Death of a 16-year-old girl. Child A may have died by suicide. Learning themes include: interagency working when there are disclosures of historic sexual abuse; the impact of sibling sexual abuse; partial disclosure of sexual abuse or assault; responsibilities of private therapists to safeguard children; peer support and influence; and school transition from secondary to sixth form. Recommendations to the safeguarding children partnership include: a multi-agency reflective learning event to explore the application of research to improve responses to child sexual abuse; undertake a multi-agency audit of cases of sibling sexual abuse to inform the learning event; contact the British Association for Counselling and Psychotherapy (BACP) asking that members are reminded that their counselling ethical framework sets out directives to refer safeguarding concerns; encourage schools to regularly audit their child safeguarding records to ensure compliance with school transfer protocols; and consider how peer mentoring could be developed and used to support children and young people who decide not to proceed with allegations of historical abuse.
      
    Serious Case Review No: 2023/C9809  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   Child AChild Safeguarding Practice ReviewJanuary 2023This LSCPR was undertaken by an independent reviewer with substantial relevant experienceof the issues raised within this review.1CONTENTS1.Introduction22.Child A33.Key circumstances prior to Child A’s death34.Findings from Exploration of the Key Lines of Enquiry55.Themes for Wider Learning106.Conclusion and Recommendations161. Introduction1.1 On 13 January 2022, the local authority made the decision that the reportedincident of the possible suicide of a 16-year-old met the criteria for a notificationto the national Child Safeguarding Practice Review Panel. The rapid review reportand decision to undertake a Local Child Safeguarding Practice Review (LCSPR)under Working Together 2018 was sent to the National Panel on 3 February 2022.1.2 Purpose and scope1.2.1 The purpose of this LSCPR is to identify and explore learning in order to preventfuture child deaths from suicide or undetermined intent, and to highlight anyimprovements to service delivery that would improve outcomes for children.1.2.2 The scope of this LCSPR is the period from 7 January 2021 to 7 January 2022.The context prior to this period has been captured through agenciessummarising any significant involvement prior to these dates which hasinformed the learning for the review.1.3 Methodology1.3.1 The methodology used has focused on the specific experience of Child A. Therehave been two main stages to the methodology, firstly for agencies toundertake a thorough internal review of their involvement with Child A toidentify single agency learning; secondly, the reviewer has met with managers,relevant practitioners, and Child A’s parents to reflect on how they assessedand responded to Child A’s needs.2Child A LCSPR1.3.2 The reason for taking this approach is to enhance the analysis, reflection andlearning through the involvement and contributions of practitioners involvedwith Child A. This included:●Their view of what was going on for Child A.●Their understanding of their role and the part they were playing.●Their thinking and their context at the time.●Their perspective on what aspects of the whole system influencedthem.●The theories and practices they were using.2. Child A2.1 Child A was 16 years old at the time of her death. She was from a mixed heritagebackground and identified as LGBTQ. She lived with her parents and her brotherwho was four years older.2.2 Child A was viewed by her parents as empathetic, funny, loving and had a greatsmile. She was dyslexic, but, once she understood her diagnosis, did not let itdefine her. She liked to prove that she was as capable as anyone else and did wellat school. She was an active sportsperson.2.3 Child A was comfortable about her sexuality and was able to be open about thiswith her parents at an early age. Subsequently, she helped others to talk to theirparents about their sexuality.2.4 The picture presented by Child A’s parents and those professionals who knew herwell, is of a young person who was the ‘rescuer’ of others. She appeared to bestrong and would seek out help for her friends.2.5 Child A’s relationships with her partners and friends appear to have opened upher feelings about her own trauma which she had kept hidden, to some extent,for several years.3. Key circumstances prior to Child A’s death3.1 When Child A was 11 years old (approximately 2017), she disclosed to herparents that she had been abused by her brother three years earlier, aged 8(approximately 2014). Her parents believed that the abuse was confined totouching and her brother would have been aged 12. Therefore, they did notreport the disclosure but sought private counselling for Child A.3Child A LCSPR3.2 The counsellor contacted the NSPCC for advice about the allegation of abuse. Thecounsellor’s recollection of this was that, following consultation with theirsupervisor, no further action was necessary as the abuse was historical and theparents were keeping their child safe. However, the NSPCC records showed thatthe advice had been that the abuse should have been reported at the time it wasknown; that the counsellor needed to follow the safeguarding guidance for theirrole; and that it had been inappropriate for Child A to make the decisions onwhat should happen, this was the parents’ responsibility.3.3 In the pandemic lockdown in 2020, Child A found it increasingly difficult to be inthe house with her brother. By 2021, Child A had broken off all contact with herbrother. In 2021, she disclosed to her school (school 1) that she had beensexually abused when she was younger, seven years previously. School 1 made areferral to Children’s Social Care (CSC) and the Police.3.4 The criminal investigation could not proceed as Child A did not want to progressher allegation. The parents were advised to ensure no unsupervised contactbetween the siblings. The case was closed by CSC and the Police.3.5It was at this time that Child A self-referred to a school drugs worker for supportwith her use of drugs, ketamine, and cannabis, and to find other ways ofcontrolling her emotions.3.6When Child A moved to a sixth form at a different school (school 2), later in2021, the information from school 1 regarding the allegation of historic abuse1was not shared with school 2.3.7Later in 2021, Child A was referred to CAMHS by her GP. She was seen for aface-to-face assessment by CAMHS and placed on the waiting list fortherapeutic intervention, which was due to commence in January 2022. Duringthe assessment, Child A disclosed that she had been raped a year earlier by anunnamed adolescent boy.3.8Throughout the following two months, CAMHS maintained telephone contactwith Child A. She was due to commence therapy 10 days after her death.3.9On the day of her death, Child A had spent time with her parents before leavingto go to school. She did not attend school but had sent messages to friends thatled to concerns for her safety. Subsequently, Child A was found deceased.1 Author note: I have used the terms non-recent and historical sexual abuse interchangeably. My rationale for thisis that I found that some research and national policy used ‘non-recent’, whilst other documents used ‘historical’.Therefore, I wanted to highlight this to inform future work by the LSCP and partners in relation to child sexualabuse.4Child A LCSPR4. Findings from Exploration of the Key Lines of Enquiry4.1 The alleged rape of Child A by a male not being referred to Children Social Careand the Police.4.1.1 The alleged rape was not referred by CAMHS due to Child A being 16 years oldand deemed to have capacity to make the decision for herself under theMental Capacity Act 2005. The decision was based on a thorough teamdiscussion to balance the immediate risks to Child A’s suicidal ideationescalating, her decision not to report it to the police, and that she needed tofeel listened to, heard and valued. Child A had assured the team that therewas no contact with the alleged perpetrator and it was thought that therewould be a possibility for the rape to be addressed at a later stage oncetherapy was in progress.4.2. The joint response to the disclosure of historical sexual abuse, and theoutcome of the investigation (2021)4.2.1 The joint response to the disclosure of historical sexual abuse did not providesufficient support for Child A and her family to come to terms with the impactof the allegation. There was a formal strategy meeting held but without therelevant health professionals, i.e. the Sexual Assault Referral Centre (SARC) ora Community Paediatrician.4.2.2 There was no referral made for therapy as a result of the disclosure. Given thedisclosure of childhood abuse and that it was known that she was self-harming,there should have been further consideration of what therapeutic supportChild A needed.4.2.3 The outcome of the investigation was that there were no safeguarding risksand Child A’s parents took the responsibility for the safety of their daughter.Yet, this was an extremely difficult situation for the whole family to address.There was no challenge to the decision by any agency. It was seen as a Policeand CSC decision and other agencies either had not been told about thecontext of the abuse or did not question it further.4.2.4 It would have been appropriate to convene a review strategy meeting todiscuss the outcome of the investigation and to explore what further supportcould be offered to the family.FINDING 1: The joint response to the disclosure of historical sexual abuse did notprovide sufficient support for Child A and her family.5Child A LCSPR4.3 The perpetrator of the sexual abuse would have been a child when it occurred,yet no one had spoken to him.4.3.1 The Police acknowledged that the investigation did not meet the standardsexpected. Too much weight was given to the response from the parents thatthey would not allow the brother in the same room as Child A. This was inabsence of the brother being asked for his view of what had happened.Therefore, the parents were left without support to help them tocomprehend what had actually happened to their children and continue tobe a family.FINDING 2: The impact of the alleged sibling to sibling sexual abuse was notexplored by any professional with Child A and the family.4.4 The referral to the commissioned specialist sexual assault referral centres(SARC) was not made on the advice that it would not be accepted by them4.4.1 There was no full consultation with the SARC as set out in the LSCP Protocol.This was due to discrepancies between the protocol and the referral criteria forthe SARC. There was some advice, from the SARC, about signposting Child A toa survivors’ service, as the SARC only dealt with referrals for abuse within theprevious 12 months. Signposting to a service for a child who has reportedsexual abuse, even if historical, was insufficient to ensure that Child A had thesupport she needed.4.4.2 This ties in with finding 1, the joint response to the disclosure of historic sexualabuse was not sufficient to support Child A and her family.4.5 The reason why the family decided to fund therapy privately, and whether thiswas appropriate4.5.1 Child A’s parents dealt with Child A’s initial disclosure to them, in 2017, alone.Herparentsthought the abuse was confined to touching and wasnon-penetrative. They reported that Child A was not upset, although she hadsome behavioural problems, and was still friendly towards her brother. Thedecision of the parents to fund therapy privately meant that there was noopportunity for professionals to understand the implications of the abuse onChild A’s emotional and mental wellbeing.Therefore, the parents sought the therapy they believed would help theirdaughter. Any professional receiving the information about Child A’s disclosureto her parents would be expected to make a safeguarding referral.6Child A LCSPRFINDING 3: The private therapist did not follow advice from the NSPCC and refertheir concerns to CSC.4.6 Agencies were aware of different pieces of information, and the reason this wasnot fully joined up4.6.1 There were numerous missed opportunities for a multi-agency review of ChildA’s needs due to assumptions that CSC and the Police would have completeda full investigation.4.6.2 The Police and CSC did not undertake a robust s.47 investigation. This led toChild A’s parents taking responsibility for her safety, without a multi-agencyreview of the impact of the alleged abuse on Child A and the whole family.4.6.3 School 1 did not share information with school 2, which was a missedopportunity to provide Child A with support in the months following herdisclosure. There seemed to be the view that it was for the Police and CSC toaddress the issues.4.6.4 Both the GP and drugs worker, who saw Child A, accepted at face value fromChild A the information that CSC and the Police were investigating theallegation about the sexual abuse. It would have been of benefit for them toseek further information from CSC to inform their decision making, with ChildA’s consent or if not obtained to consider a safeguarding referral.4.6.5 CAMHS did seek further information about the sibling sexual abuse disclosurebut did not question the fact that CSC had closed the case.FINDING 4: The omission of transferring information from school 1 to school 2 lefta gap in support that could have been provided to Child A.4.7 Whether there was a lack of critical reflection about what Child A was tellingagencies, and whether the voice of the child was fully considered.4.7.1 Child A seemed to only tell parts of her experience and feelings to differentprofessionals. It is difficult to make a firm conclusion about why she did this,but it could be that she was testing the adults in her life. She seemed to bemore honest with her friends. She also presented as a strong-willed characterwho did not want to be a victim, and she chose not to provide furtherinformation to the investigation.7Child A LCSPR4.7.2 When professionals saw Child A during her last year of life, she was 16, theage at which she could legally be assumed to have the mental capacity tomake her own decisions about what should happen following her disclosures.This meant that, within the efforts of professionals to respect Child A, theydid not take into account that she had been a young child when the allegedabuse occurred and how difficult it was for her to tell adults about it.FINDING 5: Child A only made partial disclosures to different professionals andwhen she chose not to progress with her allegation this decision was not revisitedby professionals.FINDING 6: Child A made fuller disclosures to her friends who validated her as avictim. Child A was encouraged to report the alleged abuse, but had to do thatalone.4.8 The impact of identity issues sexuality, ethnicity, and culture on Child A’smental health4.8.1 Child A’s ethnicity was mixed White British/other white. There was noevidence of any concerns in relation to her ethnicity. She came out as LGBTQto her parents when she was 11 years old. Once this happened and she had asupportive response from her parents, she settled into her sexual identityand was open about it to her peers.4.8.2 Child A’s parents described how she had several relationships with other girls,but she struggled if there were too many demands from a partner or if therewere rows. This is suggestive of an adolescent learning about relationships.4.8.3 Nevertheless, Child A’s mental health needs were significant in that she hadadmitted to self-harming and having previous suicidal ideation. Additionally,she had sought help from the drugs worker to not only stop using drugs butalso to learn to manage her emotions.4.8.4 Child A had lost the key relationships of her brother and a girlfriend, hadconflict in her relationships with other girlfriends and had reported that shehad been sexually abused. She reported to professionals that these issuesaffected her mental health. This reflects the research into risk factors forsuicide by children. The National Child Mortality Database report (2021)highlighted that 33% of suicides of children under 18 were known to mentalhealth services at the time; 62% had a loss of key relationships; 45% hadconflict with key relationships; 32% had suffered abuse or neglect, the most8Child A LCSPRcommon type of abuse was sexual abuse or rape.2 In 2017, the nationalreport into suicide in children and young people identified that 57% hadprevious suicidal ideation, 52% self-harm, 34% drug misuse and 12% abuse.34.9 Whether LSCP protocols on child sexual abuse and self-harm and suicidalideation were followed4.9.1 In terms of the referral to CSC by school 1, following the Child A’s disclosure,the protocol was followed. However, the statutory response did not meet therequirements of the protocol. It sets out the need to include the SARC at thestrategy meeting for cases of suspected sexual abuse. Had this been done thenthere could have been effective, timely, support for Child A. There should havebeen a referral to the NSPCC for therapeutic support for Child A and her family.It was reported that she refused, however, this should have been exploredwith her parents and, in the continued event of the family declining, thisshould have informed the child and family assessment as to the extent towhich the parents were able to comprehend that the abuse had occurred.4.9.2 It is noted that the LSCP protocol for child sexual abuse sets out that theresponse to allegations of historical abuse must be to the same standard asthose for current abuse due to the distinct possibility that others will be still atrisk from the alleged perpetrator.FINDING 7: The LSCP protocol was consistently followed, resulting in Child A andher family not receiving support that could have been beneficial.4.10 Whether Covid-19 had any impact on supporting and protecting Child A fromsignificant harm.4.10.1 In the 2020 lockdown periods, due to the Covid-19 restrictions, Child A didremote learning as she did not meet the criteria for in person attendance atthe school. Her brother was also at home during these periods.4.10.2 At this time, professionals working with Child A were unaware of anyallegations of abuse.3 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester:University of Manchester, 2017.2 NCMD (2021) Suicide in Children and Young People: National Child Mortality Database Programme ThematicReport- Data from April 2019 to March 20209Child A LCSPR4.10.3 However, this was a key point of change in how Child A was able to manageher emotional well-being. During the lockdown at the end of 2020, she choseto cut off contact with her brother.4.10.4 It is not clear why Child A did not disclose the alleged abuse to her teachersuntil April 2021. However, this might have been delayed due to the schoolonly returning to full in person just weeks prior to her disclosure.4.10.5 Child A was able to have access to the GP and drugs worker, face to face, andwas supported by CAMHS whilst on the waiting list for therapy. Therefore, theconclusion is that the Covid-19 pandemic did not have an impact on theagencies in their support of Child A.4.10.6 However, the restrictions that were in place due to the pandemic, did have animpact on Child A being able to manage her emotional wellbeing andresponse to the past trauma.4.11Summary of findings1. The joint response to the disclosure of historical sexual abuse did not providesufficient support for Child A and her family.2. The impact of the alleged sibling to sibling sexual abuse was not explored byany professional with Child A and the family.3. The private therapist did not follow advice from the NSPCC and refer theirconcerns to CSC.4. The omission of transferring information from school 1 to school 2 left a gapin support that could have been provided to Child A.5. Child A only made partial disclosures to different professionals and when shechose not to progress with her allegation this decision was not revisited byprofessionals.6. Child A made fuller disclosures to her friends who validated her as a victim.Child A was encouraged to report the alleged abuse but had to do that alone.7. The LSCP protocol was consistently followed, resulting in Child A and herfamily not receiving support that could have been beneficial.5.Themes for Wider Learning5.1 From the findings above the reviewer has identified six areas for wider learning●Interagency working when there are disclosures of historical sexual abuse●The impact of sibling-to-sibling sexual abuse●Partial disclosure of sexual abuse or assaults10Child A LCSPR●Responsibilities of private therapists to safeguard children●Peer support and influence●School transition: secondary to sixth formN.B It is expected that all services reflecting on the wider learning will need to payproper regard to the issues of identity, ethnicity, sexuality and gender.5.2 Interagency working for disclosures of historical sexual abuse5.2.1 The NSPCC website has advice for parents if their child has sexually abusedsomeone, but it directs to their own therapeutic services rather than advisingparents to talk to a trusted professional locally, e.g. a GP or teacher.4Nevertheless, the website does advise parents to report as soon as possible iftheir child discloses that they have been sexually abused.55.2.2 Since Child A’s death, there is a local programme in place to strengthen theprovision of support for children in relation to non-recent sexual abuse. Thisshould enable the gaps in the awareness of agencies about where to findsupport for children who disclose non-recent sexual abuse and ensure thatthese children are referred for holistic medical examinations.5.3 The impact of sibling-to-sibling sexual abuse5.3.1 It is estimated that 1.3 million affected children and adults are potentiallyfacing or experiencing sibling sexual abuse.6 Strong (2022) suggests that siblingsexual abuse is the most common form of child sexual abuse in the UK.7However,asearchforpublishedsafeguarding case reviews did notdemonstrate the extent of the abuse in the UK. The outcome of this abuse canbe shame, confusion, stigma, with both siblings feeling isolated.85.3.2 In Child A’s case, the sibling relationship was not explored to establish thefacts of what had happened between them. This reflects the wider view thatit is difficult to reliably establish the extent of child sexual abuse generally andsibling sexual behaviour more specifically. However, research suggests that it8 Strong, F. (2022) Acknowledge, address, adapt - Closing the gap between sibling sexual abuse as the mostcommon form of child sexual abuse in our homes and the most ignored form of child sexual abuse in the UKNational Project on Sibling Sexual abuse: Policy Summary Report. Sibling Sexual Abuse Project.7 Strong, F. (2022) Acknowledge, address, adapt - Closing the gap between sibling sexual abuse as the mostcommon form of child sexual abuse in our homes and the most ignored form of child sexual abuse in the UKNational Project on Sibling Sexual abuse: Policy Summary Report. Sibling Sexual Abuse Project.6 Strong, F. (2022) Acknowledge, address, adapt - Closing the gap between sibling sexual abuse as the mostcommon form of child sexual abuse in our homes and the most ignored form of child sexual abuse in the UKNational Project on Sibling Sexual abuse: Policy Summary Report. Sibling Sexual Abuse Project.5 https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/child-sexual-abuse/4 https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/child-sexual-abuse/#child11Child A LCSPRis common enough that most professionals working with children are likely towork with families affected by this issue.95.3.3 Strong (2022)10 found that professionals respond in different ways to reports ofsibling sexual abuse:1. Minimising the abuse as they don’t know how to respondand/or ignoring the abuse and focusing on issues where they aretrained, and systems are in place such as child neglect.2. Exaggerating the abuse and over-stating the problem in order togain access to children and young people statutory services.3. Catastrophising the abuse and making decisions that are anover-reaction.5.3.4 Strong (2022) states that each of these responses can be harmful to childrenand damaging to the stability of their whole family.11 Strong (2022)recommends that professionals need to work with the whole family, not solelyfocused on a child, to take a strengths-based approach.12 In Child A’s case, therewas no constructive work undertaken with the family to check the veracity ofthe allegations.5.3.5 Without the professionals explicitly accepting that abuse has taken place, thenparents can believe that, if there was abuse, it was not as serious as they fear.Yates and Allardyce (2021) describe how there is a risk that the professionalresponses to sibling sexual abuse can lead to a minimisation of the abuse,putting it down to innocent experimentation. They suggest the need for a cleardefinition of what is and is not normal sibling behaviour.135.3.6 In Child A’s case, there were gaps in the professionals’ awareness of the impactof alleged non-recent sexual abuse on the child and family. Yates and Allardyce(2021) advocate the need for reflective supervision for professionals to supporta ‘balanced and proportionate response’ in cases of sibling sexual abuse toprovide ‘reassurance and emotional containment to families’. 1414 Yates, P. Allardyce, S. (2021) Sibling sexual abuse: A knowledge and practice overview Centre of Expertise onChild Sexual Abuse.13 Yates, P. Allardyce, S. (2021) Sibling sexual abuse: A knowledge and practice overview Centre of Expertise onChild Sexual Abuse.12 Strong, F. (2022) Acknowledge, address, adapt - Closing the gap between sibling sexual abuse as the mostcommon form of child sexual abuse in our homes and the most ignored form of child sexual abuse in the UKNational Project on Sibling Sexual abuse: Policy Summary Report. Sibling Sexual Abuse Project.11 Strong, F. (2022) Acknowledge, address, adapt - Closing the gap between sibling sexual abuse as the mostcommon form of child sexual abuse in our homes and the most ignored form of child sexual abuse in the UKNational Project on Sibling Sexual abuse: Policy Summary Report. Sibling Sexual Abuse Project.10 Strong, F. (2022) Acknowledge, address, adapt - Closing the gap between sibling sexual abuse as the mostcommon form of child sexual abuse in our homes and the most ignored form of child sexual abuse in the UKNational Project on Sibling Sexual abuse: Policy Summary Report. Sibling Sexual Abuse Project.9 Yates, P. Allardyce, S. (2021) Sibling sexual abuse: A knowledge and practice overview Centre of Expertise onChild Sexual Abuse.12Child A LCSPR5.3.7 The IICSA final report (2022)15 highlighted the common experiences and theimpact of child sexual abuse on victims and survivors. It emphasised that the‘the impact of child sexual abuse cannot be overstated because many victimsand survivors have experienced harm that has permeated many aspects of theirlives.’5.3.8 The Inquiry found that it was common for victims and survivors to:‘experience emotional distress, including fear, anger, sadness and self-blame,manifestingitselfinpanicattacks,flashbacks,anxietyand signs ofpost-traumatic stress disorder’165.3.9 The Inquiry concluded that it was not unusual for victims and survivors tostruggle to come to terms with the abuse they suffered, so much so that theyself-harmed or tried to end their lives.5.3.10 In Child A’s case, there were allegations of abuse which were not fullyinvestigated to establish proof, yet she continued to perceive herself to havebeen a victim and struggled to come to terms with that.5.3.11 The Inquiry makes the recommendations to:1. Introduce laws requiring anyone working in regulated activity, a positionof trust or as a police officer, to report child sexual abuse if they receive adisclosure, witness, or observe recognised indicators of child sexualabuse.2. For the provision of specialist therapeutic support for all children whohave experienced sexual abuse. 175.4 Partial disclosure of sexual abuse or assaults5.4.1 When Child A disclosed the non-recent sexual abuse, she chose not to progressher allegation. She was also holding back a more recent allegation ofextra-familial sexual assault. There should have been a plan to revisit herdecision not to progress which might have enabled her to speak more abouther experiences.5.4.2 McElvany (2013) described how the children need time to disclose familialsexual abuse and that many do not disclose until they are adults or are onlyable to partially disclose.18 McElvany states that professionals need to18 McElvaney, R. (2015) Disclosure of Child Sexual Abuse: Delays, Non disclosure and partial disclosure. What theresearch tells us and implications for practice. Child Abuse Review. Vol.24. 159-169.17 IICSA (2022) The report of the Independent Inquiry into Child Sexual Abuse16 IICSA (2022) The report of the Independent Inquiry into Child Sexual Abuse15 IICSA (2022) The report of the Independent Inquiry into Child Sexual Abuse13Child A LCSPRunderstand how the child will be feeling, their worries and how disclosuresneed to be facilitated by the trusted adults, not left to the child.19 In Child A’scase, she was left to make the decisions following her disclosures.5.5 Responsibilities of private therapists to safeguard children5.5.1 Child A was seen by a private counsellor who sought advice about safeguardingbut did not have sufficient knowledge of what their responsibilities were totake action to report to the local statutory services.5.5.2 There are examples of other reviews in which deficits in the communicationbetween the private and public sector have been seen to have a negativeimpact on a child’s wellbeing. For example:‘When family members are accessing private services, such as counsellingor therapy, there may be information which is hidden from practitionerswhen they are considering risk. An awareness that there may beunknown risk factors should prompt practitioners to ask questions andcheck with other agencies (GPs are often the recipients of healthinformation) when assessing risk to children.’205.5.3 The statutory guidance states that:‘Every VCSE, faith-based organisation and private sector organisation oragency should have policies in place to safeguard and protect childrenfrom harm. These should be followed, and systems should be in place toensure compliance in this. Individual practitioners, whether paid orvolunteer, should be aware of their responsibilities for safeguarding andprotecting children from harm, how they should respond to childprotection concerns and how to make a referral to local authoritychildren’s social care or the police if necessary.’215.5.4 The British Association for Counselling and Psychotherapy (BACP) set out theethical framework within which therapists are required to work to enable thetherapist to make difficult decisions where necessary.22 The core principles ofthe framework include to avoid harm to the client and a commitment topromote the client’s wellbeing. It would be expected that all practitionersworking to the BACP framework will have a clear record of how to contactChildren’s Social Care, MASH, and police.22 BACP (2018) Ethical Framework for Counselling Professions.21 HM Govt (2018) Working Together to Safeguard Children 201820 Tudor, Karen and Pan-Dorset Safeguarding Children Partnership (2020) Serious case review: S39 - Child A [fulloverview report]. Dorset: Pan-Dorset Safeguarding Children Partnership.19 McElvaney, R. (2015) Disclosure of Child Sexual Abuse: Delays, Non disclosure and partial disclosure. What theresearch tells us and implications for practice. Child Abuse Review. Vol.24. 159-169.14Child A LCSPR15Child A LCSPR5.6 Peer support and influence5.6.1 When Child A told her peers about her experience, they validated her as avictim in a way that the adults did not.5.6.2 Peers can have a considerable impact in enabling a young person who hasexperienced sexual violence to feel supported. Peer mentoring can work foryoung people who have been victims of sexual violence if the young person isin control, with the knowledge that the mentor understands as they have beenthrough a similar experience23. Cody et al (2022) identified the need to ‘feelunderstood’ was key to the success of peer mentoring24. In Child A’s case, herpeers were not in a position to be able to mentor her at the time. They had notraining to support her, just the experience to tell her that the abuse waswrong and that she should report it.5.7 School transition from secondary to sixth form5.7.1 Periods of school transition should be seen as critical points for robustinformation sharing. When a transfer has been confirmed then the dispatchingschool should ensure that there are arrangements in place to forward on anyrelevant information regarding SEN and safeguarding, whilst the receivingschool should ensure that the request for information includes asking for SEN,safeguarding information or CPOM information.24 Cody, C. Bovarnick, S. & Peace, D. (2022) ‘It’s like a much deeper understanding and you kind of believe themmore …’: The value of peer support for young people affected by sexual violence. Child Abuse Review, e2789.https://doi.org/10.1002/car.278923 Cody, C. Bovarnick, S. & Peace, D. (2022) ‘It’s like a much deeper understanding and you kind of believe themmore …’: The value of peer support for young people affected by sexual violence. Child Abuse Review, e2789.https://doi.org/10.1002/car.278916Child A LCSPR6. CONCLUSION AND RECOMMENDATIONSThe following key findings have informed the themes of learning from this review, and the recommendations for the Local Child Safeguarding Partnership.OVERVIEW OF ANALYSIS AND RECOMMENDATIONSThemes for exploration (interms of reference and fromthe author)Key findingThemes for learningRecommendationsThe alleged rape of Child A bya male not being referred toChildren Social Care and thePolice.Child A was 16 years oldand considered to havethementalcapacity tomake her own decisionsaboutreportingthealleged rape and refusedto provide full details.Partial disclosure of sexual abuse orassaults1. To identify pathways for children toaccess advocacy to enable them tonavigate the system when they arereadytodo so, using the legalframeworkstosupportdecisionmaking.The joint response to thedisclosure of historical sexualabuse, and the outcome ofthe investigationThe joint response to thedisclosureofhistoricalsexualabusedidnotprovide sufficient supportfor Child A and her family.Interagency working for disclosuresof historical sexual abuse2.To contribute to the regional child sexualabuse pathway developments that areunderway3.To update the LSCP Child sexual abuseprotocol to clarify processes for SexualAssault Referral Centre referrals.The perpetrator of the sexualabuse would have been aThe impact of the allegedsibling to sibling sexualabuse was not explored byTheimpactofsibling-to-siblingsexual abuse4.Toholdamulti-agency reflectivelearningeventtoexploretheapplication of research to improve17Child A LCSPRchild when it occurred, yet noone had spoken to him.any professional with ChildA and the family.responses to child sexual abuse, andtherecommendationsfromthenational  inquiry.5.To undertake a multi-agency audit ofcases of sibling sexual abuse to informthe learning event.Thereferraltothecommissionedspecialistsexual assault referral centres(SARC) was not made on theadvice that it would not beaccepted by themThe joint response to thedisclosureofhistoricalsexualabusedidnotprovide sufficient supportfor Child A and her family.Interagency working for disclosuresof historical sexual abuseRecommendations 2 and 3The reason why the familydecidedtofundtherapyprivately, and whether thiswas appropriateThe private therapist didnot follow advice from theNSPCCandrefertheirconcerns to CSC.Responsibilities of private therapiststo safeguard children6. To share the findings of the reviewthat the NSPCC advised to make asafeguarding referral, and that theadvice should have been followed intheir view.7. To write to the British Association forCounselling and Psychotherapy (BACP)andaskthemtoremindtheirmembers that their ethical frameworkfor the counselling profession set outdirectivestorefersafeguardingconcerns.18Child A LCSPRAgencieswereawareofdifferentpiecesofinformation, and the reasonthis was not fully joined upTheomissionoftransferringinformationfrom school 1 to school 2left a gap in support thatcould have been providedto Child A.School transition from secondary tosixth form8. To encourage schools to regularlyaudit their child safeguarding recordsto ensure compliance with schooltransfer protocols.Whether there was a lack ofcritical reflection about whatChild A was telling agencies,and whether the voice of thechild was fully considered.Child A only made partialdisclosurestodifferentprofessionalsandwhenshe chose not to progresswith her allegation thisdecision was not revisitedby professionals.ChildAmadefullerdisclosures to her friendswho validated her as avictim.ChildAwasencouraged to report thealleged abuse but had todo that alone.Partial disclosure of sexual abuse orassaultsPeer support and influenceRecommendation 1 and:9. To consider how peer mentoring couldbe developed and used to supportchildrenandyoungpeoplewhodecide to not proceed with allegationsof historical abuse.The impact of identity issuessexuality,ethnicity,andculture on Child A’s mentalhealthIssues of identity were notfound to adversely affectChild A’s mental health.Whether LSCP protocols onTheLSCPprotocol wasInteragency working for disclosuresRecommendations 2 and 319Child A LCSPRchildsexualabuseandself-harmandsuicidalideation were followedconsistentlyfollowed,resulting in Child A andher family not receivingsupport that could havebeen beneficial.of historical sexual abuseWhether Covid-19 had anyimpact on supporting andprotectingChildAfromsignificant harm.The lockdown restrictionsmeant that Child A andher sibling were at home.However,atthispointChild A had not disclosedany allegation of abuse tostatutory agencies.20Child A LCSPR