Death of a 17-year-old boy of Afro-Caribbean heritage on 3 December 2013, following an altercation with three other adolescents. Courts later found that the three assailants were acting in self-defence. AX was homeless and had been provided with accommodation and emergency funds by his local authority in Barnet. AX had a history of: emotional and physical neglect, behavioural and emotional problems and involvement in criminal activity. AX was known to the police, youth justice services and housing services. Issues identified include: professionals responding to discrete episodes of anti-social behaviour as opposed to addressing the broader concerns around an increasingly dangerous lifestyle; the failure of youth offending teams to update assessments as new information emerged; a lack of information sharing between schools and youth offending teams; and a failure to properly monitor and enforce attendance and curfew orders. Recommendations include to review mechanisms for sharing intelligence between agencies and to put mechanisms in place to allow the prompt and effective transfer of oversight and supervision of young people on court orders who move between boroughs.
      
 Title:  Serious case review: Child AX. LSCB: Enfield Safeguarding Children Board Author: Alyson Leslie Date of publication: 2016  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.                              AX Overview Report    Page 1 of 48      SERIOUS CASE REVIEW OVERVIEW REPORT                                                             Child ‘AX’                                    Alyson Leslie - Independent Overview Author    January 2016         AX Overview Report    Page 2 of 48  Table of Contents  Outline of Circumstances ............................................................................... 3 Serious Case Review Background and Process ............................................... 4 Social History of AX: from Birth through Primary School ................................ 4 Commentary on AX's Early History ................................................................. 7 Learning Points from Early History of AX 10 Social History of AX: Transition to and Time at School 3............................... 10 Commentary on AX's Transition to and Time at School 3 ............................. 13 Learning Points from AX’s Transition to and Time at School 3 15 Transition to School 4 and Involvement with Youth Justice .......................... 15 Commentary on AX’s Transition to School 4 and Contact with Barnet YOT .. 19 Learning Points from AX’s Time at School 4 and First Contact with Barnet YOT 23 AX’s Period of Homelessness ....................................................................... 23 Commentary on AX’s Period of Homelessness ............................................. 28 Learning Points from AX’s Period of Homelessness 32 Period in Enfield........................................................................................... 32 Commentary on AX’s Placement in Enfield .................................................. 34 Learning points from AX's Placement in Enfield 35 Period following August 2013 Court Appearance ......................................... 35 Commentary on Period after August 2013 Court Appearance ...................... 37 Learning points from period after AX’s Court Appearance in August 2013 40 Findings and Conclusions ............................................................................. 40 Recommendations from the Serious Case Review of the death of AX .......... 43         AX Overview Report    Page 3 of 48  Outline of Circumstances  1. On 3 December 2013, an altercation took place between AX, a 17 year-old North London youth of Afro-Caribbean heritage and three youths from a different ethnic background.  2. AX was an extremely able young man, particularly skilled with numbers and in performing arts and adept at making money, even in his early school years. At primary school he told teachers about his home life, describing periods of loneliness, when he felt an absence of nurture and emotional connection and at times experienced hunger and unhappiness.  He worried about his mother who was weighed down by responsibilities and ill-health. AX was aware of his mother’s difficulties and also craved affection she was not always able to give. AX's parents had separated soon after his birth and were not in contact with each other. His father lived in South London and contact at times was infrequent particularly until AX himself could take responsibility for contact and travel, though his father always welcomed seeing him.  3.  AX had thrived on attention at primary school and responded to any form of nurture there, particularly from female staff.  He was well-liked for his engaging personality.  At times he struggled to contain his emotions and appeared overwhelmed sometimes by distress about his family circumstances.  This would manifest in emotional or angry outbursts. Neither AX nor his family were known to Children’s Services and only had routine involvement with health services throughout his childhood. 4. When AX transferred to secondary school he lost his strong school support network and his outbreaks of frustration became more aggressive when they occurred. Some of his energy was diverted into fascination with street activities or into making money.  In his search for belonging and identity he was drawn into a peer group that engaged in criminal activity such as theft, vandalism and cannabis supply and use.  Embracing this lifestyle, AX moved in his early teenage years from nuisance behaviour into supplying cannabis, and increasingly serious criminal activity culminating in being implicated in incidents of serious assault, sexual assault and attempted murder in the last year of his life. During that year he had left his mother's home and was generally unresponsive to his father's overtures to engage with him. 5. By 2013, the formerly delightful, friendly and sensitive little boy was apparently involved in acts of violence and anti-social behaviour with little thought to the risks and consequences of his actions for himself or for others, including his victims. This offending brought him into contact with Police, with local authority youth justice services and indirectly with Children’s Services. He was provided with accommodation and emergency funds by his local authority in Barnet when he became homeless and was subsequently rehoused in Enfield. 6. AX's street name derived from his success at securing money and his perceived relative wealth amongst his peers. What is apparent now is that his path was taking him amongst dangerous people and into increasingly risky situations. He had a tendency at times to react strongly if he thought he was under threat or had been slighted and he was probably not aware how dangerous some of the people he was interacting with were or how vulnerable he actually was. By December 2013, he had abandoned his allocated accommodation in Enfield, was living a chaotic and semi-fugitive existence "sofa-surfing" in north London and was sought by Police in  connection with an attempted murder charge. He also may have fallen foul of young criminals from another ethnic group which may have precipitated the lethal confrontation on 3 December 2013, although the full background is not fully understood.      AX Overview Report    Page 4 of 48  7. In the early hours of that morning, around 12.30 a.m., AX had an encounter with three youths outside a house in Enfield. The premises were registered as a house in multiple occupation (HMO), and AX had taken advantage of the absence of one tenant there, to bunk down in his room with his agreement. A dispute then arose over items alleged to be missing. The tenant and two of his friends confronted AX in the street. At least one knife was produced, but it was not clear who had brought it to the scene. The weapon disappeared afterwards. In the altercation that followed, CPS believed AX was the victim of an assault but the Court later accepted his three assailants were acting in self-defence. Within moments of the encounter, AX was injured, suffering three stab wounds and the other youths had fled. One of AX’s wounds was fatal.  A further superficial wound may have been inflicted as a signifier of a gang-related attack. AX was subsequently pronounced dead at the scene of the attack. Over a year later the spot where he died still has a makeshift shrine created by his friends. Serious Case Review Background and Process 8. This Serious Case Review has been commissioned by Enfield Safeguarding Children Board working in partnership with Barnet Safeguarding Children Board. The Review was noted to have similarities to a recent joint review by Enfield and Haringey Boards where a young man of similar background was also involved in a fatal incident. Both incidents involved young, black men known to be on the periphery of gang activity.  Due to the nature of the case and the similarities with the previous case a customised approach was developed to this Review.  9. This Review was chaired by Geraldine Gavin, independent chair of Enfield SCR, and the research and preparation of this report was undertaken by Alyson Leslie and Lynn Kelly of the Fatality Investigation and Review Team then based at the University of Dundee, now in Edinburgh. Social History of AX: from Birth through Primary School 10. AX was born on 30 January 1996.  He grew up in North London in a household comprising his mother, Mrs. X, and her younger brother, BY, who was close in age to AX.  AX’s father, Mr. X, lived in south London. The relationship between Mr. X and Mrs. X had broken down soon after AX’s birth. Mr. X went on to have two daughters from another relationship and became step-parent to his partner’s children.  Mrs. X did promote regular contact between AX and his father.  As AX became older he would travel independently to see his father and his family and occasionally spend weekends with him.  As he reached his teenage years, he preferred to spend time with his friends and the contact with his father weakened. 11. All through his life AX was extremely protective of his mother. Even after their relationship broke down around his 16th birthday, he kept in touch with her.  In the last months of his life he began to visit her more frequently.  Following the violent death of one of his contemporaries in the summer of 2013, AX did seek out his father and start to spend more time with him. His father hoped this might be a turning point, but instead AX returned to street life in North London and drifted away from his father.  12. After the death of her mother, Mrs. X had been left as a young woman with sole care of her younger, disabled brother, BY, and her infant son. She was affected by the death of her mother, and suffered depression for many years.  Mrs. X’s difficulties were compounded in AX’s early years by harassment from one of her male relatives. Mrs. X’s energies were focused    AX Overview Report    Page 5 of 48  on attending work to support her family, and she was at times debilitated by exhaustion, grief and depression.  13. The medical records available indicate that all AX’s routine childhood immunisations were given in a timely manner and that there was no significant medical history in the first four years of his life. 14. When AX began school in 2001 his general physical development was noted to be age appropriate, apart from delayed speech development. Speech therapy appointments were arranged but Mrs. X failed to attend with her son.  Six appointments were missed or rescheduled before AX finally attended an assessment at the Speech and Language Unit over a year from when he was first referred.  By then, almost a year into his schooling, AX had caught up with his peers and the earlier problems had resolved.  Given the spontaneous resolution of the speech problems once AX was socialising in school, and in light of what AX would later say about lack of emotional engagement from his mother, it is possible his speech development issues may have been related to lack of parental interaction and stimulation during Mrs. X’s periods of depression. 15. Around the time AX started school in September 2001, the family made two contacts with Police. In October 2001 Mrs. X became concerned that someone had accessed her financial information and three months later, following an incident of domestic violence, Mrs. X's brother-in-law was charged with assault against her.  This incident precipitated the family’s move to a women's refuge for protection.  As a consequence of the move, AX transferred to School 2. 16. AX joined School 2 with his uncle BY, who was of a similar age.  The school was aware that the family were living initially in a women’s refuge following incidents of domestic violence involving a family member.  Soon afterwards the family moved to their own flat.  For the rest of that year at school, AX was noted to be a settled, happy child who enjoyed the company of others, and appeared to enjoy all aspects of school life. 17. Towards the end of the school year there was an incident recorded by police of AX’s mother being involved in an abusive dispute, in which the victim claimed that Mrs. X made racist and threatening comments.  The victim subsequently declined to pursue the allegation. 18. Following a short settled period at the start of Year 2, a marked change in AX's behaviour was noted. In August of that year AX’s mother contacted Children Services seeking help with her son's behaviour.  It is unclear whether an initial assessment was done, but no further contact or information is recorded.  At school, unspecified behavioural problems continued through the course of the year, leading to AX being excluded in May 2003 for punching a teacher.  He was seen by his GP, at his mother's instigation, and a referral was made for involvement from Educational Psychology. The GP made a follow-up appointment the following week, but there is no record of any further contact being made by Mrs. X at this stage. 19. In early 2004, further unsettled behaviour again led to contact between Mrs. X, Children's Services and her GP.  A referral was made to a CAMHS project worker.  A service was offered to the family in February 2004 and the GP was made aware of proposed CAMHS involvement.  Mrs. X attended two sessions then missed her subsequent appointments with the CAMHS    AX Overview Report    Page 6 of 48  worker. AX saw the worker twice, including once when he was described as "unprepared for the session".   When Mrs. X stopped contact, the service ceased in May 2004. 20. AX’s behaviour throughout the remainder of his time at School 2 was described as erratic: he could be engaging and responsive to attention but could also lose his temper at the slightest provocation.  The school arranged repeated meetings with his mother to discuss his behaviour, but she would only attend intermittently.  Mrs. X describes that she felt completely overwhelmed in this period and at times could barely function because of depression. Mrs. X found consistent contact with school impossible to sustain, because of depressive illness and the debilitating efforts of trying to hold her family together. When she had capacity and energy to give to the needs of her family, she felt she had to prioritise the needs of BY, which were more apparent. The School noted Mrs. X was more responsive to contact about BY.  21. AX had told the school that he was at times deeply unhappy at home, that his mother spent long periods of time in her bedroom and that he was often left to his own devices.  He is said by staff to have arrived frequently at school hungry. He told his teacher that at mealtimes he had often to fend for himself and at times appeared to subsist on pot noodles.   22. He seemed to staff to be a little boy who was desperately lonely and unsettled, with little emotional engagement in his home life and who was extremely responsive to attention and nurturing reassurance from teachers. AX repeatedly said that he felt secure at school.  A learning mentor worked with him and noted AX was very bright when he was settled and able to apply himself.  23. Over the remainder of AX's schooling the school responded to AX’s distress when it surfaced and tried to manage and support his needs.  His mother only infrequently attended meetings arranged by School 2. No-one from School 2 recollects any contact with Mr. X or even having had any details about him. It appears no attempt was made to inquire about or engage with Mr. X. 24. The records of AX's time at School 2 are sparse, but give glimpses of the difficulties in his home: AX speaking of having little food at home and being left to his own devices.  Despite the difficulties, AX was a keen sports participant at school, who excelled at football.  He also was a talented musician and dancer and it was noted that he formed relationships easily with adults in school and relished their attention. 25. From an early age, AX was capable at times of remarkable social intelligence, a capacity to work out what he had to do to secure what he needed from peers and others. He turned this to good use in developing early entrepreneurial skills. AX would buy discounted confectionary and sell it at a profit in school.  His mother describes him having from a young age a fascination with money, relishing the feel and acquisition of money more than the power to acquire goods.  26. In March 2007 AX, then 10 years old, was found asleep on a bus one evening, disoriented and lost.  He told police that he moved home a short time before and was unsure how to make his way back.  AX was directed to the Police Station and was collected by his mother. At the end of Year 6 (June 2007), AX starred in the school drama production. Staff said he was deeply upset when his mother did not attend the performance.     AX Overview Report    Page 7 of 48  27. School 2 were concerned about AX’s transition to School 3, an all-boys senior school, because it had not been their preferred setting for him.  Staff thought a more local school would be better placed to support AX. Mrs. X, however, wanted AX to transfer to School 3, although it was some distance away,  as it was the school attended by her brother as it  was particularly well resourced to meet BY's learning needs.  28. School 2 staff were concerned that when AX found himself in the all-male environment he might struggle initially to adapt and to settle down.  AX's Year 6 teacher contacted the Head of Year at School 3, to ask that AX be monitored.  The teacher conveyed the concern of the primary school that AX’s behaviour was erratic and that he was prone to angry outbursts from frustration and distress. No record is now available at School 3 of the information conveyed about AX by School 2.  There is no evidence available now of a transition plan and it is not clear if all key staff at School 3 were made aware of School 2's concerns.  One member of staff from School 3 did later learn about AX and his needs by chance when attending a meeting in School 2 about BY's learning needs. Commentary on AX's Early History 29. The records of AX's early life and of his family's history are limited.  This was a family in some difficulty which for several years did not appear significantly on the radar of any agency that could have offered support.  The support from CAMHS, which could have made a difference stopped because Mrs. X did not continue with appointments.  Yet her poor track record of engagement was a consequence of her depressive illness which was a key factor in the family's problems. The family needed an approach which recognised Mrs. X's difficulties, and worked round them rather than excluding the family for one of the key presenting problems. In the absence of other input, School 2 became the source and focus of support for AX. This worked well during his time there but was lost when he moved school. 30. School 2 staff’s recollections of AX are remarkably clear seven years on because AX made such an impact and stood out through his talent, his distressed behaviour, his endearing personality, and hunger for, and responsiveness to, attention.  31. A portrait emerges of a bright, affectionate little boy at times only having limited loving nurture and emotional engagement; a background where there was often a struggle to provide basic comforts and sustenance, and experiences of at least the aftermath of episodes of violence against his mother by another family member. AX  struggled at times to make sense of a chaotic, uncertain and bewildering home life and when, as it would any six-year old, the struggle became overwhelming for him, it sometimes manifested itself in outbursts of distressed behaviour, involving anger and aggression, out of all proportion to the immediately presenting trigger. At other times, AX's confusion and distress took the form of desperately craving nurturing attention from female staff in particular. 32. School 2 was a highlight in AX's life, a place where he said he felt secure and where he was encouraged in his aptitude for sport and drama. The staff in School 2 were adept at containing and managing AX's meltdowns and supporting his needs and in so doing, reduced the needs for involvement from outside agencies.  While the extensive work undertaken by School 2 with AX is commendable, it had the unintended effect of obviating the need for a referral to Children's Services or other agencies.  That said, the School point out that they deal with many    AX Overview Report    Page 8 of 48  children with similar difficulties who they feel are children in need, and that services would be overwhelmed if every case was referred.  Additionally, even if referrals had been made to external agencies, engaging Mrs. X on any programme of intervention would have required a level of support and resources of a type unlikely under statutory criteria to be merited by the presenting problems, particularly 13 years ago when the severe and enduring consequences of emotional neglect were not as widely understood or appreciated as they now should be.   33. The first 1000 days of life are critical for a child's life-long emotional and long-term physical well-being.  Within their primary attachment relationship a child gains their sense of identity and esteem and the foundations for the skills and capacity for creating and sustaining interactions and intimacy with others. Where that relationship becomes dysfunctional, including due to parental dissociative behaviours arising from severe depression, their own childhood traumas or some forms of mental illness, the consequences for the child can be significant. Such consequences can range from small insecurities and anxieties, to profound distress, poor emotional regulation, hypersensitivity to triggers for anger and aggression, reckless behaviour, and impaired development of higher brain functions including the ability to envisage consequences for actions or conceptualise time.  Research in recent years has demonstrated that the impact of profound emotional neglect can be mitigated by positive experiences of nurture and affection, sometimes alongside therapeutic support.  34. Failure to identify children at risk of severe emotional neglect can have significant consequences not only for the child involved but also for society as we risk leaving them on a pathway of increasing behavioural difficulties, school failure, disconnection from potentially supportive communities and social groups, reckless and criminal behaviour. In Suzanne Zeedyk's terminology, we are simply "building brains for prison"1.  In areas of urban deprivation and dislocated communities, vulnerable, displaced young men who have experienced severe emotional neglect tend to be a fruitful recruiting ground for organised gangs.  35. The importance of identifying families where children are at risk of emotional neglect and working with them and their primary carer to protect them from further harm and to increase positive bonding experiences has been recognised in the London Borough of Enfield through initiatives such as training for health visitors and other frontline staff in the Shemmings' ADAM (Assessment of Disorganised Attachment and Maltreatment) Project.   36. Notwithstanding such initiatives and better and more widespread understanding of the seriousness of emotional neglect particularly for certain vulnerable groups, policy and practice in this area has been compromised by reductions in health visiting services in recent years and by insufficient priority at national and local level accorded to funding and developing effective preventive work with vulnerable children and their families in the first 1000 days of life.   37. Significantly throughout the periods of difficulty AX experienced, the School had no contact with his father and no awareness of the strong paternal family network in south London.  Schools are in a difficult position when a single parent family does not provide details of the                                                  1Zeedyck, S. (2013) 'Keeping People out of Prison'. Howard League Lecture at University of Dundee. Available at: http://youtu.be/bJPnHM_jUis http://youtu.be/bJPnHM_jUis   Accessed: 2 May 2014). -    AX Overview Report    Page 9 of 48  other biological parent, as staff cannot insist on contact information if the enrolling parent declines to give it.  Parents living apart from their children may have different legal rights and less access to information about their child.  Such difficulties are surmountable. Professionals need training and support in ways to involve separated parents in decisions about their children.  More support is required across society to encourage and equip separated parents to engage with agencies educating and supporting their children. 38. In AX's case, it can be argued the most significant contributory factor in his death was his need as a young adult to identify with offenders and with a street-based lifestyle. The choices he made set him on a pathway of increasing risks and dangerousness likely to have ended either in his incarceration for grave offences or being seriously or lethally harmed.  The roots of that susceptibility in some part lay in the impact on him of his early experiences and the absence of intervention adaptable to his changing needs. 39. School 2 provided exceptional care and support for AX and some of the happiest times of his childhood and some foundations for stability in his emotional growth.  That level and quality of support ceased when AX transitioned to secondary school.  AX, who had enough chaos and instability in his home-life, was always going to find difficult the uncertainties around major change and transition into an unfamiliar setting.   40. Although School 2 sought to highlight potential difficulties and provide School 3 with information, there was always a risk AX's needs would be lost sight of in the sheer volume of demands a new school year intake brings. The absence of any external agency or professional supporting AX took on new significance at this point, as there was no-one- social worker, mentor, psychologist, counsellor - who could provide continuity of support over the transition or advocate and articulate the need for priority to be given to assessing and responding to AX's social, emotional and educational needs.   41. Young black men, who comprise 1.5% of the UK population, are disproportionately represented in the UK prison population (14% of youth prison population).  Many will have grown up in lone parent households, many will lack regular contact with a positive male role model.  Case-based work alone through Children’s or Youth Offending Services, cannot adequately tackle this issue. 42. Population-based, community-focused strategies are also required.  In times of austerity and budgetary constraint, resource priorities become the presenting cases of actual harm or risk of harm and preventive work becomes harder to justify and fund.  More work is required to effect a shift in political priorities locally and nationally towards investment in the long-term welfare of groups of people vulnerable to alienation from society.   43. AX's father has pointed out that many young black men grow up feeling alienated from the institutions responsible for policing and criminal justice in society.  They learn distrust at an early age and as they reach adolescence that distrust sometimes shifts into a more reckless taunting and challenging of police and youth justice systems.  He argues that more and earlier outreach work by Police and criminal justice workers with young black boys is needed to build relationships, change perceptions and begin to shift cultural norms.    AX Overview Report    Page 10 of 48  Learning Points from Early History of AX  The importance of the first 1000 days of nurture in a child’s life for providing the foundation for stability in adolescence  The need to be especially alert to vulnerabilities in population groups known to have higher risk of young people becoming criminalised and to tackle these issues at both individual and community levels  The importance of identifying young people vulnerable to pressures in transitioning to secondary school and of both schools developing collaborative individualised strategies for follow-up and support.  The importance of not missing the potential contribution separated/divorced parents, particularly fathers, can make to a child's life.  Social History of AX: Transition to and Time at School 3 44. School 3 was about three miles from AX's home. He was enrolled because his uncle, BY, already attended School 3 and benefitted from its specialist provision.  BY was a young man with a learning disability and educational needs but no behavioural problems.  The distance between School 3 and the family home, which AX walked each day, gave opportunities for him to become familiar with street life in North London and the streets became the main base in his life. Soon after he started School 3 he became involved with a group of older youths, who did not attend School 3 but hung around the surrounding streets, and whose activities bordered on the fringes of criminality.  AX also started trading seriously with his peers which brought him in a welcome supply of money. He exploited his flair for buying discounted goods and reselling them and became preoccupied with accumulating money.  Initially his activities involved cut-price goods, then goods of uncertain origin.  In this period he was viewed by staff and peers as a "loveable rogue".  Over time his commercial activities progressed into supplying cannabis and possibly other class B drugs.   45. Within eight weeks of starting secondary school and becoming involved with the group of youths around the streets, AX was stopped by the Police on suspicion of antisocial behaviour.  The full details of the offences are not known and no further action was taken.  Two weeks later there was a second similar incident and over the next few months another four incidents of anti-social behaviour/minor offending were recorded by Police. No action was taken in three cases, and in another a warning given for a suspected traffic violation.  The pattern of behaviour suggested some form of group rather than individual activity.  There was no suggestion at this stage of gang involvement but AX and his street friends may well have been on the fringes of street gangs.  Although he was well-known and, on account of some of his selling activities, popular with classmates at School 3,  AX did not appear to form particularly close relationships with his peers. 46. From the recollection of one of his teachers, AX presented few serious behaviour problems in school.  Records indicate though that there were incidents when his behaviour at School 3 caused concern.  At one stage a referral was made to a Youth Service group worker and AX briefly attended group work sessions on anger management. Most of the time, however, the only problems relating to his behaviour in school involved lateness and truancy. AX was still on    AX Overview Report    Page 11 of 48  some level the friendly, charming young person that School 2 had known. His misbehaviour was perhaps more tolerated in School 3 because he was always polite and could be engaging and charming. 47. Overall, during his first two years at secondary school a picture emerges of a bright but disengaged and sometimes unsettled, boy and whose frustration and lack of self-control was still evident in occasional tantrums and episodes of antisocial behaviour mostly outside school.  In August 2009, AX was arrested for his involvement in a graffiti spraying incident where a group of youths were found randomly spraying buildings, bus stops and post boxes in a local street.  AX was given a final warning on 19 October 2009.  Prior to the warning being given, an assessment was undertaken by a local constable which concluded that AX was at low risk of reoffending and as a result he was not referred on for further intervention or sanction. 48. AX failed to fulfil the potential of his strong intelligence in school because he seemed to decide early on that he could succeed without education and become a major presence on the streets.  At times he seemed to staff old beyond his years.  He was disinterested in attempts to engage him or his mother in interventions aimed at channeling him into more productive pathways. Mrs. X rarely responded to school overtures about her son although she was more likely to attend meetings about her brother, BY, whom she found easier to support and manage.  49. Only at one stage was AX's father, Mr. X, involved with the school.  At that point AX’s mother and her sister wanted AX to move out of the area and live with his father to try to remove him from the influence of his older friends.  AX, however, was adamant he did not want to leave north London or his friends and in this he prevailed.  Mr. X had a lot of contact with his son over this period, but AX was reticent in what he shared with his father.  He did not reveal the extent of his offending behaviour or disengagement with School. As AX was becoming older, Mr. X found he had to work harder to keep contact going with his son.  He relates that he resorted to trying to entice him to come to south London by offers of shopping expeditions (and being surprised when AX showed little interest), or by encouraging AX's half-sisters, JX and KX, to contact him and ask him to visit them, knowing how fond AX was of them. 50. By his third year in School 3 AX's behavioural issues had become more serious and there were occasions when his anger and aggression quickly erupted leading to fall outs and fights with his peers. Some of these incidents possibly related to his trading enterprises. One instance in February 2010, in which a teacher was slightly hurt when trying to stop a fight involving AX, led to three day exclusion.   Exclusion only gave AX more time to engage in pursuits with his older friends around the streets and during the period of his exclusion he was stopped by Police for antisocial behaviour and verbally warned.  His mother was advised of his school exclusion, but there is no record of her making contact with the school. 51. On his return to school, within a very short period of time, AX was involved in two more incidents – one of poor behaviour (details are no longer available), and another fight where he bit a fellow pupil.  For the latter offence, and for his increasingly poor attendance, he was excluded for five days.  A few weeks later, the Governor’s Disciplinary Panel issued a warning regarding AX’s poor behaviour and punctuality.  AX and his mother were invited to the Disciplinary Panel, but neither attended.    AX Overview Report    Page 12 of 48  52. Shortly after the start of the next school year, 2010-11, AX was stopped and searched by Police in or near a known drug hotspot in North London.  It was noted that he had tried to avoid and hide from Police and was evasive regarding questioning.  The spot where he was picked up is known to be a main transport route into and through London for drugs. 53. AX was not thought by School 3 to be a member of any formal street gang but he was considered to be on the fringes of gangs who had territory adjoining the areas where the school was located.  Even some of his schoolmates who were on the periphery of offending behaviour and beginning to come on to the radar of Police and youth justice systems tended to avoid AX because he was linked to older youths who were seen as dangerous.  Rumours were rife that he was beginning to deal in hard drugs around and outside the school although he was never caught with drugs on the premises. 54. Within four or five weeks of the beginning of the 2010-11 autumn term, AX had been late 15 times for school and this pattern was constant for the rest of the year.  When he did attend it was noted that his performance in class was often exceptional in the light of how little attention he appeared to pay, how infrequent his attendance was, how distracted he often was and the complete lack of support in his home environment.  The school described him as “an extremely clever young man”. 55. In February 2011, AX began to appear on the Police radar as a potential dealer in class B drugs. The Police had information that AX was selling cannabis in school.  The information was communicated to the school, but a visit and search by Police produced no evidence. It would appear that over the next few months, AX’s frequency of offending increased and in June 2011, he was excluded for stealing in school and shoplifting outside of school.  Again attempts to engage his mother to discuss his behaviour simply failed.  The School was aware of Mr. X's contact with his son but did not approach him. Mr. X states he would have readily responded to any contact and worked with agencies to divert his son from offending. 56. From the start of AX's last year at School 3, 2011-12 onwards, most information about him comes from Police or youth justice services, first in Barnet and then in Enfield, reflecting AX’s growing involvement in criminal activity. Significantly, the seriousness of his offences grew over time.  In October 2011, just after the start of his last school year, he was the victim of a confrontation with other youths.  The Police attended, but AX failed to respond to Police requests for further information and never made any complaint.  The same pattern of poor punctuality but good performance in class when he did attend continued throughout that term. 57. A few weeks later, AX gate-crashed a party in North London and was involved in an attempted robbery.  Police attended, but did not pursue the issue and no further action was taken.  On 26 January 2012, the School informed Police that cash had been found in the school toilets.  AX was searched and found in possession of £80.  He claimed he had sold an X-Box.  The money was confiscated and returned at the end of the school day. 58. In February 2012, the Police investigated AX, having received information that he was the potential suspect for a robbery and linking him with a number of incidents.  When they caught up with him had been drinking, despite being underage, and of major concern was the length he had gone to in order to evade the Police when they tried to stop him– running through a stream, climbing over fences, causing criminal damage and injuring himself.  At one point in    AX Overview Report    Page 13 of 48  the pursuit he ran directly in front of moving traffic and straight in front of the Police van.  When he was stopped he was in possession of £135 which he could not account for and he was arrested for robbery. Despite the accumulation of potential grounds for charge and the concerns his behaviour and attitude raised, no further action was taken by Police. Although originally bailed, a letter was sent to AX on 8 March 2012 cancelling the arrangement and informing him of the outcome of the arrest.  59. Little is known of AX's home life in this period, the only official record being from May 2012, when AX’s mother contacted the Police reporting that her sister had taken her vehicle without authority and the car subsequently was found to have driven off without paying at a filling station.  No further action was taken.   AX's mother explains that in this period she was becoming increasingly worried about his criminal behaviour and that they argued frequently about the hours and company he kept.  60. In June 2012 Police stopped AX for suspicion of having drugs in a well-known drug hotspot. AX had acquired a moped by this stage and its distinctive features made it relatively easy for the Police to track him.  He was also found to be driving his moped without any insurance. When stopped he was in possession of 20-25 packages of cannabis and smelled strongly of the drug.  His phones were constantly ringing throughout his encounter with the Police.  He was arrested for possession with intent to supply and was bailed to appear on 6 September 2012 at Brent Magistrates Court.  The Youth Offending Team in Barnet was notified.   61. Shortly afterwards, AX sat exams at School 3 and completed his time there. His performance in the exams did not do justice to his considerable intelligence and he succeeded only in passing a GCSE in German. Given his poor attendance and lack of study this was a fair accomplishment.  62. On leaving school, the nature of AX's offending became increasingly serious.  Over the summer of 2012 he was arrested on suspicion of robbery of personal property.  CPS subsequently declined to charge and no further action was taken.  Two weeks later he was a named suspect for another robbery.  He was arrested, but again no further action was taken.   Commentary on AX's Transition to and Time at School 3 63. AX had started to become a street kid and fall into minor offending over the summer he was transferring to School 3. As he moved into the different environment of School 3, with different demands and disciplines, AX thrived socially by adapting from being an affection-hungry little boy looking to adults for reassurance and nurture, to becoming a street savvy youth with an established identity as a trader.  Through his enterprises and his likeable personality he became an accepted and well-liked member of the student body, although he did not integrate well with his school peers or form close friendships in School 3. He kept his life compartmentalised to a large extent, family never intruded on his “commercial” life, school and street connections were kept separate, apart from when School 3 was a useful market.  64. Looking back now, AX is remembered with fondness at the School and recollections of his charm and likability outweigh people's memories of how concerning at the time his behaviour was.  AX was, as in School 2, seen by staff as a boy with lots of potential who could be very responsive in interaction with staff.  Because AX was articulate, generally friendly and polite,    AX Overview Report    Page 14 of 48  his activities and behaviour were better tolerated.   Throughout his time at School 3, AX always had plenty money and had learned to acquire the means to look after himself. The incidents of concern to staff - episodes of fighting, lateness, potential drug dealing - taken individually never reached a level that merited referral to Children's Services.   65. While it had always been possible to refer children to social services, the recent introduction of the MASH meetings has made the process clearer and more accessible.  Research shows that professionals are more likely to use a mechanism which regularly considers cases than instigate a new referral to another agency. The latter is seen by professionals as a more significant and serious step, a "crossroads" moment. In comparison, sharing concerns about a child at a regular information-sharing meeting is seen as a more natural mechanism for progressing matters.  66. In the absence of any multi-agency approach, individual agency responses to AX were compromised by no-one agency having a comprehensive understanding of his history and background. School 3 did not fully appreciate the escalation in seriousness and frequency of AX’s offending behaviour, Police did not know the full extent of issues in School or the nature of AX’s early history.  In August 2009, for example, when AX was given a final warning by a police officer following a series of misdemeanours, the background information of his unsettled behaviour in School 2, his activities in School 3 or the problems in his own environment were not known by the officer who assessed the case to determine its disposal.  That assessment was further limited as the officer had been unable to contact AX and both AX and his mother had failed to turn up to a prearranged victim session. 67. Successive children's legislation in England has placed the onus for coordination of the assessment of young people on local authorities. As a result, professionals from other agencies can sometimes be less ready to take a lead in instigating an initial case conference or discussion with other agencies, particularly in cases of children in need, and sometimes they may have experienced a resistance by some local authority children's services when they have tried to take such cases forward.  Continuous joint training is essential to promote an approach that underlines it is everyone's responsibility to respond to children in need and emphasise that any agency can request an initial case conference.   68. A difficulty for teachers, police officers, social workers and other professionals is often that they only see isolated incidents of concern. In this case none of AX's behavioural issues in school would have triggered serious concern or possible referral to a statutory agency. The wider pattern, however, was of a young man of considerable ability, with unresolved emotional issues from his early days which could readily trigger aggressive outbursts, moving on a trajectory of ever more serious offending and deeper involvement with older youths with connections to dangerous offenders in the community.  69. At the time, professionals were tending to make decisions about AX on the basis of snapshots rather than stepping back and viewing the context, the developing history, particularly of offending, and how the pattern was likely to play out over time. None of the individual matters AX was stopped for by Police was serious, but cumulatively they pointed to an escalating involvement in criminal behaviour, albeit that proof of offending that would meet the evidential test was rarely available.     AX Overview Report    Page 15 of 48  70. Even had Police or teachers sought to secure involvement from Children's Services, such involvement at this stage would have likely been hampered by Mrs. X's reluctance to engage and by AX's refusal of all forms of intervention in the face of his unassailable conviction that he had found a route, through trading and his street connections, to financial success and a desirable lifestyle.  AX's general amiableness and likability possibly also deceived some professionals about the seriousness of the risks in the lifestyle he was set on pursuing.   71. It is clear that as time went on, AX became adept at using his intelligence and charm to deceive and misdirect professionals as well as to talk himself out of difficulties. This facility probably explains some of the management of his episodes of minor offending.  AX was plausible and polite and had an instinctive ability to divert attention away from the uncertainties and irregularities in his situation. He was convincing in his readiness to accept admonition and apparently agree to the cessation of behaviours and activities.  This may have influenced, for example, police officers assessing how to respond to misdemeanours and teachers responding to incidents in School.   Learning Points from AX’s Transition to and Time at School 3  Support strategies for vulnerable young people moving to secondary school need to continue throughout the summer of the transition and beyond.   Schools need to assess continuously whether young people are at risk of gang or criminal activity with emphasis on scrutinising and monitoring patterns of behaviour rather than individual incidents or snapshots and share the information they have in multi-agency forums.   For most of his young adult life, professionals underestimated AX’s astuteness, intelligence, capacity to strategise and to manage professionals’ expectations and responses.  The attractions and opportunities of street commerce AX had identified and determined to exploit were unlikely to have been bettered or overtaken by anything any statutory agency had to offer him.  Multi-agency training should emphasise a collective responsibility to highlight young persons in need through increasingly dangerous lifestyles and the ability of any agency to instigate a case conference or discussion.   Where the behaviour of a young person may not be capable of sustaining a criminal charge, consideration needs to be given to whether they may meet the criteria of a child in need under the Children Act. Transition to School 4 and Involvement with Youth Justice 72. On 6 September 2012, AX appeared at Brent Magistrates Youth Court and was convicted of Possession of a Controlled Drug – Class B Cannabis, and Using a Vehicle While Uninsured.  He was sentenced to a Referral Order for four months for the first offence, and for the second offence, again, a Referral Order for four months and six penalty points.  In relation to other traffic offences no further action was taken, there being insufficient evidence to proceed. It was recorded that AX was supported in his attendance at court by his father. Mr. X has no    AX Overview Report    Page 16 of 48  knowledge of this and he was not the person attending with AX. It seems AX may have persuaded an older acquaintance to either accompany him for support or present as Mr. X.  AX usually met and engaged with his father in south London so few people in his home area would have recognised his father.  73. The day following his court appearance, AX commenced a Bridging Course at School 4.  In his application he indicated that he had no criminal convictions, no involvement with Police, Local Authority or Youth Offending Teams.  Later that week he was subject of a stop and search because he smelt of drugs.  No evidence was found and no further action was taken.   74. On 17 September AX was due to attend an Attendance Centre Interview with a parent at the commencement of his referral order.  His mother did not attend as requested. AX's father was unaware of his son's court appearance, which AX had not disclosed. He told this review he would have attended any interview to support his son.   75. On 21 September AX contacted Out of Hours Service at the Emergency Doctors Out of Hours Unit stating he had had unprotected intercourse and wanted advice about sexually transmitted diseases.  He was advised to contact the local STI Clinic.   The next day, AX was involved in a disturbance with other youths and detained for possession with intent to supply cannabis.  The outcome of this arrest was no further action.   76. AX reported to the Youth Offending Service Office on 12 October 2012.  An ASSET form was duly completed. Although the form relies on self reported information there was a contribution from Mrs. X who claimed the offences were out of character and said she did not know her son used cannabis. AX by this time was seen by students in both Schools 3 and 4 as a source for the supply of cannabis.  77. AX’s family situation was assessed as stable with close relationships. The information obtained by YOT from School 3 related to his attendance and poor exam results and did not include the suspicions of drug dealing, any information about his unsettled home circumstances or his entrepreneurial activities and focus. The School's position is that the information sought by and therefore provided to the YOT education liaison worker focused on attendance and performance.  Barnet's position is that the YOT education worker made an effort to obtain full information and having received a message from the Head of Year about AX’s GCSE results left another message for him asking for him to comment on AX’s attitude and behaviour.  A conversation with the Head of Year did not reveal any concerns about drugs or AX’s lifestyle.  The different recollections and records cannot be reconciled. What is clear is that the information about AX known to guidance and year staff, would and should have provided a more complete and more concerning picture which would likely have resulted in  AX being rated at more serious risk of offending. 78. The ASSET assessment concluded that there were no indicators of vulnerability, no risk of serious harm, and no or low risk of reoffending.  Following the ASSET exercise, AX was referred to YPDAS. (Young Persons Drug and Alcohol Service). His own contribution to the assessment demonstrated either little insight or, more likely, little frankness about his situation.  His mother's contribution did not reflect the level of concern she actually had about her son at this stage.  AX ascribed his contact with the criminal justice system as down to bad luck.  He said his focus was on having his own place and being able to drive.  The only value he    AX Overview Report    Page 17 of 48  saw in contact with the Youth Offending Team (YOT) was that they might be able to assist in housing issues. 79. On paper it looked like AX was productively engaged in education, a factor that would mitigate risk of offending in the ASSET assessment. Less than one month into the School 4 programme, however, AX's attendance was already so poor he was under consideration for termination of studies.  This information later came to the attention of YOT when a member of staff from School 4 was attending a YOT meeting on an unrelated matter where AX's name was mentioned and the connection made. The YOT worker alerted School 4 to AX’s referral order.  The information about AX's poor attendance at School 4 was passed on to the caseworker, who visited School 4 with AX's case worker to speak with AX's tutor. Although they discussed AX's lack of engagement with School 4, they did not find out about the School's emerging concerns over AX's role in supplying cannabis. The risk assessment of AX was not changed in the light of what was now known about AX's poor attendance and his place at School 4 being in jeopardy. 80. On 6th November 2012, on one of his infrequent attendances at School 4, AX was involved in an incident where he used threatening behaviour towards a female student.  His attendance at School 4 was now sporadic and may have revolved around opportunities for trade, including supplying cannabis.  According to fellow students, AX had become established in college lore as a reliable source of cannabis.   81. AX had failed to attend the first disciplinary panel regarding his attendance at School 4, and in November a second disciplinary panel was convened following a period of further poor attendance. AX did attend the second disciplinary panel where his failure to mention his offences was also put to him.  AX was polite and articulate and had a convincing response to every matter raised with him.  He claimed there had been disruption in his family circumstances but that he was now living with his aunt and all was again settled. He assured the Panel he had mistakenly filled in the wrong box in relation to offences and that he had no intention of misleading the college. This was accepted as plausible; he was given the benefit of the doubt and issued with a second disciplinary warning.  It was noted that he was inevitably respectful, polite and helpful on the rare occasions he attended class. The warning was an attempt to encourage him to continue with his education and do justice to his high level of ability.  The YOT worker was not made aware of these developments. 82. Around this time AX failed to attend the Attendance Centre, because he claimed he had fallen asleep, and an initial warning was given. Because there was no regular exchange of information between the School, the Attendance Centre and YOT caseworker, the fact that AX's living situation had become unstable and the issues of his poor attendance at School 4 were not identified and so he continued to be considered at low risk of re-offending. Barnet's position is that suitable and relevant follow-up with School 4 took place during which neither the YOT education officer nor the caseworker were told the full extent of the School's concerns.  Set against this view is the ease with which this information was available when this serious case review took place. 83. On 2nd December 2012 AX was arrested for a sexual offence after Police received a report that he was a suspect in the rape of a female under 16 years. (AX remained at liberty for a    AX Overview Report    Page 18 of 48  year in respect of this alleged offence. The matter was subsequently discontinued by CPS following the fatal attack on AX in 2013).  84. In accordance with established procedure, when AX was arrested for a sexual assault, Children's Services records were checked and a social worker established there were no other children living in the home that could be at risk.  No follow-up took place because it was noted that AX was known to the Youth Offending Service in Barnet.  What was not recognised was that Barnet YOT would not be automatically alerted to these developments. 85. On 5 December AX failed to report to the Attendance Centre and a Compliance Panel was arranged for 14th December 2012.  AX did not attend because he was in Police custody for an offence of robbery with violence relating to the assault of a victim and theft of their phone on a bus in Golders Green. (In due course there was no prosecution because although AX had been arrested nearby he was not identified as being involved in the initial incident). 86. The Compliance Panel was rescheduled for 19th December but adjourned till early January after Mrs. X phoned to say AX was at an ID parade relating to yet another robbery.   87. On New Year’s Day 2013 police were called to a large fight in progress in North London. AX was identified by the victims at the scene and arrested for the offence of actual bodily harm. CCTV footage subsequently was found to be of insufficient quality to support a charge and so no further action against AX was taken following review of the evidence by a senior police officer.  88. The following day, 2nd January 2013, the deferred Compliance Panel took place to consider AX's failures to comply with his referral order. AX attended but his mother did not. He claimed he had tried to wake her but she couldn’t get out of bed because she’d drunk too much the previous day in New Year celebrations. AX’s three missed appointments were considered along with his recent alleged involvement in three offences (sexual assault, robbery, assault) and suggestions he was on the fringes of gang activity.  It was suggested at the Compliance Panel that the original risk assessment and ASSET should be reviewed in light of this new information. Contacts with YPDAS and the YOT were increased to weekly and additional appointments were made. He was urged to improve his attendance at School 4. 89. Despite the recommendation from the Compliance Panel, the case worker did not review the ASSET as instructed. The information about the three new serious offences and mention of AX's possible links with gang activity were not analysed or passed on within YOT.  90. AX did not attend his session at the Attendance Centre on the 7 January 2013. He was being texted appointments but he later explained he never received them as Police had seized his phone.   The view was taken that as it was not clear he was getting the messages, a further warning should not be initiated at this time. On 14 January information about the alleged sexual assault was received by Barnet YOT but the ASSET was not updated.  91. On 15 January 2013 there was an attempted murder in an area of North London in which two youths were stabbed. AX was implicated. He was arrested later that day with a number of youths and subsequently charged initially with GBH and conspiracy to rob. (Again AX remained at liberty for eleven months in respect of this charge and AX died before the matter came to court).    AX Overview Report    Page 19 of 48  92. At School 4 his attendance continued to be unsatisfactory and there were rumours circulating amongst students and staff that he was not only dealing drugs on the premises but that he was involved in wider drug dealing in North London.  93. School 4’s Disciplinary Committee issued a final warning on 6 February 2013.  At that meeting, AX agreed to all the conditions set out regarding attending lessons and catching up with outstanding work. 94. AX continued to default on appointments at the Attendance Centre.  A Breach Panel was scheduled for 13 February.  It appears that AX did not attend and the meeting was adjourned.  Breach action was not ultimately pursued as the order finished a few days later.  Reparation was to have been arranged, but subsequently cancelled, due to difficulties in staffing at the chosen venue following a break-in there.   95. The YOT manager, reviewing the case prior to closure, noted that a final ASSET review had not been completed and arranged for the worker to complete a closing statement.  The closing statement indicated that AX would be encouraged to accept a service from YPDAS Drug and Alcohol Service and would have additional support from Targeted Youth Services (TYS) in applying for benefits and accessing a business course. 96. A week later, School 4 terminated AX’s studies and advised him by letter his place had been withdrawn due to non-attendance.  As the referral order had expired, AX was now no longer involved with any agency.  His time was spent with his friends on the street pursuing his "business" ventures.  His mother was distressed to discover he had lost his place at college and tensions in the household grew, compounded by AX's dislike of his mother's recent partner. This resulted in AX staying away from home, "sofa-surfing" with friends. Commentary on AX’s Transition to School 4 and Contact with Barnet YOT 97. Within two weeks of starting School 4, AX was on Police radar as a potential dealer in drugs, was socialising with a group of youths linked with a gang and was barely engaged in School 4 beyond minimal attendance (on which occasions he often made significant contributions to class). The more flexible timetable of School 4's college environment left AX with more time to pursue his recreational and business interests. 98. It is the view of staff at School 4, who had a constructive relationship with AX that he had calculated that he was more likely to receive a lenient and less intrusive disposal at court in September 2012 if he were enrolled on a college programme.  He may have even encouraged someone older of his acquaintance to attend to create an appearance of family support. He appears to have managed to convey to the court the impression of studious young man with family support for whom these offences were an uncharacteristic aberration that could be dealt with by a minimal statutory requirement. He succeeded therefore to some extent in limiting the involvement of statutory agencies in his life. 99. Referral orders are a low-level sanction intended to deal with first offenders at low risk of future involvement in crime. The level of supervision undertaken by YOTs (Youth Offending Teams) of a young person on a referral order varies depending on locality. In Barnet, however, the YOT approach the task as they would any formal supervision order and the level of supervision and rigour of assessment are the same as they would be for more serious court disposals.      AX Overview Report    Page 20 of 48  100. The assessment of a young person referred by court is carried out using ASSET, a structured tool used by YOTs in England and Wales on all young offenders. It explores a young person's offending and seeks to identify factors or circumstances - educational attainment, peer influence, mental health problems - which may have contributed to such behaviour. Its primary use is to identify appropriate intervention programmes to disrupt idiosyncratic offending patterns. The tool can also highlight any particular needs or difficulties the young person has.  101. Used effectively, the ASSET tool will measure changes in needs and risk of reoffending over time.  In AX's case the ASSET contained much self-reported information.  AX characterised the offences for which he was arrested as isolated incidents. Despite her true feelings, his mother supported that view. ASSET and similar tools are only as reliable as the information they gather. In this case, information now known to have been held by School 3 and by Police could have altered the impression of stability and of isolated episodes of minor misdemeanours being conveyed by AX and provided a more realistic view of the risks presented by AX's lifestyle.  102. In the event, an incomplete picture of AX was formed. This in turn generated a relatively low risk assessment and influenced the way AX was perceived and responded to by professionals. Further, in ASSET assessments, possession of the amount of cannabis involved in the offence is designated as low level offending and would not necessarily be recognised as an indicator of more serious potential offending or of gang related drug activity.  Had YOT been able to obtain further information form School 3 and School 4 and from Police intelligence on AX’s suspected involvement in the supply of cannabis, it would have resulted in an ASSET outcome suggesting a high risk of reoffending.  103. Even though on arrest AX had been found with packages of cannabis which he claimed were a means of helping control his personal use, the level of AX's cannabis use was not considered to be  an indicator of vulnerability and the ASSET assessment did not give full weight to the likelihood that AX was involved in supplying cannabis. Although AX was never formally charged by the police for supplying drugs, consideration should have been given to this possibility and to establishing whether the poor attendance may have been the result of cannabis use or other factors. 104. The ASSET tool, at time of writing has been unchanged since 2006.  It does not reflect enhanced current knowledge about the pathways which take young people, particularly young black men, into dangerous drug-related and gang-related activity. The weighting of independently corroborated and self-reported information in the ASSET tool is not particularly sophisticated.  105. The ASSET tool has been shown in government commissioned research to be most effective when used in conjunction with another tool, Offender Group Reconviction Scale (OGRS 3 – A static tool for assessing risk of re-offending). The research recommended that the predictive component of the ASSET tool be replaced by part of the OGRS 3 tool.    106. The ASSET tool works by weighing and projecting static and dynamic patterns in offending.  For a first offence in the youth justice system, its value is clearly more limited than when a series of offences are being considered.  It is therefore important that all relevant agencies are    AX Overview Report    Page 21 of 48  mined for as much information as possible to ensure that the ASSET assessment is up to date and can provide a reliable indicator of risk, particularly in relation to first offences.   107. The research also found that: " ‘lifestyle’, ‘substance use’ and 'motivation' were highly statistically significant predictors of proven one-year re-offending. ‘Living arrangements’, ‘family and personal relationships’, and ‘education, training and employment’ were also statistically significant."  Other factors were less important to predicting reoffending. 108. In AX's case, he was already at risk of being asked to leave his college course, was itching to leave his family home and was a regular user and likely supplier of cannabis whose motivation and focus was to accumulate money and be a significant presence on the street.  He was much more established on this pathway than the ASSET interview and analysis reflected and thus at much more risk of reoffending and of more serious offending than was recognised by his caseworker. 109. In working particularly with first time offenders, it is important to recognise the limitations of the ASSET tool and to mitigate them through collecting data from a range of sources, checking for change and updating the ASSET regularly with information about changes in the stability of a young person's circumstances and changes or escalations in patterns of offending.  Of particular note in this case was the number of times AX was stopped with cause by Police, questioned and considered for charging.  Many of these incidents in themselves were not significant but together they suggested a changing pattern of more frequent and more serious offences, and pointed to someone whose risk-taking behaviour, unhealthy criminal associations and unstable lifestyle had set them on a pathway likely to lead to involvement in more serious crime, and potential harm to themselves and others.  Had this information been available to Barnet YOT they would have revised their assessment of the level of risk AX presented to himself and the public.   110. Incidents which did not result in charges still added to the growing police intelligence on AX and enabled him to be identified and occasionally monitored as a potential supplier of drugs and as someone on the periphery of gang activity. There was at that point no regular mechanism for such information being communicated to and incorporated with the YOT’s reappraisals of AX's propensity for reoffending and the stability and likely trajectory of his life and circumstances. 111. The failure to review the ASSET after the Compliance Panel of 2 January 2013 was an unnecessary error and a missed opportunity to develop a more accurate and realistic understanding of AX’s situation.  A thorough review at this point would have changed the assessments of risks and vulnerability in all three domains of assessment.   112. The unsettled nature of AX's home life, a key predictor of risk of offending, was not recognised despite the signs of AX’s mother’s failure to attend compliance panels, and the evidence of her lack of engagement.  Taken with the evidence of deteriorating college attendance and poor compliance from the start, it should have been apparent that AX was not responding to the order and that a more robust approach was required if he were to be diverted from his current pathway. 113. One of the three serious offences in which AX was implicated was a sexual allegation. Had this been recognised it should have led to further contact between YOT worker and Police for    AX Overview Report    Page 22 of 48  information about the offence to allow fuller assessment of risk. The failure of the case worker to follow through the instruction for review meant that an inaccurate assessment of AX and the risk he presented to himself or others remained on file and was the basis for some future decisions about him by other workers.  The review that should have taken place would have improved the quantification of risk to and from AX and would have led to heightened awareness and potentially different intervention.  It would most likely have influenced the recommendations made to court in his subsequent appearances and led to different disposals.  114. It also appears in this instance the breach process was not properly instigated. At the time of AX's first referral order, there were problems for the Attendance Centre enforcing and managing breach procedures. In low intensity referral orders, particularly very short orders like this one, the delay between the start of the order combined with a then two stage process  for breach of the order  meant that the problems of poor attendance were sometimes not dealt with before the order expired.  The Attendance Centre has stated that this practice has been amended, with one stage being eliminated, making a return to court for breach of the order more rapid and more straightforward to instigate and the responsibility for initiating breach proceedings is now clearly understood by everyone to rest with YOT. The Barnet Attendance Centre has also amended its procedure for following up compliance failures, in conjunction with Police partners, and the dates on case records are noted for following up. 115. Since this case, Barnet Attendance Centre has amended its procedure for following up compliance failures in conjunction with Police partners. Dates on case records are now noted for following up and must be notified to the Youth Offending Team immediately.  The Youth Offending Team now prepare the warning letters as well as instigating and following through any breach proceedings. 116. The casework and management of AX’s first referral order was deemed by the internal agency reviewer for this SCR to have been ineffective. Issues in that worker’s performance and delay by a line manager in responding to them were subsequently recognised and addressed by senior managers.  It was not possible to follow-up or to interview the case worker or the manager responsible as they have now left the service.  117. It was evident to the internal reviewer that the “Barnet Youth Offending Team – Attendance Centre Protocol” was not being followed.  There was no attempt at enforcement, and there was only limited communication between the Youth Offending Team and the Attendance Centre. The Attendance Centre sent correspondence to the wrong address for AX and there were no adequate attempts to trace him.  By the time that the Attendance Centre staff were able to locate AX, it was too late to impose breach proceedings. The separate systems in operation at that time for managing a referral order, through the Attendance Centre and via the YOT, impeded the exchange of information between staff at the Attendance Centre and YOT staff.  While AX did not have extensive contacts with the Centre, as even planned skills-development activities did not take place, his patterns of absence or even sparse information gleaned about his activities and associates could have informed the ASSET and risk assessments of YOT staff. Working arrangements are changing to provide an integrated approach to the monitoring and support of young offenders.    AX Overview Report    Page 23 of 48  118. During the period of his referral order, AX was arrested in relation to two major crimes, a serious sexual assault and an attempted murder. It was not until October 2013 that Police sought to detain AX for questioning in relation to the second charge and tried unsuccessfully to locate him. Had AX been found and charged with this offence, it is possible in the light of the seriousness of other outstanding potential charges he would have been deprived of his liberty and stayed alive.  119. Because AX had not been identified as a gang nominal, and indeed was not affiliated with any local gang, preferring to operate alone, authorities were not routinely monitoring his activity or collating and sharing information about him. Had all the information known to all agencies been capable of being collated, then all the professionals who encountered AX from the beginning of 2013 would have had a better understanding of the dangerousness of his lifestyle to himself and others, and approached his needs differently. Learning Points from AX’s Time at School 4 and First Contact with Barnet YOT  The importance of mechanisms for information sharing between YOT and Police to ensure the pooling of intelligence from Police observations, misdemeanours which do not result in charge or prosecution, from investigations and from the local grapevine.   It has been suggested by professionals that the physical co-location of services in the same building goes some way towards making communication more routine.  The necessity of seeing the ASSET as a process of continuous assessment which has to be updated, analysed and used effectively.  The importance of effective, questioning casework supervision to ensure that poor practice by any individual worker is identified quickly.   The need to brief all YOT and related staff on responsibilities in relation to referral orders without supervision components and on effective strategies for maximising the impact of such orders.  Awareness of the limitations of ASSET and similar tools and the need for informed practice in terms of understanding the implications of these limitations for determining levels of risk of offending and of harm.  The need for the parallel work of Attendance Centres and YOTs, particularly in cases of first offenders, to have points of convergence and information-sharing.  Case workers must understand the importance of compiling a good social history of first offenders in order to inform future analysis of risk. AX’s Period of Homelessness 120. No agency had contact with AX from the end of his order in February 2013 until early April 2013.  There are indications that around this time AX may have had a dispute with his mother about her then boyfriend.  He had told people he did not think this man was good for his mother, that he did not like him and the feeling was mutual. He even approached his father to see if he could move to south London.  Mr. X's partner, Ms. D, was reluctant to agree to this and AX instead moved in with a maternal aunt for a short time then stayed with friends before    AX Overview Report    Page 24 of 48  presenting as homeless. Mrs. X was also at this time worried by her son's rootless lifestyle and frustrated by his refusal to cease his street activity.  121. On 6 April there was a domestic incident in North London between a woman, Ms. W, and her ex-partner, Mr. V, who had forced entry into her house.  On gaining entry, Mr. V encountered four young black men on the premises, one of whom was AX.  Mr. V alleged that one of the group produced a knife and threatened to stab him.  Police attended and made a report to CPS but no further action was taken because of conflicting statements and insufficient evidence.  Although a small child was present in the premises when the incident took place, it is not clear if notification to Children's Services took place as required by Domestic Violence Protocols. 122. The following day, AX was observed on CCTV following another male into an alleyway and stealing his phone.  He was arrested and charged for this offence and for being in possession of cannabis.  He admitted the possession of cannabis for his personal use and stealing the phone.  He was bailed to appear at Northwest London Juvenile Court the following week on 17 April 2013. 123. Immediately following his arrest, on 10 April 2013, AX approached Barnet Housing and explained he was homeless.  AX was seen by the Youth Mediation Coordinator who also spoke to Mrs. X by phone.  Mrs. X said she was at her wits end and was unwilling to have him in the family home because he had lost his college placement and because his offending was becoming more serious.  The Youth Mediation Coordinator arranged to meet Mrs. X and AX the following day.  AX indicated that he would stay overnight with a friend.  AX did not disclose that he had been previously living with an aunt and had been living intermittently with friends for some weeks.    124. The Youth Mediation Coordinator duly met with AX the following day, 11 April 2013. All housing provision options were considered including accommodation in local authority care under section 20, semi-independent accommodation and temporary accommodation.  AX was adamant he wanted to live independently. He was given a section 17 payment pending a claim for benefits.  He was referred to Targeted Youth Service (TYS) and to the Adolescent Resource Team (ART) for follow-up. 125. After interviewing AX, the Youth Mediation Coordinator met with AX’s mother and then saw them together.  During the meeting Mrs. X refused to engage in the mediation process. She walked out, leaving AX in reception and stated he was no longer her responsibility.  As the mediation had failed, an emergency referral was made to the Housing Needs Officer to accept AX as homeless.   126. In Barnet, the Safe Start Foundation provides a Crashpad service offering a 21 day ‘cooling off’ period to young people facing homelessness as a result of family conflict. During the stay, mediation is provided by the Safe Start Team and Barnet Young Person’s Mediation Project.  At the time of AX's application, there were no vacancies at Crashpad and so he was provided with temporary accommodation in East Barnet, at Address 4.  He was contacted the following day by the ART worker but declined offers of support. He indicated he would contact ART if the situation changed.    AX Overview Report    Page 25 of 48  127. In the following days, AX contacted his father and a paternal aunt by phone and asked for help because he had a court appearance. His aunt arranged a solicitor for him. AX did not disclose he was homeless to his father or his paternal relatives. A week later, AX attended Court and pleaded guilty through his solicitor to the offence of theft.  He received an eight month Youth Rehabilitation Order, including a six week curfew with electronic tag monitoring requiring that he return to his accommodation between 10.00 pm and 6.00 am each day.  He also had to undertake 24 hours work on independent living skills.  128. AX’s solicitor made application for a standalone referral order with an Attendance Centre requirement.  Although a YOT Officer was at court, the court looked primarily to AX’s solicitor for information on his client.  Usually where a youth offender is making reappearance in court, the YOT officer would provide a report or updated ASSET or ask for an adjournment for a Community Background Report.  In the light of the information provided by AX’s solicitor, the court simply consulted the YOT worker on AX’s compliance with his previous referral order. 129. The YOT worker attending court only had access to the earlier, incomplete and outdated ASSET and so gave a neutral report.  The ASSET, which had not been updated, despite the earlier request, did not reflect fully the concerns, risks or information which had emerged during the previous supervision period.  Nothing was presented in court about AX’s homeless status, the deteriorating relationship with his mother, the termination of his college studies, the Police intelligence around his involvement in robbery and possible gang activity, or the charges he was facing, including serious and sexual assault charges. 130. The court was told that AX had not engaged particularly well with Youth Offending Team during his previous order.  Despite this, and the evidence of his continuing misconduct, in the light of the positive picture presented by his representative, he was given a modest sanction. 131. After his court appearance, the Adolescent Resource Team worker contacted AX.  Again AX indicated he was fine, suggested that his relationship with his mother was improving and said that the only advice he needed was how to find a dentist. 132. On 18 April 2013, AX had electronic monitoring equipment fitted at his flat at Address 4. Two days later he failed to attend his first Attendance Centre appointment.  An initial warning should have been issued to him by the Attendance Centre, but this did not happen.   Around that time it was noted that robberies the borough had reduced since the arrest and curfew of AX and several other young people with whom he was known to consort. 133. On 24 April 2013, the Children and Young Persons Department completed an Action Plan for AX.  He was to be encouraged to accept a service from the Young Persons Drug and Alcohol Service and was provided with support to apply for benefits and access a business course.  AX was also told to report any change of address to the Youth Court and to work constructively with the YOT. Children’s Services understood that the Youth Offending Team were involved with AX and, based on his own account, that AX was engaging with this service. 134. On 25 April AX met with the ART worker. He acknowledged he was finding his new living situation difficult and recognised that he needed to learn independent living skills.  He was assisted to apply for income support and a further appointment was made with a youth advisor.  Two days later, AX failed to attend the Attendance Centre.  At this point, a final    AX Overview Report    Page 26 of 48  warning should have been given by the Attendance Centre, but for reasons that cannot be identified, this warning was not issued. 135. Around this time, a YOT worker updated the ASSET form for AX.  It appears that this involved no additional interviews or research checks.  The incomplete work on the case from the previous order was noted and the new worker updated the paperwork. The ASSET highlighted overwhelmingly positive factors in AX’s circumstances, although it did note that the previous supportive factors, such as his mother’s relationship, were no longer available.  The risk score was increased from 8 to 12 in terms of risk of reoffending, but there was no recognition of increased vulnerability and no additional assessment. Intelligence about AX’s escalating criminal behaviour had not been shared between police and YOT. Additionally, no-one in YOT was aware of what Barnet Housing knew about AX’s living circumstances. These factors combined with AX’s lack of frankness, contributed to gaps in the updating of the ASSET and meant the assessment of risks around AX’s offending and his safety were unreliable. 136. On 30 April 2013, an incident involving other youths took place in AX's accommodation.  He later said it happened on the street outside his property.  The full facts of the incident were never clarified. 137. On 2 May, AX attended Barnet Housing and requested alternative accommodation, stating that he had been robbed and assaulted in the incident two days previously.  He said that there were on-going issues with the youths who came to his home though he also claimed they were unknown to him.  Although he had stayed in his accommodation for the two nights following the assaults, he claimed he was fearful of ever returning home and would need to be immediately rehoused.  It was noted that he smelled of cannabis and there was redness around his eye.  It was accepted he was the victim of an assault and AX was advised to report the matter to the Police.  138. AX later said he only reported the incident to Police to secure a Crime Reference Number to provide to the Council, as he thought this would expedite move back to an area where he wanted to live, closer to his former home.  He subsequently failed to respond to numerous messages left by Police and so the matter was closed.  139.  AX was advised by the Housing Officer to stay with a friend until he could be re-housed.  There is some evidence despite this advice and his claimed reluctance to return to Address 4 that he may have continued to live there. He continued to request rehousing over the following week and this was strongly advocated by the ART worker, who was basing his assessment only on AX’s account and presentation.   AX again failed to comply with his Attendance Order and did not attend for his appointment on 4 May, but again no action was taken by the Attendance Centre.  140. On 9 May 2013 AX was offered accommodation in Golders Green. He arrived at the property with a group of friends and indulged immediately in anti-social and confrontational behaviour. As a result the property company refused to accept him as a tenant. 141. Ten days later, AX was rehoused in a property in North London, Address 5.  Within hours of taking up occupancy of the flat, complaints surfaced from neighbours about antisocial behaviour.  The Property Management Officer (PMO) contacted Barnet Housing Options on 22 May, to report complaints from several sources of visitors arriving at AX’s flat through the    AX Overview Report    Page 27 of 48  night, as late as 4.00 am each night, general rowdiness and a smell of cannabis drifting through the building.  Despite a verbal warning from the PMO the problems persisted and worsened.  142. The next day further complaints were made that young people were congregating in the flat, that AX and his friends had kicked in the front door of the building, that locks had had to be replaced and that a fire panel had been smashed resulting in the Fire Brigade attending. The PMO requested cancellation of the tenancy in the interests of other tenants.   143. Barnet Housing now determined that AX had made himself intentionally homeless as a result of antisocial behaviour in his accommodation. Because of AX's age and potential vulnerability, the case was reviewed by a manager and AX was interviewed.  AX’s explanation was that he needed his friends around due to having been previously attacked and that he was now scared to be alone. His account was plausible in its presentation.  In reaching a final decision, the housing manager took account of AX's argument that he was under curfew and tagged (for another 5 days till 28 May) and if he were to become homeless he could end up in prison because he needed somewhere to accommodate the electronic monitoring equipment. This explanation was accepted and AX was admonished and exhorted to improve his behaviour.  144. AX was then provided with accommodation at Address 6 in Enfield, in an area with which he was partly familiar.  The accommodation was an HMO property (housing with multiple occupancy) where AX had exclusive use of bedsit accommodation and shared other facilities.  Mrs. X who later visited him there was concerned by the poor standard of the property and the intimidating presence and unhealthy influence of older youths with whom AX shared the property. Mrs. X became concerned that AX was unhappy in the property and thought he was spending time outside it to avoid going back to it.  She worried that he was rootless and had lost his bearings and was becoming involved in more serious crime. She did not contact any agencies with her concerns in this period. 145. AX based himself between Address 6 and the accommodation of friends nearby, sometimes sleeping in one location, sometimes in another.  He quickly made links with peers and useful drug scene contacts nearby in Enfield.  He established himself as a local supplier of goods and cannabis. 146. On 26 May Police were called to a disturbance in Enfield involving a group of males carrying weapons, one of whom was AX. The Police cornered the group in a shop whereupon AX attempted with others to exit and, on being confronted, ran back into the shop appearing to discard items.  The Police record describes the gang as a group of males “believed to be part of a gang known for committing robberies and carrying weapons”.  A discarded knife was found on the floor.  AX was subsequently apprehended and questioned, during which he appeared nervous and evasive.  He was warned as regards his conduct but it was considered there was insufficient evidence to support a prosecution. 147. The electronic monitoring company, Serco, had not been given AX’s new address, nor had AX contacted them as advised by ART.  Serco staff visited AX’s old address, Address 5, on 28 May because of an apparent curfew violation.  At some point Serco was notified, though it is unclear by whom, that AX was waiting to be rehoused.  Serco again tried to reach AX on 25, 26th, and 27th May for breaches of curfew. The May 27 curfew breach was in excess of 20 hours.  Serco subsequently recommended enforcement action and sent a breach of curfew    AX Overview Report    Page 28 of 48  order information pack to the Barnet YOT.  There appears to have been uncertainty about who was responsible for informing the court that AX had breached his curfew order, despite existing protocols.  148. The YOT worker had not previously encountered an order which had separate standalone requirements and was unaware YOT had responsibility for instigating breach proceedings in relation to curfew violations. Meanwhile the Attendance Centre had recorded several further non-attendances, but neither took action nor advised YOT of AX's persistent absences.  These factors meant breach proceedings were not started.   AX's curfew order then expired on 28 May 2013 before the position about responsibility for taking action had been clarified. 149. Barnet YOT should have informed Enfield YOT on 29 May 2013, once they knew AX’s new address in Enfield that he was living in their borough, in keeping with both protocols and good practice.  It is unlikely Enfield would have responded to or even recorded this information, however, as until a young person is formally transferred, there is no means of recording the information on the case management system.   Barnet YOT meanwhile, were unable to request transfer of the case to Enfield at this time because of a likely pending breach of his attendance centre order, as YOTs do not accept the transfer of a young person who is subject to breach proceedings, who remains the responsibility of the team taking forward the proceedings. Commentary on AX’s Period of Homelessness 150. In the light of what is known of AX's astuteness and capacity for strategising, it seems likely that, just as he had put in place elements to create an image of a young man of stability with family support prior to his first court appearance, he successfully engineered circumstances to impress the court and minimise the chance of an adverse disposal on his second court appearance.  AX used his own resources to cover his own legal representation and appears to have briefed his solicitor to seek an Attendance Centre requirement as a disposal.   151. The Court hearing his case was disadvantaged because it relied on selective, self-reported information communicated by AX’s solicitor and limited information from the incomplete and inaccurate earlier ASSET.  Had anything been communicated to the Court of the vulnerability and instability of AX’s circumstances, his repeated stops and arrests for potential offences and his suspected involvement in serious offences, including serious sexual assault and attempted murder, it is likely that AX would have received a disposal that more appropriately reflected his own vulnerability and the risk that he presented to the public.   152. Further, because AX had not had formal breach proceedings instigated during his first order because of non-compliance, the Court was unaware of the full extent of AX’s poor engagement with the Attendance Centre.  Again, had that been known, it is likely a more restrictive and more demanding order would have been handed down. 153. In relation to AX’s first presentation of homelessness, there is no question that the Mediation Officer was assiduous in trying to effect a reconciliation between AX and Mrs. X. Barnet’s Housing Options workers have an over 70% success rate from mediation.  In this case, there was no engagement from either AX or his mother.  AX was determined to move into his own property, in part to assert his independence and in part to ensure he had a settled address before his upcoming court appearance.  Mrs. X recalls that the mediation worker offered a    AX Overview Report    Page 29 of 48  range of solutions but AX was uninterested in anything but getting his own flat and she was at the end of her tether with worry about his lifestyle. She feared not only for AX but also for the consequences of his criminal associations for herself and her brother. 154. In the Southwark judgement, (G v LB Southwark (May 2009), the House of Lords established that the Children Act 1989 has primacy over the Housing Act in providing for children in need, and that the duties of local authorities children’s services to accommodate children in need cannot be circumvented by referring to the housing authority. Furthermore, where a 16 or 17 year old young person presents as homeless to a local authority and is assessed as requiring accommodation, in all but a few exceptional cases the young person will meet the criteria for S20 accommodation and therefore will become a Looked After Child (LAC), with full eligibility for funded care (and extended aftercare support after 13 weeks of care beyond their 16th birthday). 155. It is clear from records and Mrs. X’s account that the Mediation Officer did address this option with AX.  Contingent on the application of S20 powers in this case, however, would have been the informed consent of AX to pursuing that option.  (In the case of G v Southwark the young person wanted to be accommodated rather than housed and was seeking to clarify that right in law).  AX had no desire to become a looked after child and so S20 accommodation would not have been an option.  156. On a narrow interpretation of the judgement, AX’s choice thus ended all responsibility of Children’s Services for involvement in the case.  In the Southwark judgement, however, it is clear that the intention of the House of Lords’ determination is to see responsibility for assessment and care planning for homeless young people transferred from Housing to Children’s Services. It is nowhere implied in that judgement that assessment and planning responsibility ceases because a homeless young person aged 16 or 17 does not want to be accommodated.  Essentially such young people should be treated as children in need and assessed as such in order that a cogent plan can be put in place to address any identified needs, risks and vulnerabilities which would compromise their safety or well-being.  157. As this case tragically proved, 16 and 17 year olds who become homeless are likely to be ill-equipped to find stability, purpose, and a safe environment in which to discover and fulfil their potential.  In such circumstances an assessment is required which draws on a full social history in order to understand the trajectory of where a young person has come from and the direction in which they are moving, the young person’s own insights and aspirations, the insights of people who know the young person, an assessment of the likely impact of their associations and any intelligence around offending behaviour.  With such data, considered and analysed with the expertise of social workers, youth justice workers, police or community workers, better-informed options and plans could be developed and more accurate assessment of risks, threats and vulnerabilities made. 158. Had the Barnet Crashpad facility been available, a fuller assessment could have been made of AX’s circumstances and options and more intensive assistance could have been available to him around his living situation.  Given AX’s reluctance to accept help and determination to pursue his own path, however, it cannot be assumed that he would have responded to the intervention at Crashpad.     AX Overview Report    Page 30 of 48  159. The Adolescent Resource Team (ART) in Barnet offers an after-school drop in service for young people and it also conducts joint assessments with housing workers for young people, aged 16 or 17, who find themselves homeless and connects them with sources of information and support.  AX declined most of the support offered by ART.  AX’s contact with ART and Housing Officers was dominated by his desire to be relocated and by problems arising from his anti-social behaviour.  Staff had little time to acquire a fuller picture of his needs.  In this case, the ART Worker took on an advocacy role, rather than an assessment role and had to rely mainly on AX’s self-reported information. 160. AX’s determined vision of the lifestyle and accommodation he wanted, meant that nothing in the range of options offered or available to him was likely to shift his aspirations and deter him from an increasingly dangerous lifestyle, particularly where that offer came from public authorities for which he had little respect and considerable mistrust. 161. Barnet Housing’s response to AX’s report of an assault in his home was commendable in its promptness and the persistence and advocacy of the ART worker was crucial in AX’s situation being treated sympathetically.   Barnet staff had no grounds to question AX's account of the incident, which, even if exaggerated or misleading, would have been plausible and well-articulated.   162. What actually happened at Address 4 that prompted AX’s transfer to Enfield cannot be determined.  Likely scenarios suggested include that AX may have been a target in an unfamiliar area because of his known access to relatively large sums of cash; he may have been vulnerable or fallen foul of someone due to his drug supply activities; he may have been involved in a feud over a trivial matter; or he may have been a target of other youths because of the consequences of serious offences he had been involved in. The reality was his lifestyle brought him into contact with dangerous situations and people.  163. For all his intelligence and astuteness, his seeming street savvy, and his physical presence, AX at times still displayed signs of the young boy desperate for affection that his early teachers had known.  He was generally an amiable companion and could be very tender-hearted.  He was protective of his mother and worried about her.  It is likely AX was nowhere near as well-equipped as he thought to survive, let alone thrive, in the dangerous places and among the serious criminal groups he frequented.   AX was thought by some of his fellow students at School 4 to be dealing in Class A drugs.  This likely would have brought him in contact potentially with older, more sophisticated criminals, from different, close-knit gangs and rival ethnic groups.  164. At no stage during this period was Barnet Housing or Barnet YOT aware AX was a possible suspect in an attempted murder in the area.  AX’s powers of persuasion are evident in his argument to dissuade Barnet from considering him as intentionally homeless after the disastrous tenancy at Address 5. His argument of imminent imprisonment were he to be considered homeless, clearly swayed the housing manager, though it is surprising the actual position was not clarified with Serco. 165. Uncertainties around responsibility for instigating breach proceedings in relation to AX's curfew delayed a return to court which might have resulted in a more restrictive order.  While the errors and uncertainties appeared no more than minor administrative issues, their cumulative effect was a significant lost opportunity to divert AX from his risky activities and    AX Overview Report    Page 31 of 48  serious offending. Such an order could have provided an opportunity for engaging AX in compulsory interventions to move him away from his dangerous lifestyle. It must be recognised though that AX’s obsession with his money-making activities and his identification with aspects of gang culture limited considerably the likelihood of a successful diversion into a safer lifestyle. 166. There was a point early in 2013 when AX approached his father, worried about his safety after a friend had died in an episode of street violence.  He wanted at that stage to break from his lifestyle. Mr. X could not offer AX a home because of factors in his current relationship and he was at a loss how to help. Mr. X had not been involved with any of the agencies dealing with AX and was unaware of sources of support.  In the event, AX’s resolution to change his lifestyle waned and he remained involved in increasingly violent offences and in trading in drugs.  Opportunities for change do arise even for people caught up in a dangerous lifestyle; sometimes, as in this instance, they do not coincide with ready access to the support needed to maximise them. 167. The last two years of AX’s life were characterised by separate agencies holding discrete pieces of information about him which were not aggregated and examined.  Single episodes which, if pulled together, would have shown a pattern of worrying behaviour and circumstances, were dealt with discretely.  For example, the immature and anti-social behaviour AX displayed when he attended the property in Golders Green or at Address 5 was not followed up or communicated more widely amongst professionals; missed Attendance Centre appointments were not actioned or reported and their significance as part of a pattern of increasing disengagement and recklessness was not recognised.  168. Professional responses tended at times to be aspirational rather than evidence based, reactive rather than anticipatory.  For example, the closing summary from ART is upbeat and positive and talks about potential for the Targeted Youth Service offering AX support on education and training and his application for a Job Seeker’s Allowance. The difficulties around AX’s antisocial behaviour and the many complaints received regarding the presence of groups of young people in the properties where AX lived were not addressed. The summary concludes by saying that there is no on-going need for intervention with this young person. 169. When problems were recognised, in AX's contact with agencies, the response was often warnings and admonishments to better behaviour. Such efforts had proved singularly unsuccessful in the past. It should have been evident from AX’s recurring anti-social behaviour, his growing pattern of offending and his disengagement from education, family and other support, combined with his poor compliance with court orders, that this was a young man on a downward trajectory and that the possibilities of him following through on his assurances of changed behaviour, lacked credibility. For those reasons alone it was important to ensure a smooth transfer of responsibility and information and a degree of transitional planning when AX moved to another borough. 170. Since AX’s death, arrangements in Barnet between the Youth Offending Team and Housing have been improved so YOT now attends any homeless persons assessment for cases of young people which have been recently closed and where the Barnardos Advocate is not involved, in order to share information and assist the process of determining the best option for the young person.      AX Overview Report    Page 32 of 48  Learning Points from AX’s Period of Homelessness  Local authorities need to focus on fulfilling the spirit of the Southwark judgement and ensuring comprehensive assessment for all homeless 16 and 17 year olds and realistic planning for those with identified vulnerabilities and needs.  Importance of all YOT staff being familiar with breach processes for curfew order violations.  All forms of professional assessment of homeless young people to avoid focusing on a current snapshot view of the young person and to consider the long-term trajectory of young person’s life and experience, what is changing and the implications of change.  Period in Enfield 171. AX was settled in Enfield by the end of May 2013. The ART worker in Barnet closed the case on 29 May.  While the evidence of the preceding weeks suggested AX would struggle to maintain a tenancy independently, AX insisted he did not want further support that everything was fine; his tag was being removed and, alongside his own sources of income, he continued to receive subsistence payments up until 20 June 2013.  172. On 1 June, AX again failed to keep an appointment at the Attendance Centre.   A warning letter was sent on 11 June. This was the first warning letter sent to AX although he had already missed appointments on 4 May and 11 May. This letter was sent to one of AX’s previous addresses, Address 4.  The Attendance Centre was unaware that AX had moved twice in the interim.  AX did contact the Targeted Youth Service in June to discuss Benefit claims, but again failed to attend the Attendance Centre on 15 June.  A second warning letter was sent – again to the wrong address.  As the transfer of case responsibility to Enfield YOT had not yet been effected, because AX was in breach of an existing order, responsibility for securing AX’s compliance with court orders remained with Barnet. 173. On 16 June AX was stopped by Police in a drugs hotspot and was noted to be smelling of cannabis.  He was by that time known to Police as a top five robbery nominal in the borough.  The following day he attended his GP surgery for a health check.  He claimed to be a non-smoker and not to drink alcohol.  On 22 June AX again failed to attend the Attendance Centre.  He continued to fail to respond to the Attendance Centre, although he kept in touch with the Targeted Youth Service which was his route to securing benefits. 174. On 9 July AX was stopped by the Police.  He twice tried to avoid the officers before being engaged and was evasive when questioned. Officers noted he was smelling of cannabis and believed he was supplying the drug. He was detained for possession of drugs.   AX was then found to be in possession of a stolen phone and Oyster Card and arrested for handling stolen goods.  The outcome of this was no further action. 175. A summons for AX to attend court regarding the possession of cannabis from 7 April 2013 was issued on 10 July. The notification was sent by the court to the wrong address and so AX did not attend. The case was adjourned until 24 July. 176. On 11 July there was discussion instigated by Serco between the Barnet Youth Offending Team and Serco about AX's curfew violations in late May.  Serco had sent the breach pack to    AX Overview Report    Page 33 of 48  the Barnet YOT before the cessation of the curfew order.  It emerged the pack had been originally filed by mistake, without the relevant worker being aware it had arrived.  The curfew had by then expired six weeks previously. 177. When the lapse came to light in mid-July 2013, a YOT worker checked if AX had been attending the Attendance Centre.  This was the first YOT follow-up of AX since early May.  Meanwhile there was a further failure by AX to attend the Attendance Centre on 13 July. 178. What emerged over the next few days as the YOT worker continued their inquiries was that Attendance Centre letters had been sent to AX's original address with no response and that despite warnings issued, there had been no follow-up and the Attendance Centre had had no contact from AX since April. 179. In total AX had missed eight appointments: his first Attendance Centre appointment set by the Court on 24 April and then seven consecutive appointments – 27 April, 4 May, 11 May, 1 June, 15 June, 22 June and 13 July.  He had made no effort to start his 24 Hour Order. Because of the address error and failure by the Attendance Centre to follow-up AX's breaches, no effort had been made to hold him to account and take him back to Court.  180. On 23 July, AX was again stopped by Police, along with another male, on suspicion of robbery. AX had been identified by name by the victim.  He is said to have threatened the victim with a knife.  AX was arrested for the robbery and possession of cannabis for personal use and bailed.  While he was being questioned on these matters, and was in custody, his court appearance for possession of cannabis, dating back to April, took place on 24 July.  There was an adjournment until 7 August and Enfield YOT was notified AX was now resident in their area.   181. Enfield YOT received the notification from court on 25 July 2013 in respect of the adjournment for the sentencing of the possession of cannabis offence, first heard on 7 April 2013.  Enfield identified that AX was subject of an eight month Youth Rehabilitation Order and a standalone Attendance Centre Order, that there was an outstanding 24 hour Order and that a six week curfew order had been completed.  Contact took place with Barnet YOT and a formal request to Enfield to take over the oversight of the order was made by Barnet on 29 July 2013.   182. Enfield’s practice in relation to standalone Attendance Centre requirements was to send out their own warning letters from the Youth Offending Team, but otherwise there was no difference in practice to Barnet YOT.  Enfield YOT initially refused to accept the transfer because of the absence of a fully updated ASSET. The most recent ASSET was then provided but this proved to be the inadequate closing summary from the previous referral order.   183. It was agreed that Barnet would retain responsibility for AX’s order until breach action in relation to attendance and curfew violations was completed and AX resentenced and, at that point when there was clarity about the requirements, the order would be transferred to Enfield. 184. Enfield were advised AX was now housed in a licensed HMO (house in multiple occupation) at Address 6 but neither Enfield or Barnet YOT  were fully aware of the history leading up to his move to that accommodation. 185. On 7 August 2013, AX failed to appear at Court and a warrant was issued.  It appears that Enfield was never informed of the court outcome on 7 August and so did not pursue it. On 8    AX Overview Report    Page 34 of 48  August, AX was stopped by Police in a crime and drug hotspot.  Checks revealed there was a warrant out for him and so he was arrested and subsequently bailed to attend court on 28 August.  Enfield YOT was not automatically informed. 186. On 11 August AX was stopped again on the street for similar cause.  Over the next month his movements on the street were at times noted or monitored by Police for intelligence purposes. Commentary on AX’s Placement in Enfield 187. Concern was raised in the aftermath of AX’s death that he may have been a gang nominal placed at an unacceptable risk by being allocated accommodation in an area that fell within the territory of a rival North London gang.  This speculation led to unwarranted and uninformed criticism of Barnet staff and policies. Closer study of AX’s circumstances revealed that AX himself raised no objection to and indeed welcomed this placement. He resisted efforts of ART to provide support, asserting that he was capable of living independently and the accommodation was suitable. 188. Further, the issue of AX's gang affiliation is not entirely settled. AX and his immediate friendship group had formed themselves into Group A which is thought to have some affiliation with an established gang, Group B.   Group A appears to have been defined more by its commercial and criminal activities than by its territoriality.   189. Research into the experience of gangs (Tita et al 2005) indicated that the concept of territory is often perceived differently by gang members compared to people in the wider community who tend to have ideas of fixed territorial boundaries defended by gangs. The research found that while some gangs are preoccupied with the maintenance of the boundaries of their defined territory, many other groupings tend to have a conception of what Tita termed "set space" - areas where they hang out and engage in their activities, Such areas not necessarily being contiguous. Within a wider-defined territory some gangs may have several set spaces.   190. The research of Aldridge et al 2010 challenged the received wisdoms that street gangs in the UK are always grounded in territory and that gang members always reside in the areas where their gang exists. They found many gang groupings had members whom they described as "Residential Outsiders".  As similar research with US gangs found, gang members’ territories and neighbourhoods of residence are not necessarily directly coterminous. 191. Even if Group A had been more territorially defined or conscious, than it appears to be, it would not necessarily have been problematic for AX to be living or perceived to be living in another area.  There is no substantive or contemporaneous evidence to suggest that either the assault AX endured in Address 4, or the final lethal assault was due to him being perceived as a member of one gang residing in the territory of a rival gang.  192. In reality, AX was living an increasingly dangerous life in terms of the company he kept, the offences he appeared to be involved in and the expanding scale of his cannabis supply activities.  His fondness for money drove him to take risks and certainly brought him into contact with dangerous situations and people. Neither the motive for the fatal conflict in December 2013, nor for the earlier assault in May 2013 can be determined beyond doubt.  The evidence of AX’s lifestyle suggests that these assaults were not due to gang affiliation but    AX Overview Report    Page 35 of 48  more likely a consequence of AX's lifestyle which was becoming so risky he would at times carry or have access to a weapon. 193. In the course of this review helpful information was gathered on gangs in North London, on pathways by which young people are drawn into gangs and on community initiatives to disrupt the processes by which young people are attracted to and by gangs. The findings indicate that the patterns of AX’s activities would likely either have drawn him in due course into closer alignment with a local gang or, through his ambitions and activities brought him into conflict with some gang. 194. Opportunities were missed to compel AX's engagement with statutory agencies through the failures to follow-up on his eight missed Attendance Centre appointments and the breaches of his earlier curfew. The lack of consequences for his failures to comply with court sanctions combined with the repeated lack of action following Police stops or questioning must have contributed to AX's confidence that he could continue his irresponsible and criminal behaviour with impunity, and possibly even emboldened him in more reckless acts.  195. The absence of a comprehensive picture about and assessment of this young man is a glaring feature of agency engagement with him over the last nine months of his life.  The discussions between Enfield and Barnet about responsibility for AX appear to have been couched in terms of arranging management of a case rather than the imperative to get a handle on this young man's non compliance with court orders and risky behaviours. AX's interests and the need to work for the best outcome for him were the greatest priorities in the situation and should have dominated all transfer discussions and outweighed all other considerations.  Learning points from AX's Placement in Enfield  Importance of professionals not holding too rigid views of gang structures and “territory”.  Needs of young people to be foremost in any discussions, and to prompt swift resolution of, any case transfer complications.    During the period of case transfer between areas, both parties have to be considered as one extended team and must keep each other updated on case developments. Period following August 2013 Court Appearance 196. On 28 August 2013, AX attended Court and pled guilty to possession of cannabis.  The previous Youth Rehabilitation Order imposed on 17 April for theft was revoked and a new one was imposed with the requirement of 30 hours Attendance Centre contact.  The Barnet Court Duty Officer could not obtain available dates for a first appointment or details of the relevant Attendance Centre from the Enfield YOT Duty Team. It was later agreed that the Enfield YOT would write to AX with a first appointment.  An email was sent by the Court Duty Officer to Enfield YOT with confirmation of this outcome.  197. AX left the court without an Attendance Centre appointment. He was unlikely to have been proactive in following up the requirements of the court order, particularly as his lifestyle was becoming more unsettled and he was at different times moving around to avoid certain    AX Overview Report    Page 36 of 48  acquaintances.  The necessity of prompt follow-up of AX by Enfield YOT was recognised by the Duty Officer and an initial appointment was sent out to AX. Unfortunately no check had been made on his current address following his court appearance and the appointment was sent to an address recorded incorrectly on Enfield's database and would not have reached AX. 198. The fact that AX did not have a scheduled contact with the Attendance Centre was not immediately picked up in Enfield.  Even when AX's subsequent failure to attend was identified, no warning letters were sent nor did discussions appear to take place within Enfield or between authorities about AX's failure to comply with the court order.  199. On 9 September 2013, Wood Green Attendance Centre contacted Enfield YOT advising that AX had missed his first appointment and asking for confirmation he had been notified of it. When it was realised the initial contact letter from Enfield YOT had been sent to an incorrect address unsuccessful attempts were made to reach AX’s mother.  Although there was correspondence between Barnet and Enfield about the court proceedings, this was not recorded on the Enfield system and no compliance discussions took place between the Enfield caseworker and their manager.   The Attendance Centre did not follow-up the later non-attendance of AX beyond sending further correspondence, which was again misdirected. 200. Despite AX not reporting to the Attendance Centre in Enfield at any time in the period between the making of the order on 28 August 2013 and his death in December 2013, no warnings were sent by the Enfield Youth Offending Team as per their protocol.  No records were kept of non-compliance and therefore there was no effort to report the breach of the order to the court and have AX summoned to appear.  AX’s address was incorrectly recorded on the Case Management System so correspondence would not have reached him.  201. On 1 October 2013, AX was stopped by Police while in a motor vehicle with friends.  He was nervous, evasive and smelt of cannabis. Along with the occupants of the car he was wearing clothing similar to gang colours. A search of the vehicle found no drugs.  The fact AX was a suspect in an attempted murder and in a rape case was not noted. This proved a missed opportunity as two days later Police contacted the  case manager at Enfield YOT and advised that AX was wanted in relation to an attempted murder investigation from January 2013, and sought his contact details.  Police were given AX's contact details (which were out-of-date) and the date and time of AX’s next Attendance Centre appointment.  As the notifications of the appointments had been sent to the wrong address, AX did not know of or attend his next two appointments.   202. On 15 October, the YOT case manager contacted the Attendance Centre to advise that letters to AX had been returned by the Royal Mail having been sent to a wrong address. A further letter was then sent to AX’s most recent address, Address 6, with appointments for 26 October, 9 November and 23 November. By this stage, however, AX had left or was on the point of leaving Address 6 and for the last weeks of his life would live at various friends' houses. 203. On 20 October the Housing Needs Officer at Barnet was advised by the Emergency Accommodation Team that AX was no longer staying at the HMO accommodation at Address 6.  Attempts to contact AX were unsuccessful.  The Housing Needs Officer contacted the Enfield YOT for information and was advised that AX had not been seen since the start of his order and was wanted by the Police. It was speculated that AX may not have been staying at    AX Overview Report    Page 37 of 48  his accommodation because he was avoiding the Police.  It has subsequently become apparent that he may also have been avoiding certain acquaintances.    204. The Emergency Accommodation Team checked the premises again the following day and established AX had not been seen at the accommodation for around three days. It was decided to terminate his accommodation agreement in anticipation this would trigger contact from AX.  Barnet Housing sent letters to Address 6 but no response was received. It later emerged that he was living sometimes with friends, sometimes in similar accommodation nearby which had been temporarily vacated by an acquaintance.  205. Over the next few weeks, in the period before AX’s death, despite his being subject of a court order, no agency was able to contact him or determine his whereabouts and condition.  He had intermittent contact with his family, visiting his mother a few times but was reticent about his activities.  His father tried to encourage him to visit his extended family in south London and encouraged AX's half-siblings to appeal to him to visit. AX made excuses and did not visit.  206. On 28 October 2013, Police attended an address in North London to arrest AX, but he was not there. On 4 November 2013, Barnet Housing, having had no further information about or contact from AX, closed the case. 207. The same day Police again contacted the Enfield YOT to check if AX had been in touch.  At that point AX was wanted by the Police for questioning in relation to offences of attempted murder and conspiracy to rob, and was still on bail for a sexual offence for which a positive forensic match had now been obtained. 208. Although AX had not attended any of his Attendance Centre appointments and further failed to attend on 11 and 24 November, no action was taken and no breach proceedings were instigated. 209. Sometime on 2 December 2013 the original occupant of the room where AX was staying returned and a dispute arose over his belongings.  That youth sought out two friends and returned looking for AX. Shortly after midnight, in the early hours of 3 December 2013, a fight broke out on the street in front of the house which resulted in AX being attacked by the occupant of the room and two older youths.  A knife was produced and AX was stabbed three times in the chest, one of the wounds proving fatal.  The three assailants fled. When London Ambulance Service arrived, AX was pronounced dead at the scene.  The weapon was never recovered.  210. Police arrived and took over the management of the scene. A major investigation team was established, resulting in three young men being charged with murder.  They were subsequently acquitted at trial in June 2014.  No-one else is being sought in connection with AX’s death. 211. According to Mrs. X and other family members, the money which AX had accumulated was not recovered after his death. Commentary on Period after August 2013 Court Appearance 212. AX was not seen by Enfield YOT or Wood Green Attendance Centre between the imposition of an order on 28 August and his death. A series of lapses and mistimings occurred, none    AX Overview Report    Page 38 of 48  especially significant in its own right, but accumulating to allow AX to slip below the radar of agencies with a statutory obligation to monitor and assist him.  213. On 28 August AX appeared in court in one borough and the disposal was an order which would be supervised in another borough into which he had moved. The unavailability of simple information about a first appointment time and location is not uncommon in such circumstances, and can usually be quickly rectified.  In this instance, a series of delays and a bureaucratic error meant AX was able to avoid contact with the Enfield YOT and failures by that team and by the Attendance Centre to instigate sanctions for his non-compliance with his order meant he remained at large, unsupervised in the community. Not only was he now a suspect in three serious crimes - attempted murder, rape and robbery-  but also, because of the risks he appeared to have been taking in his pursuit of financial success, his lifestyle was becoming increasingly dangerous. 214. Enfield's request that Barnet hold the case pending completion of breach proceedings and updating of the ASSET was reasonable. However, additional measures should have been taken by Enfield to monitor and support AX in complying with a new order, particularly in the light of his known pattern of avoidance of contact and lack of compliance. Staff's primary focus in both boroughs needed to be what could be anticipated about AX's conduct and his likely lack of compliance, rather than the mechanics of the transfer.  215. When AX appeared in court in late August, the full extent of information about the dangerousness of his lifestyle was unknown to either Barnet or Enfield YOTs because Police intelligence on AX was not routinely shared.  Police in Barnet were also unaware of his change of location.  The Police intelligence, if available to the YOTs, should have led to a reappraisal of the risks around AX's lifestyle and behaviour. By early October 2013, even after Enfield Police alerted the Enfield YOT to the gravity of offences in which AX was a suspect, no further reassessment of risk was undertaken nor different plans made for working with him.  216. Uncertainty in Enfield about the process for instigating breach proceedings in standalone orders impacted on the case and highlighted lack of clarity in national guidance. The Youth Justice Board is currently clarifying the Youth Offending Team roles and responsibility in relation to standalone Attendance Centre requirements, for example resolving existing uncertainty whether it should be standard practice that an ASSET is undertaken. In this case, as more information began to emerge about AX, and particularly the nature of his offending, and his unsettled existence, good social work practice would dictate that a reassessment of risk and of circumstances was required.  217. There is no clear reason for the failure by the Attendance Centre and by Enfield YOT to instigate breach proceedings given AX's failure to comply with his order over a three month period. While it may have been assumed within Enfield YOT, after 13 October 2013, that AX's arrest by police was imminent, that was not a justification for inaction. Systems which should have prompted checks on his status failed and simple mistakes like a wrongly recorded address compounded the difficulties.  Changes in oversight arrangements, bringing Attendance Centres under the same management as YOTs should improve the system by creating better channels of communication and more safeguards. 218. The importance of maintaining accurate contact details is highlighted by the number of communications, particularly from the Attendance Centre, which failed to reach AX.  By    AX Overview Report    Page 39 of 48  18 July 2013 AX’s address was widely known and communications, including those sent in August by Enfield YOT, should have reached him up to early October when AX began living a more nomadic existence. 219. Policing intelligence from the past year on AX, including his alleged involvement in attempted murder and rape and the escalation of involvement in criminal activity should have made him a priority for observation, first in Barnet and later in Enfield.  Had the information known to individual officers and to each force been more effectively collated, AX might have been brought to court earlier to answer for the more serious offences or  have had greater restrictions placed on his liberty and been compelled to engage in more robust programme work. 220. From the time AX started secondary school there were over 20 occasions when he came to the attention of Police.  Most encounters did not result in any sanction or charges.  When decisions about charging AX were being considered or reviewed, more weight should have been given to the extensive pattern of offending behaviour that was now apparent.  When AX moved from Barnet, given the gravity of offences for which AX was under suspicion, police in Enfield should have been alerted earlier to his presence in their area and to the volume of intelligence on his alleged activities. 221. The absence of a forum for pooling information and improving the identification and analysis of the trajectory AX was following proved significant.  New MASH arrangements implemented since this case will aid the collation, sharing and joint appraisal of intelligence and information about prolific young offenders. 222. It is inevitable that everyone connected with AX wonders whether had action on AX's failures to comply with Attendance Centre and other court requirements in Barnet and in Enfield been handled in accordance with procedures, the response of the court might have been an intervention that would have removed him from the fatal encounter of 3 December 2013. They wonder also whether an earlier arrest by Police, for the offences committed almost one year earlier, and likely subsequent charges, would have deprived AX of his liberty and at least kept him alive.  223. Any such speculation has to be balanced with the reality of the seriously dangerous risks AX's lifestyle and activities were routinely placing him in, and with which he was far less well equipped to deal than he realised. Much as AX loved his family, he resisted their pleas and attempts to dissuade him from his lifestyle, just as he declined support offered by Housing and ART in Barnet, again because he over-estimated his abilities to be independent and manage his activities. 224. Opportunities to remove AX from street-life and crime, or at least curtail his activities, were lost through failures to prosecute him, delays in arresting him and, most significantly, failures to return him to court for non-compliance with orders. The most significant opportunities to change the outcome of the destructive pathway AX followed in his last year of life, however, occurred much earlier, in the period when he was transitioning to senior school and was beginning to be drawn into reckless and offending behaviour. The life and tragedy of AX highlights the importance of early identification of and response to young people at risk of moving into harmful activity, whether or not they are formally identified with any gang grouping.  It is the intense hope of AX's family and friends that through his death momentum    AX Overview Report    Page 40 of 48  and priority is given to initiatives which identify and seek to divert young boys from street-violence and offending and to housing older youths living alone in supported settings. Learning points from period after AX’s Court Appearance in August 2013  Professionals need to understand the nature of YOT authority to supervise and require cooperation in compiling ASSETs, in respect of young people on standalone curfew or attendance centre orders.   Transitions are crucial – they often mark points where engagement from or contact with young people is lost. The primary focus during transitions should be the need to understand the needs and risks in the young person’s situation rather than implementing the logistics for or mechanics of the transfer.  The adoption of the Baton Principle when the need arises to transfer responsibility for orders between authorities: responsibility and activity by the transferring authority should not cease until they have evidence that the receiving authority has acknowledged responsibility for the case and is moving forward on outstanding issues.  Inter-borough transfers of YROs should require a frank exchange of information and professional opinions, in person or by phone, covering a checklist of items but focusing on transmitting an understanding of what can be anticipated about the likely trajectory of the young person’s life.  It is vital that the transfer of orders is viewed constructively by the receiving boroughs and not as something that they should attempt to obstruct.  Knowledge of a young person's likely involvement in more serious offences should prompt an immediate reassessment of contact arrangements and risk.  Non-compliance with court requirements such as referral orders must be taken seriously, actively and promptly pursued and returned to court.   Findings and Conclusions  226. While it is clear that the circumstances and timing of AX’s death could not have been directly predicted by any of the agencies with which he had been in contact, possible opportunities for changing the outcome or influencing elements in this and future cases are explored.  Other conclusions reached from the review of this case are:  a) The origins of AX’s attraction to an irregular lifestyle rooted in street life and criminal activities can be traced from his unsettled childhood which had at times lacked emotional stability and had required him to become self-sufficient from an early age. b) AX was a highly intelligent and shrewd young man who applied his abilities to minimising the intrusiveness of authorities in his life and to securing his goal of financial success based on enterprise mainly around illegal substances and activities.    AX Overview Report    Page 41 of 48  c) AX was provided with outstanding support as a child from School 2.  d) The loss of School 2 teacher support, the limited continuity across the transition to School 3 and his exposure during his daily commute to School 3 to people and sources of suspicious / illegal income were factors in AX being attracted to increasingly criminalised behaviour involving increasingly grave offences. e) The most likely opportunity for successful diversionary work with AX was around the transition between primary and secondary schools: once he was established in School 3, he was adamant in his pursuit of a street-based lifestyle and had a steady income from his trading activities including the supply of cannabis. f) AX’s social intelligence and his ability to manipulate professionals and engineer outcomes was frequently underestimated. g) Although AX was frequently stopped / arrested by Police and suspected of involvement in numerous offences, latterly often involving knife crime, there was rarely sufficient evidence to pursue charges. h) AX was determined to leave home and secure his own accommodation as soon as possible.  He and his mother were resolute in refusing mediation in their strained relationship when offered assistance after he presented as homeless. i) Over the last two years of AX’s life, professionals were generally responding to discrete episodes of anti-social behaviour or individual crises and not fully recognising the patterns and trajectory of AX’s increasingly dangerous lifestyle. j) The failure to complete/update ASSET tools and failure to balance their limitations with the application of professional analysis and judgement led to an insufficiently accurate appraisal of the risks of AX befalling harm or re-offending. k) Errors in professionals’ understanding of responsibility for monitoring and enforcing attendance and curfew orders and failures to instigate breach proceedings in the wake of non-compliance were instrumental in AX avoiding consequences or more restrictive sanctions from the Court. Overall, AX was not served well by the system that was in place to monitor his compliance with court sanctions and to hold him to account if he failed to fulfil his obligations.  l) While AX and some peers had formed a loose grouping which had some affiliation with an established North London gang, this was not a primary driver of his activities. m) AX’s anti-social behaviour in relation to two tenancies and three properties should have been recognised as predictive of a limited capacity to sustain a tenancy in an HMO in Enfield without on-going monitoring and intervention. n) Administrative errors, delays and uncertainties around Enfield YOT's responsibility resulted in AX avoiding scrutiny while subject to an attendance order from August 2013 and in a failure to alert the court he was in breach of that order.    AX Overview Report    Page 42 of 48  o) The risks presented by and to AX from his lifestyle and criminal activity should have been reconsidered by Enfield YOT once the gravity of the offences for which he was sought by Police became known in October 2013. p) Police efforts to arrest AX, who was implicated in serious offences, faltered because he did not show up at Attendance Centre appointments in October /November 2013 and could have taken more account of AX's family's knowledge of his lifestyle. q) In the last two months of his life, AX had gone to ground, including abandoning his tenancy in an attempt to avoid arrest by Police and possibly avert conflict with older acquaintances involved in criminal activity.   227. AX's case was a devastating tragedy resulting in the loss of a young man of extraordinary ability and potential.  The consequences for his family will endure with them for the rest of their lives.   AX's death has affected many people who knew him, staff who taught him and professionals who encountered him. They are united with his family in seeking to ensure that learning from this death and from other violent deaths of teenagers is used to bring about effective interventions at community and national level as well as in individual casework, to prevent more young people dying on the streets of North London.   228. In the course of this review it became apparent lots of public sector, voluntary organisation faith community and individual effort is taking place to work with young people on dangerous lifestyle pathways and with young people at risk of following those routes, through education, research, information and through creative, sporting and learning opportunities.  The LSCBs who have worked on this review believe they have a key role in promoting collaborative work and innovative work to reduce teenage violence fatalities in North London.       AX Overview Report    Page 43 of 48  Recommendations from the Serious Case Review of the death of AX Agency/Agencies will take responsibility for refining the Action Plan, resolving issues and reporting evidenced progress to both LSCBs at 6 monthly intervals until there is agreed sign-off on the completion of actions. The goals of Agency Level recommendations are to:  address systemic weaknesses   strengthen practice   enhance the effectiveness and responsiveness of services  improve individual case work  It is acknowledged that none of the issues or deficits identified in standards of practice highlighted by the review of AX’s history, engagement with agencies and death, contributed directly to his death.  The improvements and actions suggested here aim to affirm good practice standards amongst professionals who work with young people in north London and who are concerned to divert them from street crime and violence in north London.  A number of matters have already been addressed by agencies following on from internal scrutiny in the aftermath of AX's death. Barnet YOT, in particular, has made a number of improvements in systems and practice. These are Agency Actions Already Instigated as Result of this Review  Barnet YOT/MPS Bail to Return dates/ outcomes now recorded on record Barnet YOT/YPDAS Where referral made to YPDAS, young person's attendance and failures to attend now rapidly reported to YOT Barnet YOT Critique of casework and supervision: two workers providing /managing assessment and supervision of court order below acceptable agency standard are no longer working for agency Attendance Centers Failures to attend on short referral orders: no Compliance Panel stage required now so young person's return to court for breach of order can be expedited Barnet YOT/Housing Agencies New protocol means where a young person is undergoing assessment by Housing, and they have recently been completed a supervision order, YOT will participate in joint assessment where to share information and assist in development of full understanding of young person's needs and circumstances. Barnet YOT Court officers now record who attends court with young person Barnet YOT Case closing checklist now completed before manager sign-off on orders which are finishing.  Practice is now that caseworker must evidence their liaison with a range of agencies and their analysis of information received at that stage before manager will agree closure of case.     AX Overview Report    Page 44 of 48  Barnet YOT Case transfer when young person moves to another area: confirmation now sought from receiving area that they have been notified of the young person's presence. Attendance Centers/Barnet YOT YOTs to be notified of all missed attendances. Barnet YOT will do all warning letters and all breach actions. Enfield YOT  An audit has been undertaken of YOU cases to ensure enforcement of Court Orders is being followed  A meeting was held with the Attendance Centre lead to ensure the protocol was up to date and understood.  Enfield Community Safety is now notified of all case transfers into the borough     AX Overview Report    Page 45 of 48   Recommendations for Further Actions by Agencies Agency/Agencies Issue  Action  Outcome Sought Timescale Notes Barnet YOT and MPS; Enfield YOT  Barnet CSC, Enfield CYPS Police intelligence about escalating levels of AX's criminality, increasing gravity of his offences, associations and serious matters for which he was wanted for questioning not available to YOT and was not always available to police officers dealing with AX on street or staff at Attendance Centre. Agencies to review mechanisms for sharing intelligence and provide recommendations to respective agencies, leading to a strategy going to LSCBs. Review to consider extent to which MASH and other arrangements meet this need, what other measures, if any are required, whether co-location of staff enhances information exchange LSCBs to be satisfied that arrangements for sharing of intelligence on young offenders are suitable and effective in alerting  all agencies to escalation of offending/dangerous behaviour  Report to LSCBs by Mar 2016 Sharing intelligence is critical to assessment of risk and to ensuring intervention for effective supervision of young offenders and accurate reporting and suitable recommendations to court.  Barnet YOT, Enfield YOT, Educational Establishments Information obtained by Barnet YOT from Schools was not as comprehensive as it could have been and focused on AX's attendance. Schools had significant information about AX's history, associations, commercial enterprises, drug use/supply and lack of engagement Meeting to be convened of YOT representatives in each area with educational establishment representatives to look at how significant information staff in schools and college had about AX could have been secured and used  Agencies and LSCB to be satisfied that processes for liaison with School are as effective as possible bearing in mind pressures on both YOT staff Report to LSCBs by Mar 2016 YOTs may want to look at data collection tools, at need to go back to junior schools to understand young person's history. Schools may want to look at liaison arrangements.    AX Overview Report    Page 46 of 48  and teaching staff Barnet YOT Enfield YOT Standalone order requirements. Issue has been raised with Youth Justice Board YJB guidance being reviewed. LSCBs to be kept appraised of progress Report to LSCBs - update on progress made by YJB by July 2016 LSCBs can add weight of their concerns if this issue is not promptly addressed by YJB Barnet YOT/Enfield YOT Need for smooth transfer arrangement for oversight and supervision of young people on court orders moving between boroughs Teams to work together to ensure mechanisms allow not only prompt transfer notifications and acknowledgement of notifications but also enable effective transfer of intelligence and maintenance of effective supervision relationships Both agencies content that transfer arrangements work in best interests and to advantage of young person LSCBs to be updated on arrangement by July 2016     AX Overview Report    Page 47 of 48  Attendance Centers Inconsistencies in recording practice and in sharing of information with YOTs about missed appointments and general degree of engagement Attendance Centre and YOT representatives to address performance issues. Attendance Centre staff to attend learning event from this review Agencies content with standard of recording and transfer of information. Report to Board on operation and liaison arrangements by March 2016  Educational Establishments/Police/Children's Services/YOTs Reviewing mechanisms for ensuring support for vulnerable young people during transitions between primary/secondary school and school/college, particularly in case of boys at risk of being drawn into offending/violence/gang activity.  Early identification and intervention are crucial to discouraging young people from dangerous lifestyle trajectories.  Transitions are key times in young people's lives when more intensive support may be needed.  A short life multi-disciplinary task group (mainly frontline staff) should look at this issue and identify policy and resource issues that need consideration along with examples of good practice that can be built on.  Better identification of young people who may be at risk and earlier intervention.  Innovative approaches to support of young people through transitions Report to Board on proposals and on any strategic issues to be taken-forward by Boards by March 2016  Children's Services, Housing, Legal Services Ensure legal duties arising from Children Act are fulfilled in relation to all cases of young people (16-17) presenting as homeless Determine resources required for legal services teams in both boroughs to undertake a joint sampling exercise in respect of such cases managed in past two years. Exercise would consider if S20 options properly considered and if S17 obligations fulfilled. Feasibility of exercise determined and resources allocated as needed. Report to Boards by June 2016     AX Overview Report    Page 48 of 48  MPS Levels of distrust and disengagement amongst young men from minority ethnic groups, specifically young black men  Case for resourcing of Policing for community work and engagement work in schools, pre-schools and other settings to build relationships and shift attitudes.   Strategy report to LSCB Report to Boards by Sept 2016      Today, 11th January 2016, sees the publication of the Serious Case Review (SCR) report for ‘AX’ which involved the death of a 17 year old male who was stabbed following an altercation with three other young men at the end of 2013. AX was living in Enfield at the time of his death and was known to Enfield Youth Offending Service and so Enfield Safeguarding Children Board have undertaken the review and commissioned the report. AX however, spent much of his life in Barnet and was engaged with a number of agencies there and so throughout the process of the review Enfield Safeguarding Children Board worked closely with colleagues from Barnet to ascertain what happened and when and to identify how we can collectively learn from the premature death of this young man.    The events covered by this report took place over two years ago.  Agencies have not awaited the completion and publication of this review before tackling the issues arising from these events and many of these recommendations have been identified and addressed already.  The report concludes that the circumstances and timing of AX’s death could not have been directly predicted by any of the agencies with which he had been in contact.  However, possible opportunities for changing the outcome or influencing elements in this and future cases have been explored thoroughly. A number of findings have been identified and listed toward the end of the report. Some of these findings are listed below;   AX was a highly intelligent and shrewd young man who applied his abilities to minimising the intrusiveness of authorities in his life and to securing his goal of financial success based on enterprise mainly around illegal substances and activities.  The origins of AX’s attraction to an irregular lifestyle rooted in street life and criminal activities can be traced from his unsettled childhood.  The most likely opportunity for successful diversionary work with AX was around the transition between primary and secondary schools: once he was established in School 3, he was adamant in his pursuit of a street-based lifestyle and had a steady income from his trading activities including the supply of cannabis.  AX’s social intelligence and his ability to manipulate professionals and engineer outcomes were frequently underestimated.  Although AX was frequently stopped / arrested by Police and suspected of involvement in numerous offences, latterly often involving knife crime, there was rarely sufficient evidence to pursue charges.  Over the last two years of AX’s life, partnership agencies were generally responding to discrete episodes of anti-social behaviour or individual crises and not fully recognising the patterns and trajectory of AX’s increasingly dangerous lifestyle.  The report helpfully identifies a number of actions that have already been undertaken in both Enfield and Barnet agencies in response to this report and its findings. These include;    In Barnet there is a new protocol to ensure that where a young person is undergoing assessment by Housing, and they have recently been completed a supervision order, YOT will participate in joint assessment where to share information and assist in development of full understanding of young person's needs and circumstances.   Attendance Centres : For failures to attend on short referral orders there is now no Compliance Panel stage required now so a young person's return to court for breach of order can be expedited   Court officers now routinely record who attends court with a young person   A comprehensive audit has been undertaken of Enfield YOU cases to ensure enforcement of Court Orders is being followed  There are a number of recommendations included at the end of the report. The ESCB is assured that much has already been done to address them and is committed to continuing to monitor and review their implementation. The recommendations are complemented by more detailed, agency-specific recommendations, identified during the process of the review which have been incorporated into detailed action plans. There are some wider recommendations, aimed at influencing factors which draw young men to street violence and criminal behaviour, which will be taken to the London LSCB chairs network for further consideration.   Geraldine Gavin  Independent Chair, Enfield Safeguarding Children Board   Contact: For all general queries about the Overview Report and the SCR process Grant Landon      Enfield LSCB Business Manager    Grant.Landon@Enfield.gov.uk      0208 379 8337       