experienced multiple foster placements since coming into foster care – this had not promoted trusting and meaningful relationships. 5.3.3. Children’s Services have reflected that ‘… One of the difficulties with Jordan was that is she felt she had been portrayed negatively by someone this would detrimentally impact on her relationship with them and so information sharing and managing this sensitively was always a challenge. It was important for the few people that Jordan trusted and confided in i.e., the allocated Social Worker and the [support] worker, that these relationships were maintained as they were the only people who had any insight into Jordan’s life; however, it took time for these relationships to develop and this for Jordan to begin to open up and share information with them. At times a lack of information about Jordan, her family and the community around her negatively impacted on the full risk being known …’.  5.3.4. Attempts by the Youth Justice Service to engage Jordan in voluntary work were not effective. Despite attempts, the Service was unable to establish a strong relationship with Jordan resulting in them having very limited leverage in comparison to other statutory work that might have been underway.  Working Together (2018) refers to what children have said that they need, and which should guide the behaviour of practitioners ‘… vigilance: to have adults notice when things are troubling them, … understanding and action: to understand what is happening; to be heard and understood, and to have that understanding acted upon …’ (p.10).     Page 12 of 20 5.3.5. Warwickshire Police have concluded that Jordan was mostly treated as the suspect; risks to Jordan herself, despite her age, were generally not assessed. This resulted in a very different style and nature of relationship being formed with her by the Police and Jordan viewing them with distrust. As such, opportunities to assess risk to Jordan were missed. Examples include; - March 2019, when 15 years, Jordan being brought into custody under the influence of alcohol following a breach of the peace. A Child Protection Incident was not raised and there was no information shared with the MASH. The information was ultimately referred back to the Police in May 2019 by the Social Worker who had gained more information from Jordan about the incident and there being a possibility about a sexual assault or exploitation. It resulted in the information being shared with the Police CSE Team.  - July 2019, with there being a serious domestic assault on Jordan’s mother by her father. The risk to the mother, and all of the children was not fully assessed by the attending Officers, despite there being injuries, the attendance of paramedics and the children clearly being frightened. No efforts were made to locate the father, who had left the property, and no consideration was made to arresting him, despite there being reasonable grounds to do so. Some hours after the incident, and only due to the efforts of another Officer who reviewed the incident logs and history, identifying a pattern of domestic incidents, was this rectified. Revisiting incident logs and chronological information is an example of good practice to identifying risks; it resulted in information being shared with Children’s Services, a joint visit and the use of a 28-day Domestic Violence Prevention Order being imposed on the father. This incident eventually acted as a catalyst for the children being removed from the parents’ care. However, the effectiveness of the Prevention Order has to be questioned given it was known the father was breaching it; it placed an emphasis on the mother to not allow him in the family home which clearly has implications for her, and the children’s safety. - November 2019, the Police were called to the Hospital due to Jordan’s violent behaviour whilst intoxicated and saying she felt suicidal. Although comments regarding Jordan feeling suicidal were recorded on the Police Storm log12 this information was not recorded on the Athena13 investigation database or in the referral to Children’s services. There is also no reference to this information on the custody record. This information should have been shared with Children’s Services and the Custody Sergeant in order to accurately assess risk.  - An incident in March 2019 when Jordan had received threatening messages, which was reported to the Police. Police advised that they would visit her to take further details the same day it was reported; this did not happen and caused Jordan some distress. Police visited the following day and encountered some resistance, which in part was fuelled by Child1 being unhappy that they had failed to visit the previous day.   5.3.6. The narrative for Jordan about Police involvement in her life was that they either treated her as the problem i.e., the suspect rather than the victim, or Jordan viewed the Police as not being interested, or that they caused her further problem. One exception to this has been captured. Warwickshire Police made many good efforts not to criminalise her any further than was necessary, and did, on occasion, take a trauma informed approach to some decisions, thereby allowing her the opportunity open up and talk about the domestic abuse in the family home and her other childhood experiences. She explained that she had not said anything previously as she did not want her siblings taken away. The specific efforts of one Police Constable plus the Missing Person Coordinator to either try and resolve a number of issues through a problem-solving approach, or share vital information about missing episodes, are examples where practice was child centred and used to inform risk and safety management. 5.3.7. There was continuity of worker for Jordan, as the Chair of the Child Protection Conference from July to October 2019, then became the Independent Reviewing Officer (IRO) at the point that Jordan became accommodated in September 2019 and subject to an Interim Care Order. This is an example of good practice where the continuity of worker supports a better understanding and tracking of risk and protective factors. This continuity was not achieved in the same way for Prada due to the initial IRO leaving post and two reallocations being needed.   12 A Storm Log is a data capturing framework and system used by the Police.  13 Athena is an intelligence and case management system used by Warwickshire Police.    Page 13 of 20 5.3.8. There are numerous examples of the Social Worker listening and capturing Jordan’s views and these being shared at forums such as Child Protection Conferences and Looked after Child Reviews. These include ‘Jordan has expressed that she likes her current placement but wants to be closer to [home] as she misses her friends and she wants to be closer to her friends without relying on transport to take her places …’. ‘… Jordan wants to stay in her current placement and is willing to work with [the foster carers] in order to stabilise the placement. She is desperate to not have to move on …’, ‘… Jordan is also disappointed that her time at Positive Impact has been reduced and is apprehensive about starting a new education provision …’. Again, continuity of worker is an important factor.  5.3.9. The use of a venue for an annual review of Jordan’s Education, Health & Care Plan (EHCP) that was familiar to Jordan and her mother in May 2019 in order to make it easier, and more likely, that they would attend was child focused.  Despite earlier failed attempts to engage Jordan and her mother in this annual review process, this tactic proved successful and is an example of good practice where the Special Educational Needs Coordinator was able to exercise influence and encourage Jordan and her mother to share their views. Allowing young people more control and in environments of their choice is recognised as a positive manoeuvre14.  5.3.10. The Hospital Consultant took the time to listen and understand Jordan’s account of a domestic incident which resulted in her having a child protection medical. Jordan was able to describe the events of the alleged assault as she was given time to express her views, which were then documented. 5.3.11. Similarly, Prada had experienced considerable fracturing in her family relationships. Her cognitive understanding of these fractures was, in part complicated by the challenges of having ASD and its implications for social and emotional regulation – but nonetheless were impactful on her emotional wellbeing. Prada had also not benefitted from having a reliable and consistent peer network due to her multiple educational placements.  5.3.12. She experienced a number of changes of Social Workers, and other professionals in her life. The efforts of the Inclusion Mentor are noteworthy as this showed that Prada would share information and confide in someone when given the chance to; this included using formal and informal opportunities to develop and promote a more trusting relationship. To some considerable extent, the success of the Alternative Education provision, described above, was due to the efforts of a dedicated Inclusion Mentor who continued to transport Prada to and from the Alternative Education provider from November 2017 to July 2018 but maintained her involvement with Prada into 2019; in many aspects going beyond her role given the complexities that Prada faced. Case recording shows that Prada would talk about both past and current experiences, her behaviours, the risks to her, the behaviours of other people she was seeing in the evenings and weekends. The Inclusion Mentor was able to encourage reflection and gain insight, particularly helping Prada think how she might approach situations differently. In particular, case recording and risk assessment, highlights Prada’s vulnerability to harmful online activity and exploitation; the Inclusion Mentor used home visits and car journeys to weave in key messages about how to stay safe online and other discussions around safety and relationships. This is an example of good practice which highlights the importance of relationship-based work and using informal opportunities to gather information which can then inform safety planning. The organisation may want to draw learning from this. Ensuring there is sufficient local resource of skilled support workers who can work with vulnerable children with complex needs may be an area that the relevant services will wish to examine. 5.3.13. Despite struggles to engage with Children’s Services prior to leaving the family home in July 2019, Prada did engage reasonably well with her Social Worker, which allowed her to help shape and influence her care arrangements; this included being open to regular visits from her Social Worker, overcoming some initial reluctance to accept joint visits with a Barnardo’s worker from the Child Sexual Exploitation Team, expressing a view that she wanted to live independently and was capable of moving forward with her life – resulting in her placement at the Supported Accommodation in February 2020 and being closer to friends and family.  5.3.14. The response initiated by the Missing Practitioners to the missing episodes through Return Home Interviews show an understanding of Prada and the level of risk and vulnerabilities. Prada engaged well with the team and completed most interviews offered. She spoke about her feelings of being let down by having to end her placement  14 Contextual Safeguarding Network, Learning Project 3: Holistic approaches to safeguarding adolescents, February 2019, Peace, D., & Atkinson, R., University of Bedfordshire & The International Centre: Researching child sexual exploitation, violence & trafficking.    Page 14 of 20 at the Alternative Education provider, how nobody really understood about the feelings that she had towards other people and animals. She also spoke about feeling unsupported, hating where she lived, angry, and that she could possibly want to ‘… hurt somebody very badly and go to prison for doing so …’. Prada disclosed varying reasons for the missing episodes in terms of both push and pull factors; placement difficulties, her needs not being met, wanting to meet friends, return to her home area including significant travel between different areas and engaging in activities with her friends for which there was significant existing concerns including newly formed associations. Through these interviews it was possible to identify a pattern whereby Prada seems to have normalised her activities and the harm she experienced. Additional triangulation and curiosity with other agency information, including that of the Supported Accommodation provider would have added an extra dimension to the information that Prada was providing them with, and potentially helped risk assessment and safety planning. Notwithstanding this, information was shared with the Police and other allocated workers. These examples highlight the importance of developing a relationship with young people that are experiencing considerable turmoil, yet have little stability in their lives. 5.3.15. The Youth Justice Service captured Prada’s views on a number of occasions, thereby suggestive of some form of relationship being established. These included Prada stating that ‘nothing much will come of her life …’, ‘… no-one could help her ...’, and reflections that she ‘sees too many people each week since being put on child protection plan …’, and that ‘… her drug use is not an issue and that she wants to be back in full time education, but no one is listening to her. She said she will be much happier in school instead of spending the whole day at home not doing anything. She says she will do some prevention work but is not sure if it will work as she is naturally drawn to conflict and trouble follows her everywhere …’; plus Prada stating that ‘… she will easily pick a fight with a group of people and is not scared by anything … if she saw people arguing and she knew one of them she would intervene even though the argument had nothing to do with her and she would likely punch whoever was in the wrong … if someone said something she did not like she would hurt them … enjoyed smoking cannabis and did not see the need to stop …’. 5.3.16. Prada formed a relationship through her involvement with CAMHS who were able to provide continuity with supporting her mental health needs and prescribed medication regime. 5.3.17. During the initial days of the national lockdown due to Covid-19, Prada appeared to have a good understanding of the risks and reasons for the national lockdown but was missing visits from her father. She agreed to working with a Targeted Support worker and some daytime educational provision if only because of being bored. An assessment visit by the Social Worker provided a helpful snapshot to understanding how Prada was going to respond to situational risks created as a result of a national lockdown. However, the snapshot was just that; the following day Prada expressed a number of doubts and worries ‘… [I] am the only one who has lost everything, whilst her Mum has still got her kids, still got her house, and still has her man …’, not wanting to take her medication, not seeing a future or knowing what would help ‘… you could offer me anything in the whole world tomorrow and I wouldn't be able to tell you … '. She acknowledged that '… everyone is trying to help …', but she didn't think she could be helped. These reflections may, in part, be attributable to Prada’s background and the adversity she had experienced but also have to be considered in the context of Covid-19 restrictions being imposed and this having a detrimental effect on her emotional wellbeing which, in turn, increased risk.  Learning point: The importance of building and maintaining relationships with children and young people should never be under-estimated. There is considerable research1 supporting this view, with it providing opportunities for earlier intervention and prevention, plus more effective interventions during times of crisis. Learning point: Promoting the resilience of young people and strengthening the protective factors around them are important aspects of prevention. Building resilience requires internal capacity but also external influencers. By providing targeted support at the earliest stage, it can promote resilience. This means that ‘… children and young people must be enabled to establish and maintain trusting relationships with key adults, and these should not be fragmented through organisational structures or processes …’1.  Learning point: When working in a multi-agency context with complex cases, the strategic network that surrounds the vulnerable child should identify which individual/s are best placed to build a trusted and meaningful relationship – ideally in collaboration with the child. However, this has to be balanced with the risk associated with relying on just   Page 15 of 20 one person to fulfil this role – especially for those young people that have experienced considerable trauma and are at high risk of harm. The support of other professionals advising or supporting the nominated person will be important.  5.4. The sufficiency of alternative care placements that can provide the support and stability needed 5.4.1. The experiences for Jordan and Prada highlighted in this review concerning placement matching and placement instability reflect what are known challenges faced nationally15; with an increase in demand for placements alongside the reduced availability of placements that can care and support children with complex needs. This finding resonates with the findings set out in SCR Sophie. 5.4.2. Jordan was removed from her parents care via Police Protection in September 2019 and was placed in and out of, her local area. She did not settle into any of the placements, often was absent and sometimes sofa surfed staying with friends. Jordan expressed a clear wish to remain in the local area to her parents; having acted on this wish and despite agreements from her that she would adhere to a set of rules which aimed to keep her safe, the rules were not kept to. The impact of Covid-19 restrictions did not help the situation and ultimately another placement outside of the local area was found. During this time, she had been running away, using alcohol and drugs, had contact with the Police, and had been staying with friends overnight. There was nothing settled about Jordan’s life or her lifestyle. 5.4.3. In October 2019 Prada was initially considered suitable for staying in a residential Children’s Home, however on visiting it was clear to all that Prada was not going to abide by the boundaries, rules and expectations of the Home; in fact, it was considered that her placement in such a Home may even increase the risk to her, and other young people placed in the Home. There were no further residential offers available for Prada but two supported living options were offered. In the interim Prada had been staying with a family friend but this arrangement was becoming untenable; it is not clear the extent of assessment undertaken about the suitability of this family friend arrangement and whether it could ever have been a seen as a solution that would provide Prada with some stability.  5.4.4. Prada’s initial placement in supported accommodation in one area in October 2019 was deemed unsuitable for a number of reasons, one being that it was identified, in December 2019, that the area ‘was a hotbed for CSE’. This known information was not explored prior to placing Prada and as such was a missed opportunity to limit further risk to Prada. This resulted in her being placed closer to home in February 2020 in Supported Accommodation A, where it was thought risks could be managed more effectively with increased professional visiting and known service provision being easier to access. She remained in this placement until committing the assault on Jordan. Although not without challenges, this placement proved to be somewhat successful in helping identify risks Prada faced, develop positive relationships with staff and become more settled; the level of risk reduced significantly compared to what it had been. Her father was also visiting, which was seen as a protective factor. However, Prada would not share information about who she was associating with and often told misleading stories of her whereabouts, staff monitored and reported her conversations heard over the phone with others and shared concerns with professionals. Her risk assessment was updated after each incident occurred or when a significant event occurred but it has to be recognised that staff were unable to restrict her movements which made safety management more challenging and unpredictable.  5.4.5. The details set out above highlight some challenges. These include;  15 ADCS, Interim Report Safeguarding pressures phase 7, December 2020.   Statutory guidance states ‘… When a child becomes looked after the responsible local authority will arrange a suitable care placement. In doing so, the child’s allocated social worker, supported by local authority management and resources, should do everything possible to minimise disruption to the child’s education (2.69) … Having the most suitable placement available is a vital factor in improving placement stability, which in turn is a critical success factor in relation to improved outcomes for looked after children (3.254) …’. The Children Act 1989 guidance and regulations Volume 2: care planning, placement and case review, June 2015.   Page 16 of 20 - Sourcing sufficiently experienced and skilled foster carers or alternative care providers to meet the needs of children and young people that have experienced considerable trauma in their lives. - Having a range of placement resources available both within the local area in order to adhere to good practice expectations and statutory guidance16, but also outside of the local area, should circumstances require the child or young person to be placed further afield. Dealing with the added risks of each child gravitating back to their home area increases this challenge. - Helping those children and young people who find abiding by rules and expectations more challenging.  - Those responsible for sourcing and finding placements being able to use information and local intelligence to inform placement choice and suitability.  - The assessment and use of a connected person17 arrangement as an interim solution to greater problems with sourcing a more permanent arrangement.   5.4.6. Research conducted by the Children’s Commissioner found ‘… Children living far away are likely to have more complicated and fragmented histories. They are more likely to be older children … and more likely to have experienced multiple moves while in care. Being so far away from their hometowns can be another trauma for children who have already had difficult upbringings. More than half of children living out of their local area have special educational needs and a quarter have social, emotional and mental health identified as their primary need. These are therefore often children who struggle to process change and need routine and consistency to stay calm and content. They may take a long time to build trust with adults and feel settled, and yet this group are at risk of chronic instability ... Children living far away are also known to be at much higher risk of going missing … Their vulnerability also means that they are easy targets for exploitation by criminal gangs, who are expanding drugs markets through ‘county lines’ activity into semi-rural areas …’.18 5.4.7. Children’s Services have a lead role and responsibility for sourcing placements for children that become looked after. Reports submitted to this review by Children’s Services set out a number of appropriate measures and actions which reflect the learning they have captured as a result of interrogating their practice in relation to their work with Prada and Jordan; these measures and actions mostly target front-line practice. The issue that is less apparent relates to a more strategic solution to the shortage of suitable placements for children that are unable to live at home with their birth families, where there is a level of risk and complexity necessitating a skilled approach, and where special educational needs are a significant factor.  6. Conclusion  6.1. This Child Safeguarding Practice Review was triggered as a result of an assault by one young person against another; however, on initial review of information it became apparent that there were some parallels in history and agency involvement with both young people and that the triggering assault should not be the focus of the review. The review therefore set out to examine the quality and effectiveness of local procedure and practice in identifying and responding to adolescents with complex backgrounds and who are drawn into behaviours which increases risk.  6.2. The review has specifically examined four features that emerge from documents provided by a number of agencies, discussions with practitioners involved with each of the young people, and reflections by a case review Panel. The review has also benefitted from the contributions of one of the young people and allowed some insights from her perspective to inform the findings. Features examined included; - Using information about both pre-disposing and situational risks, to aid safety planning. - Educational provision and attendance being a key protective factor.  16 a) The Children Act 1989 guidance and regulations, Volume 2: care planning, placement and case review, June 2015, b) Pass the parcel: Children posted around the care system, December 2019, The Children’s Commissioner.  17 The Children Act 1989 guidance and regulations, Volume 2: care planning, placement and case review, June 2015.  18 Pass the parcel: Children posted around the care system, December 2019, The Children’s Commissioner.    Page 17 of 20 - The importance of trusting relationships when working with young people and assessing risk. - The sufficiency of alternative care placements to provide support and stability. 6.3. Findings have been made in respect of each of the features detailed above, with specific learning points for practitioners, managers, leaders and trainers. SCR Sophie (Warwickshire Safeguarding Children Partnership, 2018) and the Challenge & Learning event (Warwickshire Safeguarding Children Partnership, 2019) highlighted a high number of issues very similar to that which this review has found. The Partnership will wish to seek assurance that sufficient pace and progress is being made in terms of embedding the learning from all three review exercises.  6.4. It is also worth noting the comments from one manager connected to the Child Exploitation & Missing Service, for Warwickshire Children’s Services, highlighting specific learning that has been acted on – not just as a result of this review but as part of an overall improvement journey in responding to young people that have a profile similar to Prada and Jordan. Whilst it is recognised that there is further improvement work needed, changes to date include; - Improved triangulation of information & application of curiosity to missing episodes by Missing Practitioners. - Improved engagement with placement staff (and parents/carers/family) to build up a wider picture. - Development of MOSAIC database forms to better reflect child exploitation and guidance of how to act upon it within assessments and meetings via Disruption and Safeguarding support. - Integration of multi-agency child exploitation into other meeting forms about the young person to ensure the process is followed in accordance with a one meeting one plan approach. This was highlighted in SCR Sophie. - Improved system to identify when Missing Intervention Meeting thresholds are met and escalate requirement for meetings. - Review system in place to monitor open Child Exploitation Assessment Tools to promote expeditious completion. - Work remains in terms of enhancing capacity and capability of parent/family support provision, embedding a contextual safeguarding approach, and raising awareness about procedures and aligned expectations relative to missing and exploitation.   6.5. In conducting this review, it is apparent that there is a great willingness across Partner agencies involved to learn and strengthen their practice and that changes which support that change are, in part underway. Continued efforts are needed to maintain momentum. The revised strategy, Tackling the Exploitation of Children and Adults in Warwickshire (2020 – 2023)19, is supporting improvement activity and includes; - A named lead for exploitation, with clearer lines of accountability about safeguarding children and adults. - An improved picture of the prevalence of exploitation within Warwickshire. - Improved awareness about referral pathways to report concerns across organisations, and escalation processes in place to support agencies to resolve disagreements for children and adults that are being/at risk of exploited. - A safeguarding week of focused events examining the following topics: Transitional Safeguarding, Digital Dangers, Hate Crime, Child Sexual Exploitation & Criminal Exploitation, Victim Blaming Language. 6.6. Additionally, the strengthened arrangements for the SEND & Inclusion Strategy and Change Programme with refreshed formula for SEND Panel meetings introduced in April 2021 are a recent development. It is too early to comment on the impact of any of these measures. 7. Recommendations 7.1. Agencies that have participated in this review have been able to reflect on their own policies, procedures and practice. Where necessary changes have already been made as well as actions for further change being set out in single agency action plans. The Partnership will wish to seek assurance about the pace and effectiveness of these actions and improvement being implemented and embedded.   19 Warwickshire safeguarding: exploitation strategy 2020 - 2023   Page 18 of 20 7.2. As noted above, there is already a direction of travel in regards to improvement activity. The following recommendations are for the Partnership to consider as a means of strengthening the multi-agency arrangements for responding to young people who have complex backgrounds and who are drawn into behaviours which increases risk.  1. Seek assurance, through regular focused review and audit activity, that new initiatives recently implemented i.e., revised SEND Panels, intelligence and information sharing practices in cases that are complex in nature, are becoming embedded into day-to-day practice. 2. Ensure that the learning identified through this review is disseminated across the Partnership using a variety of mechanisms and routes and in a timely and effective way i.e., learning briefings, webinars or podcasts, Designated Safeguarding Lead networks, Safeguarding Lead networks for GPs, new staff induction, Partnership events. Further to this, a regular programme of audit and assurance exercises should be scheduled in order to gain evidence that the learning is having an impact on practice.  