Appendix 6 (b)
LOCAL SAFEGUARDING CHILDREN BOARD
BLACKPOOL
SERIOUS CASE REVIEW
EXECUTIVE SUMMARY
CHILD B
September 2008
Independent Author
Kathy Mann
CONTENTS
Page
1. Factors Leading to the Serious Case Review 3
2. Terms of Reference 3
3. Membership of the Serious Incident Review Group 4
4. Contributors to the Review 4
5. Summary 4
6. Review Group Recommendations 5
1. Factors Leading to the Serious Case Review
The subject of this Serious Case Review (SCR) is Child B. On 14th September 2007 Child B was convicted of sexual assault and was sentenced to 5 years in Youth Custody and 5 years extended licence.
At the time he committed the later offences and when he was sentenced Child B was a looked after young person and lived in an independent residential home. Child B had previously been given a Final Warning on 5th December 2005 in relation to a sexual offence, believed to have been committed in 2004, on a child who would have been 4 years old at the time. The exact timing of the original offence which resulted in the Final Warning being issued is unknown as it was reported by Child B’s mother and subsequently the mother of the victim some considerable time after the offence was said to have taken place. Throughout Child B’s involvement with Children’s Targeted Services there had been several observations and suggestions that he had behaved in a sexually inappropriate way both with children and adults.
At a meeting of the Serious Case Review Group (SCRG) held on 26th November 2007 agreement was reached to make recommendation to the Chair of the Local Safeguarding Children Board (LSCB) that a SCR should be initiated. The SCR was agreed on 20th December 2007.
Individual Management Reviews (IMRs) were commissioned from services involved with Child B and his family in Blackpool. Additional historical information was provided from a trawl of the files from the Isle of Man (IoM) where Child B lived until 2000. The review period for the purposes of the Serious Case Review was February 2001 to 25th November 2006.
2. Terms of Reference
The Serious Case Review was convened following the processes outlined in Working Together 2006. The overall aim of the combined overview report is to bring together and relate the information and analysis contained in Individual Management Reports (IMRs), together with information commissioned from any other source. In line with Working Together 2006 this management overview report will:-
· Consider agency involvement with the family
· Analyse that involvement
· Identify lessons to be learned
· Make recommendations for action
Areas to be Considered in the Review
1 The review will consider in detail the period when Child B first came to the attention of services in Blackpool ie 2005, until the point at which the allegations leading to his conviction were made.
2. The review will also consider Child B’s early life experience when living on the
Isle of Man.
3 The review will consider the circumstances of his being placed in a Blackpool Children’s Home and the local school.
4 The review will look at the work undertaken by agencies and in particular addressing the following:
Ø The information available to staff working with Child B during the above period.
Ø Were risk assessments completed to an acceptable standard, given the information available.
Ø Were plans made appropriate to Child B’s need.
Ø If the review considers that some weight should have reasonably been given to the information available, which information is referred to? How should this have influenced planning.
5 Where appropriate, the review will identify learning points for local safeguarding agencies.
3. Membership of the Management Review Group
Representatives from the following agencies made up the membership of the SCRG. The meetings were administered and facilitated by the LSCB Administrator. Members were:
Detective Inspector Lancashire Constabulary
Learning and Achievement Advisor/Inspector
Senior Service Manager Targeted Services
Independent Chair
Designated Nurse Child Protection Blackpool Primary Care Trust
Designated Doctor Child Protection Blackpool, Fylde and Wyre Hospitals Trust
4. Contributors to the Review
Reports for the Serious Case Review were received from:
Children’s Targeted Services Social Care (undertaken independently by NSPCC)
Children’s Targeted Services Education
Blackpool PCT
Lancashire Constabulary
5. Summary
In his very early life and before moving to Blackpool Child B experienced poor parenting and parental rejection. Welfare services were involved with him from being a baby.
Child B and his family moved to Blackpool in 2001 and apart from some involvement with Health Services they did not come to the attention of Children’s Targeted Services, Education Services or the Police until late 2004.
From this point onwards the Serious Case Review noted that information about Child B was not collated by any one agency, was not shared adequately between agencies and was not used in planning services for him. In addition there was some evidence which indicated some information about Child B had not been recorded.
There was little information about how Child B functioned within his own family and there was no information about his parents and their ability to manage his behaviour.
There were inconsistencies in the way in which Child B was dealt with. Child B had some special educational needs which were not taken account of in relation to his actual age and his functional age. An assessment had been undertaken which concluded that Child B had some significant developmental delay.
There were times when Child B was not seen for the child he was and in relation to his offences he was treated as an adult sexual offender. At the time his first offence was said to have taken place he would have been aged approximately 12.5 years. The Crown Prosecution Service had advised that the issuing of a Final Warning in respect of this offence would ensure that Child B would receive help from agencies delivering youth offending services.
When Child B was involved with the Youth Offending Team there was some success in working with him. Unfortunately due to resource issues that service downgraded Child B as being of low risk which meant he would no longer receive a service.
Child B was admitted to care in the summer of 2005. His mother was unable to care for him. Until he was sentenced to Youth Custody in September 2007 Child B lived in two residential care homes.
Residential homes reported mixed progress with Child B. There were reports of inappropriate behaviour both from him and from other young people in the homes. There appeared to be limited risk assessments undertaken in both homes both in relation to Child B and other young people in the homes.
Staff in the homes tried to undertake steps which would ensure that Child B’s behaviour was monitored appropriately but this was not always possible due to staffing levels and the behaviour of young people.
Overall agencies involved with Child B provided him with a good level of service and support but failed to take into account his more complex needs and behaviours and monitor those appropriately and did not protect him or other young people adequately.
6. Review Group Recommendations
Local Safeguarding Children Board
1. The recommendations contained in the individual IMRs should be accepted by the LSCB.
2. The LSCB should ensure there is an effective inter-agency information sharing protocol in place and regularly audit its effectiveness.
3. The LSCB should ensure that the Youth Offending Team and Police review the “appropriate adult” system so that it does not leave young people without such support in Police interviews.
4. LSCB should ensure that Children’s Targeted Services and Adult Mental Health Services should develop a protocol for working with children and young people when parents are deemed not to have capacity under mental health legislation.
All Agencies
1. When any agency comes into contact with a family who have moved into their area they should seek information from the previous area and obtain records and files as a matter of routine.
2. All agencies should use historical information contained in those records to inform their assessments.
3. All agencies should maintain their records to relevant standards and use the detail to inform assessments, make plans and decisions.
4. Risk assessments undertaken by all agencies must ensure that the assessments include both the risk posed by a young person and the risk to them.
5. If an adult is known to have assaulted a child outside their family, agencies
should consider safeguarding issues in relation to the perpetrator’s children as well as the victim.
Children and Young People’s Department
1. Schools should monitor student use of inappropriate sexual language and discuss with the named teacher to progress thinking and possible referral to Children’s Targeted Services.
2. The Children and Young People’s Department should review the criteria used by Youth Offending Team to determine who will continue to receive a service when resources are stretched when the criteria for service has already been met.
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