Significant and sustained sexual abuse of two female siblings by their step-father. Step-father was convicted of a number of offences in June 2013, including: rape and making an indecent photograph. He had a previous conviction for a sexual offence against a 7-year-old-girl and was placed on the sex offender register from 2000-2005. An initial assessment was made when step-father moved into family home in 2007. A number of further assessments were made between 2007 and 2012, following referrals from police, schools and children's father. School made several referrals identifying concerns about relationships and behaviours within the family. In 2012, siblings' brother was referred to the NSPCC for assessment and behaviour work. After reviewing the family case history, the NSPCC persistently raised concerns over: robustness of risk assessments; mother's capacity to protect the children; risks and implications of children's behaviour; and neglect issues. Following a review of the case and further investigation, step-father was arrested. Issues identified include: misplaced assumption of mother as a protective factor; over-reliance on the children making a direct disclosure; and insufficient knowledge and understanding of sex offending, offender profiles and risk. Makes various interagency and single agency recommendations covering children's services, the Local Authority, police and probation services.
      
 Title:  Serious Case Review CN10. LSCB: Devon Safeguarding Children Board Author: John Kirby Date of publication: 2014  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.                                        Serious Case Review CN10  April 2014    1  SERIOUS CASE REVIEW CN10: OVERVIEW REPORT    Contents   PAGE 1. Introduction 2 1.1 Summary of circumstances leading to Serious Case Review 2 1.2 Terms of Reference 2 1.3 Methodology 3 1.4 Agencies / Contributors 3 2. Summary of Findings 4 3. Facts 6 3.1 Family Composition 6 3.2 Outline Chronology 6 3.3 Agencies involved with family and recorded levels of awareness 9 3.4 Agencies who had previously worked with Step Father 11 3.5 Ethnic Cultural and Equality Issues 11 4. Analysis 12 4.1 Events, decisions, associated actions and extent to which different decisions and actions would have led to a different course of events 12 4.2 Views of family members 19 4.3 Extent to which Mother understood risks posed by Step Father and the appropriateness of steps she took to protect her children 20 4.4 Involvement of Father with the children and his knowledge of the risks that Step father posed to the children 22 4.5 Examples of Good Practice 23 5. Learning 23 5.1 Social Work and Multi-Agency Assessments 23 5.2 Child’s View and Experience 25 5.3 Rule of Optimism 25 5.4 Sharing Key Information 25 5.5 Full Picture of Circumstances for child and Family 26 5.6 Consideration of all adults in household and beyond 26 6. Recommendations 28 6.1 Recommendations for improving Safeguarding and Systems 28 6.2 Recommendations for Individual Agencies 29        2   1 Introduction:  1.1 Circumstances leading to SCR:  In June 2013, Step Father was convicted and imprisoned for sexual offences against his two stepdaughters. He had admitted five counts of rape in respect of one child in the household, four counts of making an indecent photograph or pseudo image of a child, one count of taking an indecent photograph or pseudo image of a child in respect of one of the children and two counts of sexual activity with a female child (aged 13 – 17 years and offender aged 18 or over) in respect of the other child in the household.  The Step Father had a previous conviction (in 2000) for a sexual offence against a girl aged 7 years in1999 for which he had received a hospital treatment order (one year) and a probation order (three years). He had also been placed on the sex offender register from 2000 until 2005.   The family were referred to the Children’s Social Work team for assessment in 2007 when it was learned that Step Father had moved in with this family. After the initial assessment no action was taken to prevent Step Father living in the family and he subsequently married the mother the following year.   A series of further concerns were investigated over the following five years but the Step Father remained in the home throughout until his arrest in the latter part of 2012.  An internal audit of Devon County Council Social Care files was completed by an independent social worker early in July 2013 and identified a number of significant issues relating to the quality of practice in the protection of these children.   The Serious Case Review Group of the Devon Safeguarding Children Board considered this independent audit and the circumstances surrounding these offences and concluded that the criteria for a serious case review were met in that; “a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.”  1.2 Terms of Reference:  This Review considered all agency involvement with this family from 1999 when Step Father committed the sexual offences against a child but in detail from 2007, when he moved into the family home, until his conviction in June 2013.  There is an older brother, who is now an adult but was a child in the household during the period that the abuse took place and was consequently included in the scope of this review.    3    The Review considered whether any agency was, or should have been, aware of the child protection concerns in relation to these children and if so, whether these concerns were responded to in accordance with that agency’s child protection policies and procedures and established good practice.  The Review examined the extent to which agencies were aware of Step Father’s presence in the family and the risks that he posed to these children.  The Review looked at the extent to which the children’s Mother understood the risks that the Step Father posed to her children and the steps she took to protect them.  The review established the level of the Father’s involvement with the children during this period and his knowledge of the concerns that Step Father posed to the children.   The review was asked to take account of relevant lessons learned from research.  1.3 Methodology:  In line with “Working Together” 2013, consideration was given to the type of review required. Given the historical nature of the circumstances, the Social Care Institute for Excellence (SCIE) methodology was not considered appropriate. The ordinary method of undertaking a Serious Case Review (SCR) was also considered but given that many of the staff concerned had left their respective agencies, it was decided that it would be difficult to complete Individual Management Reviews (IMR’s) Consequently, it was decided that a thorough file review of the period outlined with the addition of permissive interviews with both the parents would provide sufficient learning to enable the requisite improvements.  Both Parents were invited to contribute to the review and provided with clear terms of reference and outline of the nature of their involvement.  1.4 Agencies / Contributors:  Devon County Council (DCC):   Director of Safeguarding,   Senior Manager, Children’s Social Work,  Senior Manager, Safeguarding and Children’s Specialist Services,  Professional & Governance Lead (Social Work) Babcock LDP (Education):   Education Safeguarding Officer Devon and Cornwall Police:   Detective Sergeant  Devon Probation Service:   Assistant Chief Probation Officer  4  Virgin Care Ltd. (Public Nursing and Integrated Children’s Services):   Child Protection Lead  NSPCC:   Inspector Devon Partnership NHS Trust (Mental Health Services):   RCA facilitator  Family Members:   Father and Daughter (2) were both interviewed as part of the independent review.  Mother, Son and Daughter (1) were invited to contribute but did not respond and so elected not to do so.    2 Summary of Findings:  The local authority did not effectively fulfil its duty to make enquiries into whether the children in this family were likely to suffer significant harm.   There appears to have been an insufficient knowledge and understanding of sex offending, offender profiles and the resultant risks to the children in the household by the investigating social workers and their front-line managers. This appears to have influenced the assessment of risk in 2007 which in turn had implications for the subsequent handling of the case.  The records containing information about Step Father, which were available in 2007, and could have clarified both the level and nature of risk posed by him, were not accessed. This important information did not inform the first or subsequent assessments of action required to protect the children.  Step Father was not interviewed as part of the first initial assessment and the significance of him denying responsibility for his offence, and Mother believing his explanation, were not appropriately factored into the assessment of risk.  There was an over-reliance on Mother being the protective factor for her children, despite her overt statement that Step Father had pleaded guilty to avoid a custodial sentence, and her own health issues, which progressively appear to have impacted on her ability to be able to supervise the interactions between Step Father and the children.   The original omissions meant key information about risk did not inform casework and planning. It set a pattern for the handling of the case until 2012. Subsequent referrals and concerns were dealt with, to some extent, as separate issues. Key linkages, which could have given insight into the abuse being perpetrated, were not made between the various signs and symptoms being displayed behaviourally by the three children. There was an over reliance placed on one of the children making a  5  direct disclosure and there is little to suggest that the voices of the three children were comprehensively sought or heard.  Opportunities were missed to at a number of points to take a fresh look at the case and consider the implications of the children’s behaviour until the NSPCC became involved in 2012. In the subsequent assessments (2008 / 2009 / 2010) Step Father’s role in the household was considered mainly via the testimony of others. He absented himself from interviews and was not proactively sought out by social workers until 2011.  As with many earlier serious case reviews, this case file review points to information being held in disparate places and to no single agency or collaboration of agencies understanding the full picture. Referrals were made, and assessments followed, but these appear limited to the immediate concern and were not set in the wider context of the shared experience of what it was like to be a child growing up in this family.   It seems that the schools and others involved the social work services and the police appropriately, but the investigation / assessment that followed was not broad enough and resulted in inadequate safeguarding. The outcomes of some Initial Assessments were either not shared or, not fully shared with other agencies and this may have impaired multi-agency understanding of risk.   There was an over reliance on, and insufficient challenge of, Children’s Social Work by the other agencies until the involvement of and, external challenge from the NSPCC led to more comprehensive background checks being undertaken and to action to protect the remaining daughter in the household. However, on-going services to support the Son were not identified or provided.  Mother was aware of Step Father’s conviction in 2000. She told social workers that she accepted his explanation that he had only pleaded guilty to the offence, after legal advice, in order to receive a Treatment Order rather than a prison sentence. Her understanding of the risks he posed to the children is not clear from the case records. Social work assessments accepted her assurances that she was supervising Step Father’s contact and interactions with the children, and so protecting them from abuse. She told social workers that she had left the children in the sole care of Step Father whilst in hospital in 2008 and was given repeated advice that she should not leave the children in Step Father’s care. At times she raised, and then withdrew, direct concerns about Step Father’s behaviour and interaction with the children.   Professionals did not involve Father or inform him about Step Father’s conviction in 2000 and the potential risks he posed to the children. Consequently, the protection Father might have offered his children was not explored. Father’s level of involvement with his children was limited until Daughter 1 went to live with him in 2011. There is a record of Father contacting the Children’s Social Work team with information about Daughter 2 being held down by Step Father in 2011.   6  3 Facts:  3.1 Family:  Father (lived away from family since 2007) Mother Son Daughter 1 Daughter 2 Step Father (in family home from 2007 until 2012 but now serving a custodial sentence)  Older daughter (Father’s older daughter from a different relationship and who lived separately throughout)  3.2 Outline Chronology:  Pre 1999:  Son and Daughter (1) were born in 1995 and 1997 respectively.  Family supported from 1997 onwards through Joint Agency Team (a multi agency team, which included some Devon CC social work staff and providing services for children with special needs).  1999:  Step Father arrested and charged with indecently assaulting a girl (7 years old). He resided in a specialist hospital on bail from October.  2000:  Daughter (2) was born in 2000.  Step Father pleaded guilty and was sentenced for offence. He received a Probation Order, (three years duration) with a one year Treatment Order. His name was placed on the Sex Offender register for 5 years. The Probation Service was given latitude to extend the length of the Treatment Order.  2000 – 2002:  Step Father participated in an inpatient treatment programme in Hospital A risk assessment completed in the course of his treatment concluded that he presented a moderate risk of re-offending and highlighted a risk area with pre-pubescent girls. He was assessed as having a mild learning disability;  Step Father was discharged from hospital in March 2002 and placed in specialised / supported housing;  Further “relapse – prevention” work with Step Father undertaken by the Probation service.  2003:  Probation involvement ended on 14.1.03.  7   2004:  A Fair Access to Care Services (FACS) assessment was completed in respect of Step Father by Adult Social Care but his need was assessed as low and no services provided.  Psychiatrist saw Step Father for a final time in October and offered a final appointment in spring 2005, which he did not attend.  2005:  In April 2005 Step Father’s Sex Offender registration ceased.  2007:  In February / March Mother and Father separated and Father left the family home.   Reports of Son being bullied at school;  At some point afterwards Mother started a relationship with Step Father (exact date not clear);  In October information was received by Joint Agency Team that Step Father was staying in family home, a referral was made to Children’s Social Work Team on 6.11.07 and the first Initial Assessment (IA 1) completed on 12.11.07.  2008:  In August a second Initial Assessment (IA 2) was undertaken following information that Mother was in hospital and had left the daughters in sole care of Step Father. The case was closed after advice had been given to Mother not to leave the children in care of Step Father.  In November 2008 Mother and Stepfather married.  A third Initial Assessment (IA 3) was completed on 24.11.08 following concerns expressed by the school about changes to the behaviour of Daughter 1. The case was again closed with the school being asked to complete a CAF (Common Assessment Framework).  2009:  On 12.2.09, on completion of a CAF, the school re-referred the case with a series of concerns about relationships and behaviours within the family some of which had been outlined by Mother. A Strategy Meeting (SM 1), an Initial Assessment (IA 4) and Section 47 (S 47 1) enquiries followed in which no direct disclosure of abuse was made and the case was closed.  During the autumn the father moved away from the area to another part of the UK.  2010:  Police 121a notification about Daughter 2 having stolen money;  In November there was a Police referral re Daughter 1 having sexual intercourse with a boy aged 13 whilst watched by another minor. There were also continuing concerns about the Son’s behaviour and interests.  8  Subsequent to the ensuing Initial Assessment (IA 5) the case was opened and a Student Social Worker undertook 1:1 work with Daughter 1;  In December the Son complained to his respite carer about being hungry at home.  2011:  On 27.1.11 a strategy meeting (SM 2) was convened following school concern about Son’s behaviour and actions at school, Mother’s reported depression and concern about the nature of material potentially being held on computers within the family home;  On 8.2.11 a follow up strategy meeting (SM 3) was held to discuss concerns (as above) and the neglect of all three children. The primary school reported Daughter 2 breaking down in front of class and saying “life is terrible” and the Police had followed up a report of the children being left alone / locked out of the house. After careful consideration police concluded that there was insufficient evidence to obtain a search warrant for the premises;  Core Assessments (CA 1) were completed on all three children in April and a Family Intervention Worker started working with Mother to improve the state of children’s rooms and to ensure that they had regular meals;  On 17.5.11 Daughter 1 told her school that her sister (Daughter 2) had been crying as a result of Step Father holding her down and threatening to smack her. A strategy meeting (SM 4) led to a single agency Section 47 enquiry (S 47 2) being undertaken by Children and Young People’s services and the family was followed up as a “Children in Need” case. Father had also made a referral regarding this in the preceding week;  In June rows between Daughters 1 & 2 about clothes resulted in Mother intervening physically between them both. The Police investigated and concluded Mother had used reasonable force. The relationship between Mother and Daughter 1 broke down and, after a brief period staying with her older half sister, Daughter 1 went to live with Father. Children and Young People’s services then closed the case.  2012:  In February 2012 Occupational Therapy assessment of Mother noted that she reported having suffered from back and mobility problems since her adolescence;  In June a referral to the NSPCC Treatment team (for assessment and behaviour work with Son) was made by the Joint agency Team.  In July a strategy meeting (SM 5) was convened after NSPCC shared concerns with Children and Young People’s services and the Joint Agency Team about the robustness of assessments and the safety of Daughter 2 in the household. A further Initial Assessment (IA 6) was completed in respect of her.  In August / September relevant background information was sought from the Forensic Psychiatric service and Probation.  In October a further strategy meeting was held (SM 5), a Section 47 (S 47 3) investigation was undertaken in relation to Daughter 2 and further Core  9  Assessments (CA 2) were completed for Daughter 2 and Son. The NSPCC commenced a specialist assessment in respect of Son.  A Legal Threshold meeting was held followed by an Initial Child Protection Case Conference on 24.10.12.    A few days after the case conference Daughter 2 moved out of the family home to live with her father.  On 12.11.12: the Police obtained a search warrant to search for material believed to be held electronically by a member of the household. They visited the family household and arrested Step Father after he had attempted to conceal pornographic images of children. A Police investigation into Step Father then followed.  2013:  In January the Child Protection Plan for the Son ended.  In February the Son’s case was closed by Children’s Social Work Team;  Step Father was charged and pleaded guilty to sexual offences against his two stepdaughters;   In June Step Father was sentenced.   3.3. Agencies involved with the family and levels of recorded awareness  Key agencies known to be involved with the family at the point at which Step Father moved in to the family and beyond were:  Devon County Council Children’s Social Work Team (from 2007)  Joint Agency Team – working with Son (involved from 1999 through point of notification of Step Father moving into the family home and beyond)  High School  Primary School (for Daughter 2)  School Nursing services with all three children throughout their childhood  Devon County Council Adult Social Care – due to Mother’s longstanding medical needs (from February 2012)  Police (in 1999 / 2000 and from 2007)  NSPCC – to work with Son following referral from Joint Agency Team on 20th June 2012  Further Education College (for Son)  The Children’s Social Work Team were notified by the Joint Agency Team that Step father had moved into the family home in October 2007. A DCC Chronology in respect of Daughter 2 indicates that in November 2007, the head teacher of the school was aware of the situation and would monitor the children and report any concerns immediately. It is not made clear whether the school records were accessed to provide background information to the family assessment. On at least four occasions during the period 2007 to 2010, the High School referred their concerns for the children, and due to concerns regarding  10  neglect of Daughter 2 a referral was also received from the Primary School (17.02.2011). The Further Education College were involved at the point of the strategy discussions in 2012 (July and October) and by that time had been managing concerns regarding Son’s behaviour in college. The college and High School had the full information as far as was shared with the participants of the strategy meetings. The Joint Agency Team (JAT) was involved in supporting family as a result of Son’s special needs and behaviour over a considerable period of time. They referred the family for an Initial Assessment in 2007 when they became aware of Step Father moving into the family home and were involved in subsequent referrals and strategy meetings they also referred Son to the NSPCC for help in dealing with his behaviour.   In October 2012, the police reported that their chronology was very similar in content to the information gathered by the NSPCC from DCC records, and reported to the strategy discussion in that month; possibly indicating that whilst the information was held, it had not been assimilated or triggered direct action or raising of concerns. Interagency working between the police and social work services is evidenced, and some joint visits recorded, but shared analysis of the implications of the information held by both agencies is inadequate. The police had not however been informed of the third Initial Assessment (in November 2008) and the likelihood that Mother had been in hospital again at that time with the children presumably left in the sole care of Step Father.  The School Nurse service were involved with all three children throughout their childhood and provided appropriate levels of universal and targeted service to meet the health needs that were identified. School Nurses were not contacted by the Children’s Social Work team regarding the risks posed by Step Father until November 2008. School Nurses received Police 121a notifications, regarding incidents about the children, from June 2010 onwards but the service appears not to have been involved in multi-agency meetings until 2011.   The NSPCC appear to be the first agency to have raised concerns about the ‘assessment of safeguarding’ and to have gathered the information together in a systematic way set against the known signs and symptoms of sexual abuse. In this way, they provided the recognition that the children had potentially been ‘disclosing abuse’ indirectly over a period of time, without actually making overt disclosures. This is in keeping with the NSPCC research of 2010, which includes a finding that: “Children may disclose sexual abuse by directly telling someone about it. They may also disclose less directly, sometimes unintentionally, over a period of time, through a variety of behaviours and actions, including discussions and indirect non-verbal cues. In this respect, disclosure should be seen as a process that occurs over time."1                                                         1 Reference: Children and young people disclosing sexual abuse: An introduction to     research, Debra Allnock, Child Protection Research Department, NSPCC, Fresh Start April 2010, p1, http://www.nspcc.org.uk/Inform/research/briefings/children_disclosing_sexual_abuse_pdf_wdf75964.pdf  11  3.4 Agencies who had previously worked with Step Father  Several agencies were involved in work with Step Father prior to his involvement with the family in 2007:  Hospital – October 1999 – March 2002 and transfer to Learning Disability Medical Services. Step Father had out patient follow up until 2005;  Probation Service (for period of Probation Order 2000- 2003)  Devon County Council Adult Social Care – 1999 - 2005  The Forensic Psychiatric service had assessed and treated Step Father. The risk that he presented was assessed and documented whilst he was an inpatient. The following information was recorded in relation to risk:  Risk Factors: Learning Disability (mild degree), Dependent personality traits and Low self-esteem;  Specific mental health factor: Anxious emotions predominate. Threats of self harm and harm to property (not people);  Early indications of relapse: Interpersonal relationship problems;  Targets: Risk of further sexual abuse to minors, especially pre-pubescent girls;  Identified “high risk” situations: Child minding, even with adults nearby.  Multi-agency Public Protection Arrangements (MAPPA) meetings were held on a three monthly basis and Step Father was followed up by Probation service on his discharge from hospital in 2002. There is evidence on the Children’s Social Work team file that in 2012, as part of the assessment of the family, an approach was made by the Social Worker to Devon and Cornwall Probation Trust who confirmed that Step Father’s community order had expired on 13th January 2003 but that all records would have been disposed of if an offender did not commit any further offences within a six year period. As there was no record of such an offence by Step Father, then no historic paperwork was available from that source.  A Devon County Council paper file exists for Step Father, and was researched as part of this review and throughout this file, there is evidence that whilst Step Father undertook work on his offence whilst in Hospital, on discharge there remained clear statements of potential risk posed by him, specifically towards pre-pubertal girls.  There is no evidence that this was read at, or subsequent to the 2007 notification.  3.5 Ethnic, Cultural and Equalities Issues: No ethnic or cultural issues were identified.  Father was not informed of potential risks to his children or actively considered in assessments until 2012.      12   4 Analysis:  4.1 Events, Decisions and Associated Actions and extent to which different decisions and actions would have led to a different course of events:  Significant opportunities to protect the children were missed in the response to the initial information about Step Father moving into the family home. An Initial Assessment (IA 1), completed on 12.11.07, set the pattern for the Children’s Social Work team handling of the case and the fundamental omissions made at the time, were not addressed until after the NSPCC raised concern in 2012.   The Community Care Worker in the Joint Agency Team ascertained the basic information and appropriately raised concern with their Practice Manager. An initial visit was made by a social worker and the community care worker from the Joint Agency Team. It clarified that Step Father was moving in and asked about Mother’s knowledge of and attitude towards his offence in 1999. Step Father denied committing the offence and said he had pleaded guilty to avoid a custodial sentence. Mother said that she believed Step Father. During this interview Mother also outlined how recently the younger daughter had got into the shower naked with Step Father and cited Step Father getting out and telling Mother about it as an example of how she and Step Father were acting protectively. A referral was then made to the Children’s Social Work team and the Police. In doing so the Community Care Worker also related a separate incident when she had been visiting when the older daughter had got changed for something and stripped off in front of her.  At the point of learning that Step Father was about to move in with the family, the Children’s Social Work Team knew (from the original notification) that he had a conviction against a child, had been treated in Hospital and been the subject of a three year Probation Order. The significant opportunity to robustly gather and evaluate the available background information was missed. As a consequence detailed background information in relation to Step Father’s offence, his subsequent response to treatment, and associated risk assessments was not obtained from either the Probation Service or the Forensic Psychiatric Service. The Devon CC Adult Care record, which also contained important and relevant information, was not accessed or read. Consequently, the assessment was started without information about the level and nature of risk Step Father had been assessed as posing to children, and to pre-pubescent girls in particular. It seems that it took until 2012 before the then social worker sought permission to access the historical files held by the Hospital and Probation service in respect of Step Father. The DCC Adult care records appear not to have been accessed at any point. These records, could have clarified both the level and nature of risk posed by Step Father, and so this important information did not inform the first or subsequent assessments.   13  The opportunity to convene a strategy meeting to focus on the risks to the children and give consideration to instigating Section 47 enquiries was not taken. The applicable national guidance at the time of the original notification would have been the 2006 version of ‘Working Together to Safeguard Children’, which sets out expectations on local authorities: ‘The safety and welfare of children is the responsibility of the LA, working in partnership with other public organisations, the voluntary sector and service users and carers.’2  With respect to the investigative role, the 2006 Working Together document states: ‘LAs, with the help of other organisations as appropriate, also have a duty to make enquiries if they have reason to suspect that a child in their area is suffering, or likely to suffer, significant harm, to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.’3  This guidance should then have been applied in relation to the initial assessment carried out with regard to the children. In addition, ‘Every Child Matters’4, a significant government Green Paper, published in 2003 with its focus on five key outcomes for children was a key influence on social work practice at that time.  On a local level, in 2006 agencies were signed up to the South West Child Protection procedures which reinforced the need for interagency working and sharing of information to protect children.  In carrying out the Initial Assessment the social worker interviewed Mother but not Step Father. Mother advised that Step Father told her that he had not been guilty, and had only accepted a guilty plea on legal advice in order to avoid a custodial sentence (and receive a hospital treatment order instead). There does not appear to have been a detailed exploration of what Mother actually believed about her partner’s offence.   Given the nature of sexual abuse it is highly unlikely that even a very close level of supervision could have protected the children from Step Father. Social workers however, accepted mother’s assurances that she would ensure inappropriate contact between Step father and her children would not take place. There are references to Mother having taken and continuing to take appropriate steps to ensure that the children are safe. Some of these steps are described and appear to rely heavily on agreements between Mother and Step Father following reported lengthy discussions between them.  Mother also appeared reliant on Step Father’s version of events, and yet her role as an on-going protective influence was given high profile.                                                         2 Reference: ‘Working Together to Safeguard Children’, 2006, HM Government, Section 2.9, page 41 3 Reference: ‘Working Together to Safeguard Children’, 2006, HM Government, Section 2.16, page 44 4 Reference: ‘Every Child Matters’ September 2003, HM Government, Green Paper p 6-7  14  In 2003 Lord Laming in his report in to the death of Victoria Climbie5 coined the phrase ‘respectful uncertainty’ in describing the way in which social workers should view information passed to them by parents… to ensure that an appropriate level of questioning occurred and information was not taken purely at face value. In this case, a decision was made within a week that their mother could provide adequate protection, seemingly based largely on her testimony. It was a major omission that the Step Father was not seen, interviewed or challenged as part of the Initial Assessment on 12.11.07 and it was left for him to contact social worker if he wanted to.   In 2009 the Peter Connelly Serious Case Review which drew attention to the risk implicit of not considering the impact of an unrelated man joining the household and set this out starkly: “One of the potentially dangerous scenarios in child protection is an unrelated man joining a vulnerable single parent family.” 6  Whilst the Children’s Social Work team knew Step father had been sentenced to a Treatment Order there is little evidence of any consideration that Step Father’s treatment in Hospital may have had limited or no effectiveness in reducing his potential risk.  A contemporaneous assessment of the risks he posed does not appear to have been considered. There is little to suggest that the voices of the three children were comprehensively sought or heard.   There appears to have been no consideration of, or contact with, the children’s father to discuss either the concerns about Step Father or the care arrangements for his children. This was a continued feature of the case until Daughter 1 moved to live with him in June 2011 and he was not informed of Step Father’s conviction until 2012 when Daughter 2 moved to live with him as well. As a consequence he was not in position to act to protect his children.  There is little to suggest that the voices of the three children were comprehensively sought or heard as part of the first Initial Assessment. The implications of the daughter’s behaviours as outlined by the Community Care Worker in the referral do not appear to have been considered in the context of the information about Step Father’s conviction.  There is no evidence discussion with other agencies regarding the outcome of this Initial Assessment (other than the Primary School) prior to the case being closed.  The Emergency Duty Team were involved nine months later in August 2008 after the Joint Assessment Team received, and confirmed, information that Mother was in hospital and had left her two daughters in the care of Step Father. There was a local                                                       5 Reference: The Victoria Climbie Inquiry Report, noted in: ‘The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information?’, Sheryl Burton, C4EO, Safeguarding Briefing 3, November 2009, p5.  6 Reference: Haringey Safeguarding Children Board, Serious Case Review: Baby Peter, Executive Summary, February 2009, p.16  15  authority - Police discussion about the appropriateness of an overnight “welfare visit” given that Step Father had sole care of the children. The conclusion was that a more measured multi-agency approach with an in depth assessment of risk including Probation involvement the following day was appropriate since Step Father had been resident in the home for a number of months and Mother was happy that the children were with him. A discussion between the Child Abuse Investigation Team in the Police (CAIT) and the Children’s Social Work Team on 21.08.08 concluded that there would be a single agency response by Children and Young People services.  Whilst the initial decision, in November 2007, not to prevent Step Father living in the home had arguably put a greater onus on services having to prove significant harm, this second referral and the Initial Assessment (IA 2), undertaken on 26.8.08 also missed a number of opportunities.   In advance of the visit there is no evidence of checks being made with Probation as had been envisaged by the Emergency Duty Team – Police discussion.  Given the emphasis the first Initial Assessment had placed on the close level of supervision that Mother had undertaken to provide to ensure that inappropriate contact between Step Father and her children did not take place, Mother leaving the children in the sole care of Step Father (due to her health problems requiring in patient hospital care) raised concern that suitable arrangements had not been made. The opportunity to undertake a more detailed assessment of Mother’s capacity to protect the children and question her assertion that she had no one else able to care for them was not taken. Reports of mother’s health problems were a feature in the case from this point onwards but the significance and implications for her physical capacity to protect the children do not appear to have been taken into consideration when social work assessments and involvements took place.  Mother and Step Father married in November 2008.  Mother could not be contacted at the time of the third Initial Assessment in November 2008 when concerns were reported about changes in the behaviour of Daughter 1 and the record indicates that Mother could not be seen and may have been in hospital again. There is no record of the implications of Mother’s absence being considered or of enquiries about whether she had been in hospital and if so who had been caring for the children. There is no record of Police being informed about this referral or consulted as part of this third Initial Assessment.   The strategy meeting (SM 1) held on 13.2.09 was recorded briefly, there were discussions about the risks of Step Father being in the household, but professionals were conscious of earlier assessments, their conclusions and, the lack of direct evidence regarding significant harm to the children. The section 47 enquiries that followed the strategy meeting focused on the nature of the relationship between daughter 1 and Step Father rather than either the Son’s reported concerning behaviour, or whether Mother was protecting the children adequately. Daughter 1 made no disclosure of an inappropriate relationship with Step Father. She said she  16  was happy at home and liked him. There was a mistaken assumption that Mother was able, and acting to protect the children so that Step Father was not being left alone with them. This remained unchallenged even though there had been direct evidence that Mother had left him with sole care of the girls in August 2008 and, possibly in November 2008. In a subsequent interview on 16.2.09 Mother retracted her concerns even though she had seemingly attempted to protect her children by voicing some concerns about the closeness of Daughter 1’s relationship with Step Father, and so precipitating the referral and strategy meeting. She said she had no concerns about her daughters’ behaviour with Step Father.  During the autumn, the father, who had limited contact with his children, moved away from the area to another part of the country.  The fifth Initial Assessment (IA 5) completed on 8.12.10 following reports of Daughter 1 having sexual intercourse with a 13 year old boy was dealt with appropriately in criminal terms but missed opportunities to consider her behaviour in the light of the wider background / concerns and to reconsider the original concerns re Step Father.  The strategy meetings (SM 2 & 3) held in January and February 2011 considered neglect and a range of behaviour concerns alongside the original risks for the children. Professionals noted that Step Father had remained in the household since 2007 and that a series of Initial Assessments had not identified direct evidence that the children had suffered harm from Step Father. It was mistakenly held that Mother had followed advice to protect the children and not left them in sole care of Step Father.  The Police carefully considered if there was sufficient evidence to obtain a warrant to search the computers in the home but concluded there was not. They asked for further information to be passed to them about the computers in the family home and details of who had access to them.   The Children’s Social Work team started to work with the family as a “Children in Need” case. Core Assessments (CA 1) were completed on all three children in April and a Family Intervention Worker started working with Mother to improve the state of children’s rooms and to ensure that they had regular meals. It was noted that because of her ill health, Mother was often in bed during the evenings. The children were assessed as being young carers on account of their mothers’ health problems and received some support as a consequence.  The Core Assessments were completed but focussed on Son’s behaviour, communication and support to improve standards in the family home. The wish of the children to see their father was noted but there appears not to have been any social work contact with him. If the professionals involved had been more aware of the case history and the risk assessments previously completed in respect of Step Father then the concerns may have taken on a different significance.    17  Following a disclosure by Daughter 1 to her school that Daughter 2 had been crying as Step Father had held her down and threatened to smack her (May 2011), a visit was made to Mother and Step Father. This meeting appears to have given advice to Step Father that he should not ‘parent’ Daughter 2 because of his conviction. It is not clear what message Mother took from this meeting as to what constitutes ‘parenting’ given that few would see holding a child down and threatening her as suitable parenting in any circumstances. There was no record of a discussion with Father about the concerns about Step Father living in the family household at the point his daughter went to live with him.  In April / May 2012 the Mother outlined concerns she had for Son and in the Joint Assessment Team made a referral in respect of Son to the NSPCC Treatment team who then became involved and, after reading and analysing the Children’s Social Work team records, persistently articulated the concerns they had identified from their analysis of the case history including:  The assessment of risk in relation to the children was not robust and had failed to include significant information from Probation and Forensic Psychiatric service about the level and nature of potential risk Step Father posed to them;   Mother’s capacity to protect children needed to be reassessed;  Risks and implications some of the children’s behaviour and attitudes presented;  Neglect issues;  This led to an appropriate and necessary reconsideration of the risks across the summer and autumn and detailed background information was sought about Step Father from Forensic Psychiatric service and Probation.  A further Initial Assessment (IA 6) was completed in respect of Daughter 2 and relevant historical background information was sought. Hospital records were read and a synopsis of these records was recorded. A request was also made to access archived Probation records but this was not possible because it appears they had been destroyed in accordance with the policy to destroy records if no further offence committed within 6 years of cessation of an order.  The reconvened strategy meeting, in October 2012, was in possession of historical information from the Forensic Psychiatric service (that Step father had been assessed as presenting a moderate risk of further sexual abuse to minors with pre-pubescent girls) and information from the NSPCC who had been working with the Son. The lack of current information regarding any assessment of possible risk posed by Step Father was highlighted by the NSPCC who also outlined the reconviction rates for sex offenders assessed as medium risk using a current risk management tool, Risk Matrix7. The risk posed by Step Father was to be dealt with via a risk assessment and the social worker followed up with a home visit.                                                        7 Reference: David Thornton, Risk Matrix Guide 2007   18  The July and October 2012 strategy discussions both took place in the context of the Strategy Discussion Standards (published July 2011 and with reference to the national Working Together document of 2006)8 and appears to have followed due process in so far as the resultant plan progressed to a Section 47 enquiry with a view to a possible Initial Child Protection Case Conference depending on the outcome of the assessment. There was however a divergence of views between the Independent Chair who in their recorded summary thought “…the Local Authority would possibly struggle to convene a child protection conference at this point just in relation to the risk posed by Step Father” and the social worker whose chronology entry in respect of Daughter 2, also dated the same day (5th October 2012) shows “Reconvened strategy meeting. The outcome being to convene an Initial Child Protection Case Conference for Son and Daughter 2.” This is followed on the 12th October by an entry: “Home visit to Mother and Step Father: explained ICPC and concerns for Daughter….. Mother willing to engage and understanding of the concerns, with a safety plan in place. Step Father not wanting to engage and agitated by conversation about his conviction.” This is at odds with the minutes of the plan of the October strategy meeting, which gives the outcome as a Section 47 investigation, which once carried out would lead to the decision as to whether an ICPC would be called. This seeming level of confusion on the part of local authority staff may have influenced the views of other agencies (and indeed that of the family) in being able to understand the mechanism to assess the potential risk and the subsequent proposed plan to deal with any risk identified. The subsequent Section 47 investigation did support the need for an initial child protection conference, which took place on 24.10.2012.  Step Father’s lack of engagement is a feature of the case, with evidence of non-engagement peppered throughout, for example not working with the community team on discharge from Hospital, through to remaining upstairs when workers visited the family household, and having no contact with professionals who were involved with the children. This factor linked with Mother’s seeming ability to wittingly or otherwise convince successive professionals that she was able to protect her children, may be seen in the context of the term ‘disguised compliance’ coined by Brandon et al:  “Apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted. Where parents ...engineered the focus away from allegations of harm, children went unseen and unheard.”9                                                       8 Reference: DCC Way We Do Guide, Strategy Discussion Standards, http://www.proceduresonline.com/devon/childcare/epoint/user_controlled_lcms_area/uploaded_files/wwd-assessment-strategydiscussion.pdf July 2011  9 Reference: Brandon, M. et al.(2008a) “Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005”. Research Brief DCSF-RB023 (PDF). London: Department for Education and Skills (DfES).  19   By 2012, workers would also have had knowledge of the Baby Peter Connelly Serious Case Review which drew attention to the risk implicit in not considering fully the impact of an unrelated man joining the household. The Peter Connelly Serious Case Review set this out starkly: “One of the potentially dangerous scenarios in child protection is an unrelated man joining a vulnerable single parent family.” 10 Step Father’s lack of engagement (whether passive, or more likely active) and his role in the household should have been given more scrutiny, especially as the girls made disclosures regarding his threats towards them, and the Son appeared to be inappropriately influenced by him.  A Legal Threshold meeting was held followed by an Initial Child Protection Case Conference on 24.10.12.  Father was invited to and attended this conference and was subsequently informed about Step Father’s convictions. Shortly afterwards Daughter 2 moved out of the family home to live with her father.  On 12.11.12: the Police obtained a search warrant to search for material believed to be within the family household and whilst searching the premises arrested Step Father after he had attempted to conceal pornographic images of children. A Police investigation into Step Father then followed. Both daughters were interviewed and he was subsequently charged and pleaded guilty to sexual offences against his two stepdaughters.   In January 2013 the Child Protection Plan for the Son ended and the case was closed in Devon a month later after a child protection case conference had been held in the area where Daughters 1 & 2 now live with their father. In June Step Father was sentenced.  4.2 Views of Family Members:  Father and the youngest daughter contributed to this review. The youngest daughter was the victim of significant and sustained sexual abuse. She showed courage in taking part and said in retrospect that two things would have helped her:  Firstly, it would have made a difference if she had felt that her mother would have listened to, and believed her, so that she could have confided in her; Secondly, she wished that social workers would have visited the home and so have seen what things were like rather than seeing her at school.  The Father was very concerned that he had not been informed of concerns about Step father when he should have been. He had said that when the first of his daughters moved to live with him in 2011 she had spoken about some of the issues but that she had been very angry to start with and he hadn’t been sure how much to believe her.                                                                                                                                                          10 Reference: Haringey Safeguarding Children Board, Serious Case Review: Baby Peter, Executive Summary, February 2009, p.16  20   4.3 The extent to which the children’s Mother understood the risks that the Step Father posed to her children and (the appropriateness of) steps she took to protect them.  The children’s mother did not take part in the review and analysis is based on the management reviews submitted.  Step Father informed Mother of his conviction for sexual offences against children in 1999. He told her that he did not commit the offence and that he had pleaded guilty after discussions with his solicitor in order to avoid a custodial sentence. The initial referral on November 7th 2007 indicates that Mother accepted Step Father’s version of events. Mother convinced the workers assessing the situation that was taking appropriate steps protect her children by not leaving them alone with Step Father. It is also noted she was aware of the importance of Step Father acting to protect himself from potential allegations.  The way Mother understood the risk that her husband posed to the children, is not clear from the case records. Her appreciation of the need to put in safeguards to protect her children was limited (e.g. leaving them in Step Father’s care when attending hospital for a planned in-patient intervention) and not helped by social workers failing to be clear themselves about the level of protection required.  The conclusions of the first Initial Assessment signalled to Mother that it was acceptable for Step Father to be in the household and the second assessment in August 2008 did not lead to protective action even though it had been clear that Mother had left her daughters in the sole care of Step Father.  Given the nature of sexual abuse is highly unlikely that even a very close level of supervision would have adequately protected the children from Step Father. Social workers had however, accepted Mother’s assurances that she would ensure inappropriate contact between Step Father and her children did not take place.   At points Mother raised, and then withdrew, direct concerns about her husband whilst also appearing to convince professionals that she understood the need to provide protection and could do so. At other times records show that Mother minimised her husband’s actions as being within her view of what constituted reasonable parenting (e.g. ‘restraining’ Daughter 1 when he pushed her on to the bed and threatened to hit her).   Mother’s own needs do not seem to have been recognised fully, even when there was direct evidence of inadequacies in her care of her children e.g. neglect of Daughter 2, Daughter 1 being in risky situations, and the interaction between Son and his sisters was becoming frightening to them. Mother appears to have been compliant during interactions with social workers and police, but ineffective in  21  managing the care of her children; her situation has echoes of the ‘Emotional Neglect’ model described by Ayre.11  In addition to the doubts regarding her attitude to the offence, also at potential variance to Mother’s place as a protective factor were the reports indicating that her physical health was not good, and that she stated in 2012 (to an occupational therapist) that she had suffered back and mobility problems since adolescence. These problems were such that by 2011 her children were recognised as young carers, and offered information and attendance at a young carer’s group, although their mother did not wish to acknowledge their respective status as carers.   As previously commented, Step Father is noticeable by his absence throughout the case files. When home visits were taking place, he absented himself – remaining upstairs, or showing himself only briefly. He did not participate in any aspect of the children’s school lives. (This is typified in his own case record, which predates his involvement with the family, where he did not engage with the support services set up to assist him on his discharge from Hospital.) This meant that Mother took responsibility for any interaction with authority figures.  Once Step Father had been part of the household for some time with no allegations having been made by the children, it appeared to give credence to his role in the family as far as the professionals were concerned. The marital relationship receives little commentary, and what information there is appears to be from Mother or the children.   There are also examples of Mother seemingly being open to advice from professionals, for example: 1 At the points at which social workers conducted initial assessments and investigations and offered advice re protecting her children; 2 Taking advice from the Joint Agency Team worker (October 2007) in respect of encouraging Daughter 2 to be appropriately dressed when walking around the house, as inadequate boundaries had been put in place by Mother in respect of this; 3 Responding to assistance from a Family Intervention Worker in respect of taking a more active role in caring for her daughters and addressing the state of the house in 2011.  Following a disclosure by Daughter 1 to the High School that Daughter 2 had been crying after Step Father had held her down and threatened to smack her (May 2011), a visit was made to Mother and Step Father. This meeting appears to have given advice to Step Father that he should not ‘parent’ Daughter 2 because of his conviction. It is not clear what message Mother took from this meeting as to what constitutes ‘parenting’ given that few would see holding a child down and threatening her as suitable parenting in any circumstances.                                                       11 Reference: Patrick Ayre, “Understanding and assessing neglect”, Department of Applied Social Studies, University of Bedfordshire, Park Square, Luton,  http://patrickayre.co.uk   22  The repeated closure of social work involvement in the family reduced opportunities for workers to assess Mother’s understanding of the need for, and competence in protecting her children (which was further reduced as key information had not been accessed).   4.4 Involvement of father with his children during this period and his knowledge of the concerns that Step Father posed to them.  The children’s father was interviewed in the course of the independent review and analysis is based on that interview and management reviews submitted.  Father left the family home in February 2007 and he was not seen as part of any of the assessments or enquiries made in the period 2007 – 2011 and so not informed about Step Father’s offences, by the statutory agencies, until his disclosure request to the Police as a result his participation in the Initial Child Protection Case Conference held in October 2012.  Father had limited contact with his children until the older of the two daughters in the household went to live with him in 2011. Father said that Step Father opposed him having contact with the children that it caused tensions and argument and, as a consequence, he did not push for contact.   When the first of his daughters moved to live with him in 2011, Father said she spoke of some of the issues at home but that he was not sure what to believe because she was angry and so he did not make contact with Children and Young People’s services in Devon to seek a detailed discussion.  There is little evidence that professionals involved with the family chose to seek to involve Father in the children’s lives; however, there are multiple references to the children wishing to see more of him, and also to the antagonism expressed by Mother and Step Father to these wishes In February 2011 after father had moved away form the area contact was apparently set at once a year at Christmas.  In May 2011 Father seems to have contacted Children’s Services to report a concern that Step father had pushed Daughter 1 onto a bed and threatened to hit her after an argument occurred between her and Mother. By June Daughter 1 had moved to live with her Father. There is little information as to how this arrangement was set up.   Records do not indicate the level of knowledge that Father had of the children’s circumstances, their daily lives or any risks that the children were exposed to. As described above, on becoming aware of a concern, Father took appropriate action to report it. He appears to have had very limited involvement with the children on a day to day basis; but despite this the children’s testimony suggests that their view of their father was positive.   23  This raises questions as to why Father was not given more opportunity to be involved in the children’s care. However, the context of intermittent contact with the family, without sustained involvement or an understanding of the risks involved combined with Mother and Step Father’s overt antagonism towards increased contact was perhaps influential in this instance.   4.5 Examples of Good Practice:  There were two examples of “good practice” in this case:  NSPCC analysis of historical information (which had been known / available to professionals for several years) to clarify risks to children; and  NSPCC persistence in communicating these concerns.   5. Learning:  This case highlights the importance of front-line practitioners and their managers understanding and assessing the risks posed to children by sex offenders. A synopsis of the findings of five recent serious case reviews12 highlighted similarities between weaknesses in practice in those cases, and those pertinent in this review are set out below.  5.1. Social Work and Multi Agency Assessments  The social work assessment for the children did not adequately take into account known information regarding potential risk posed by Step Father. The multi-agency working was weak, and because the social work team lacked information about potential risk, this appeared to influence the approach taken by other agencies.  ‘Assessment is one of the most critical, complex and controversial areas of child protection practice and approaches to assessment models ranging from the diagnostic, predictive, broad social and bureaucratic, have all been in use in recent years’ (Holland 2011).13    In this instance, the assessment process was inadequate and did not research or take account of known information relating to risk presented by Step Father. The voices of the children were present at intervals, especially when heard by school staff or through individual casework intervention, but their thoughts and feelings are under-                                                      12 Five Recent Serious Care Reviews, Policy Briefing, Tri X, November 2013, http://www.trixonline.co.uk/website/news/pdf/policy_briefing_No-99.pdf  13 Reference: Holland, S. (Second Edition, 2011) Child and family assessment in social work practice, London:Sage  24  represented generally through the records. Experiences of the sibling group as a whole, as being children of this particular household is not evidenced. It appears that incidents were dealt with as individual situations and not seen in the context of the historical whole or the familial whole.  Little predictive assessment if any took place in relation to the potential of abusive behaviour on the part of Step Father. Conclusions appear to have been drawn based on the lack of disclosures or allegations by the children, Step Father’s longevity as a household member and his wife’s supposed ability to protect the children. Signs and symptoms of sexual abuse being displayed by the children were seemingly not recognised until the NSPCC became involved. Recidivism amongst sexual offenders appears to have been downplayed. There are specialist assessment models available for assessing risk by a person with a historical conviction now having access to children, which could have been deployed to safeguard the children.14 Mother’s denial of guilt of her husband could also have been better understood through such a model.  Prior to 2012 some assessment did take place when there were concerns about the children’s behaviour but, this does not seem to have been approached in a systemic way, where consideration of how the whole family functioning could have highlighted the abuse being perpetrated by Step Father. The children’s difficulties did not seem to have been seen in the context of them potentially being a victims of abuse (if not physically or sexually, then emotionally), although the potential influence of Step Father in relation to encouraging sexist attitudes was explored.  Cross agency assessment and sharing of information is little evidenced, and where it did take place, it appears that the indicators of abuse taking place were not fully recognised.  Analysing significant harm is an area of assessment that was given a full review in 2012 by the Department for Education. This review noted that,  “Evidence from a range of sources has identified that although practitioners are good at gathering information about children and families, they find it challenging analysing complex information in order to make judgments about whether a child is suffering, or is likely to suffer, significant harm.” 15  In some respects this is applicable to the situation of these three children as much information was known (although some of it was not accessed early enough) but the analysis of what was known was unsystematic and over-reliant on supposition.                                                        14 Reference: specialist assessment programme, NSPCC, model for assessing risk of reoffending of person with historical conviction now having access to children http://www.nspcc.org.uk/what-we-do/the-work-we-do/priorities-and-programmes/sexual-abuse/good-practice-for-asessment/assessing-the-risk_wda87174.html  15 Barlow, Jane et al, Systematic Review of Models of analysing significant harm, Department for Education, March 2013, p4. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/183949/DFE-RR199.pdf    25  5.2 The child’s view and the child’s experience were not central to the practice or consideration of the case   Records of the views and experiences of all three children are patchy at best and there is little evidence of any direct work with the girls, although an intervention by a student social worker with Daughter 1 appears to have enabled her to have a voice at that stage. The behavioural difficulties and presentation described for each child, particularly in their school or educational environment indicate distress and yet appear to have been seen for example as risk taking (by Daughter 1 in engaging in sexual activity with one boy whilst watched by another) or as a simple indicator of neglect (for example Daughter 2 breaking down in tears at school because her life was so difficult). If viewed in combination, questions would have been more likely to have been asked about the experiences of the children as a sibling group in the home, and whether their behaviours and presentation indicated an experience of abuse.  Later in 2012, direct work was requested for Son through a specialist programme run by the NSPCC, as a result of which the risk posed by Step Father and the lack of information regarding his risk of recidivism was highlighted as an issue.   5.3 Rule of optimism and tendency to start again with each incident or new engagement with the family applied   Optimism was applied to the level of understanding demonstrated by Mother in relation to the potential risk posed by Step Father (her boyfriend and later husband) and also in relation to her ability to safeguard her children. Optimism also appears to have been exercised in relation to believing that a lack of direct allegation from the children meant that all was well, and in seeing Step Father’s long-term involvement in the family as evidence that he posed limited risk.  Each referral in respect of the children appears to have been dealt with as a separate issue between 2007 and 2011, with it being as late as 2012 before a more systematic approach was collated by the NSPCC. This disparate approach may have been compounded by the involvement of two different teams – the Joint Agency Team for Son and mainstream social work teams for the girls.  5.4 Key information was not shared across the professional network involved with the child and family   Key information was not properly sought, and therefore not shared (for example the records held in relation to Step Father’s treatment in Hospital, which clearly indicate potential future risk to children). A letter was sent to Probation service but did not reveal any further information as the records had been deleted. The Hospital was approached and gave permission for the information to be accessed but regardless of this, the information was already available through DCC’s own records regarding Step Father and not accessed.  26  The School Nurse was not informed about the risks posed by Step Father moving into the family until November 2008 and the police were not informed about the third Initial Assessment in 2008. Information that had been known to agencies was not remembered correctly so that the strategy meetings in 2009 and 2011 both were accepted that Mother was acting to protect the children.  5.5 No one had a full picture of all the circumstances of the child and their family  No-one had a full picture of the circumstances of the child and their family – for example, Mother’s health needs and level of dependency was not factored in to the assessment of her ability to be vigilant in protecting her children, which combined with her view of Step Father’s conviction should have given cause for concern.  Domestic violence, drugs or alcohol misuse or psychological problems were features of these cases Records indicate that when angry with both daughters, Step Father had pushed them on to the bed and held them down, raising concerns of possible domestic violence, and certainly inappropriate chastisement, yet this does not appear to have been properly explored, other than to remind Mother and Step Father that she should take the parenting lead.  In nearly all cases there was evidence of resource and organisational, capacity and capability problems in key social care, police and NHS agencies  Whilst the initial decisions made in relation to this family appear to have been taken on the basis of there being no role for social care as there was no evidence of allegations, these decisions will have been made in the context of Devon County Council Children’s Social Work service having undergone a Joint Area Review (JAR – published October 2006)16 which raised issues around consistency, thresholds and evidencing practice and performance.  Organisational issues within that context were relevant in this case. 5.6 Consideration of all adults in the household and beyond Recently updated information on the South West Child Protection Procedures alerts workers to consider all care givers in the household when assessing a child’s situation: “Of particular importance is the need to consider all caregivers within the family. As identified in many serious case reviews, including that in relation to Peter Connolly, the role of fathers, male caregivers and others such as lodgers within the family environment is often not considered, particularly if they are hidden through work or through active non-disclosure by others. It is therefore important to consider the role                                                       16 Joint Area review of Services to Children, Published 10th October 2006, Ofsted, http://www.ofsted.gov.uk/local-authorities/devon   27  of individuals as seen from a child’s perspective. As Brandon et al. (2009) suggest, while knowledge about the status of the relationship (e.g. father, step-father, etc.) is important, this is less urgent to establish then what role they play in caring for the child, and what risks they pose or protection they may provide.” 17 The potential of increased risk of abuse for children living in households where one parent, usually the father figure, is unrelated to the children has also been researched, 18 so whilst being part of a reconstituted family is not a risk indicator of itself, it should be considered as part of the comprehensive assessment. Mother’s willingness to co-operate and supposed efficacy as a protector of her children has been described throughout this review. In the Action for Children paper on Neglect, one definition of neglect is as follows: “Lack of supervision and guidance – this involves a failure to provide an adequate level of guidance and supervision to ensure a child is physically safe and protected from harm. It may involve leaving a child to cope alone, abandoning them or leaving them with inappropriate carers, or failing to provide appropriate boundaries about behaviours such as under-age sex or alcohol use. It can affect children of all ages.”19 In the situation in which the children found themselves, there is evidence that appropriate boundaries and adequate levels of support and guidance were not in place (e.g. Daughter 1 engaging in under-age sex, Son accessing pornography at school, Daughter 2 having to cook for herself from a very young age). Step Father was considered to have a low IQ, and thus may have had difficulty functioning in a family/parental role. The Son also received specialist help for his additional needs, which adds another dimension to the assessment of need and of neglect within the family as he would have required extra support whilst growing up. Mother was not the only parent however, and Moran’s research brought together in the ‘Action for Children’ paper suggests that the Father could and should be considered as important in contributing to an improvement in the care of children.                                                       17 Reference: South West Child Protection Procedures, http://www.online-procedures.co.uk/swcpp/procedures/knowledge-hub/parenting-capacity-families/   18 Lawrence M. Berger, Christina Paxson, and Jane Waldfogel, “Mothers, Men, and Child Protective Services Involvement”, Child Maltreat, 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845296/    19 Dr Patricia Moran, “Neglect: research evidence to inform practice”, Action for Children Consultancy Services, part 4 phttp://www.actionforchildren.org.uk/media/143188/neglectc_research_evidence_to_inform_practice.pdf   28  Until 2012 there was very limited use of national research to inform practice. In analysing the case the NSPCC made appropriate use of models for assessing risk20.  Finkelhor’s Model of Sexual Offending (1984);  Wolf’s Cycle of Offending (1985);  Thornton’s Risk Matrix Guide (2007); and,  Assessment Intervention and Moving on (AIM 2) assessment tool commissioned by the Youth Justice Board.    6 Recommendations:  6.1 Recommendations for improving Safeguarding and Systems:  6.1.1, Develop and implement a system to ensure multi agency training, practice initiatives, and quality assurance systems to improve assessment and front-line practice in relation to safeguarding children from sexual abuse;   6.1.2, Develop, maintain, and use a multi-agency model of chronologies to summarise key involvements and assessments;  6.1.3, Ensure “non resident” parents (with parental responsibility) are informed about child protection concerns for their children and that consideration is given to their potential contribution to the protection and care of the children;  6.1.4, National Probation Service to review and implement a policy (that complies with the Data Protection Act 1998) to ensure that historic case records of offenders who have been assessed as posing a risk to children are retained for an increased period that is in proportion to the risk posed by the offender.   6.1.6, Ensure protocols are developed to ensure full representation at Multi Agency Public Protection Arrangements (MAPPA) meetings, and that individual sex offenders are monitored, with information, and concerns  appropriately escalated if they move into a household with children;  6.1.7, All services engaged primarily with adults to develop practice tools that will enable staff to identify the risks that adults may pose to their children and assist in fulfilling their safeguarding responsibilities . Ensure that they share information appropriately; refer to the appropriate child protection agencies and work together to safeguard children.                                                         20 Reference: specialist assessment programme, NSPCC, model for assessing risk of reoffending of person with historical conviction now having access to children http://www.nspcc.org.uk/what-we-do/the-work-we-do/priorities-and-programmes/sexual-abuse/good-practice-for-asessment/assessing-the-risk_wda87174.html   29  6.2 Recommendations for individual agencies:  6.2.1 Local Authority: • As lead agency, ensure social Workers and first line managers have a good understanding of sex offending, offender profiles, and risk implications for children. Ensure that this knowledge and understanding is routinely used to inform and guide assessments, information sharing and plans to protect children; • Ensure that the capacity of the “non abusing” parent to protect children in the household is fully explored within assessments;    • Ensure “non resident” parents (with parental responsibility) are notified about child protection concerns concerning their children and that consideration is given to absent parents and their potential contribution to care of their children;  6.2.2 Police: • Quality Assure the effectiveness of MAPPA meetings and report findings regularly to participating partners through the MAPPA Senior Management Board   6.2.3 Probation: • Urgently review (in conjunction with Ministry of Justice) policy for destruction of historic case records in relation to offenders who have been assessed as posing a risk to children;  • To develop with other agencies an alert procedure to ensure that offenders previously subject to Multi Agency Public Protection Arrangements (MAPPA) who pose a risk to children are immediately reviewed by MAPPA in the event that the offender moves into a household with children.   • MAPPA Strategic Management Board (SMB) to ensure that that the DSCB is informed about agencies that regularly fail to attend MAPPA meetings in relation to risk to children.      Author: John Kirby (Independent Reviewer)     