CR 1 Critical Incident Review September 2011 to May 2012.

1. CR 1 Critical Incident ReviewSeptember 2011 to May 2012.

2. Content • Contextual background. • The reasons for the review. • Key learning for agencies including further reflection & potential challenges. • Key Multi-Agency themes. • Family perspective. • Next steps.

3. Family composition Father (FATHER PJB) mother (MOTHER JB) Subject CHILD CR 1 SIBLING 2 (SIB.SBB) SIBLING 1 (SIB.KB)

4. Contextual background • July 2006; CR1 acquired brain injury after RTC aged 10 years. Hospitalised for 3 months. • Later in 2006; Attends a specialist school • End of 2006; Family raise concerns regarding sexual disinhibition & sexually inappropriate behaviour at home & in the community. • 2008; integrated into main stream school

5. Contextual background • Escalating behaviour resulting in sexual activity & sexual assaults involving GMP in 2009 and two allegations of rape 2010 & 2011 • Bailed for 2010 rape allegation. Bail condition of no-contact with victim but attended same school. Later found not guilty. • Found guilty of the rape against a vulnerable young adult in 2011. Sentenced in March 2012 to an indeterminate secure Section 37 Mental Health Act Hospital Order.

6. What did the review look at? Total of six terms of reference including: - • Assessments accurately identifying need & risk. • Analysis in relation to services, plans & strategies. • Effective application & review of strategies. • Communication & working together. • Single & Multi – Agency response to increased risk & need. • Timeframe; 2006 to 2011.

7. Learning – Children’s Services. • Delay in recognition of CR1 as a disabled child & therefore a child in need. • Joint working – Disability vs. Safeguarding. • Risk assessments not sufficiently holistic. • Failing to recognise behaviours as child protection. (Sexually Harmful Behaviour & associated procedures). • Insufficient challenge in relation to the quality of assessments. • Absence of social work chronology.

8. Good practice – Children’s Services. • Clear management oversight. • Focus on the voice of the child. • Recognition of additional needs including advocacy. • Good interagency communication & mutual challenge. • Case recording. • Support from SIU to the risk management process. • Alignment of Disabled Children’s Social Workers with mainstream teams & clear referral pathways.

9. Key messages – Children’s Services. • Response to GMAP intervention. (Delays, funding, lead professional, acknowledgement of CP concerns). • Convening, structure & process of strategy discussions. • Children’s Services have now re-aligned Disabled Children’s Social Workers within mainstream social work teams and developed a clear referral pathway to social work services and Specialist Resource Centres. This is viewed as an improvement in relation to compliance with practice standards regarding services to disabled children and their families.

10. Learning - Health • Roles of School Health professionals confusing. • Review of system to flag children subject to ‘CIN’ case planning to facilitate effective & robust method of implementation. • Stronger health representation at strategy discussions. • Chronology of significant events document and robust safeguarding children supervision within CAMHS service. • Retaining safeguarding focus when working with CYP who have ‘Acquired Brain Injury’.

11. Learning – Education. • Communication of key information, particularly when transferring schools. • Facilitating specialists to attending Multi-Agency & service meetings prevents delay & promotes progress. • Explicit language used for communicating expert information to understand and manage risk. • The presentation of the young person conflicted with shared concerns about behaviour and risk.

12. Good practice – Education. • Voice of the child. • Timely development & implementation of strategies to meet additional need & risk. • Series of Multi-Agency & school meetings facilitating, monitoring & reviewing additional needs. • Quality of reviews & risk assessments improved over time. • Creative solutions to remove barriers. (Residential opportunities, sporting opportunities, learning in 6th form).

13. Key messages – Education. Education and Schools may wish to reflect on the fact that given the volume of school based meetings, assessments, planning and review concerned with the provision of education in this case. How their educational assessments, which do not appear to currently form part of a robust multi-agency risk assessment process, will take account of this.

14. Learning & good practice- GMAP Learning; • Challenge and escalation if peripheral role of statutory safeguarding service experienced. • Clear parameters for engagement of GMAP services. Need to be confident young person is safe & supported to undertake therapeutic work. Good practice; • Clear strategies and models of intervention that were reviewed. • Employment of reliable evidence based models & strategies. Visual imagery.

15. Learning - GMP • Coding of computerised incidents was inaccurate. • Wider knowledge of safeguarding issues associated with child on child abuse to be disseminated across the force. • Information sharing regarding vulnerable children. (Early involvement). • Convening and recording of strategy discussions. • Effective record keeping (OPUS database).

16. Learning – GMP continued… • Difficulties experienced in conducting suspect interviews of children with additional needs. • Lack of awareness of support available from specialist interview advisors. • Risk of professional drift. • Lack of clarity about safeguarding policy. • Clarity of roles in ‘Child on Child’ abuse investigations.

17. Key messages - GMP • Over reliance on implementation of revised GMP Safeguarding Children Policy & associated ‘Manual of Guidance’. • Embedding of safeguarding culture within GMP. • Wider responsibility of the ‘Mentally Disordered Offenders Panel’ extending to safeguarding. • Wider responsibility of ‘Nightingale Officers’ extending to safeguarding. • Scope to reflect on the priority given to the requirement to facilitate a multi-agency response for cases of this nature at all stages.

18. Learning - Connexions • Clarification for all staff & managers of appropriate actions to be taken following completion of reports for case reviews. • Void in relevant knowledge & expertise following restructure. Audit of remaining skills & knowledge required. • Facilitate in house consultation, mentoring, briefing & training. • Knowledge of sexually harmful behaviours.

19. Learning – YOS. • Improved system of communication between YOS & Custody Staff. • Awareness of ‘Appropriate Adult Scheme’ & functions. • Safeguarding role of ‘Appropriate Adult’. • Preventative role of YOS, including the provision of services that facilitate safeguarding. • Engagement of YOS pre & post charge. ( Bail supervision & support package) • ASSET tool & associated screening questionnaire, which facilitates specialist intervention & provision. • Facilitation of safeguarding provision for CYP detained in police stations. (HMIC ETC).

20. Multi-Agency themes. • Safeguarding children with a disability. • Sexually harmful behaviours. • Interaction with parents. • Bail conditions.

21. Family perspective. • Found certain expert medical advice unhelpful e.g.'Tie his trousers up’. • Related well to ‘Carol Kendrick Centre Staff’. • CR1 didn’t understand the advice given to him. • Didn’t think that medication was the best option but they used it. • Peer group and friends suggested relevant experts & services the family could access. • Insufficient support from CSC beyond CP concerns.

22. Family perspective continued… • GMAP a long time to access because of funding. • GMAP wanted involvement from CSC but they were unable to become involved for lengthy period. • Self referral for help; “We were struggling. Felt we were locking him up”. He had no social interaction with others. • Mum just wanted some rest bite. CR1 spending all time with her. • Didn’t meet the criteria for the Disabled Children’s Team. No alternatives offered.

23. Family perspective continued…. • “We weren’t experts. Where were the professionals?” • Focus was CR1. “What about our other children?” • GMAP didn’t work. We were honest with them. They seemed to believe CR1 too easily. • Requested residential accommodation from GMAP but they said we were doing fine. • We tried to give our other children normality. • Current Doctor states that if CR1 had earlier effective intervention, then things could have been different.

24. Family perspective continued…. • We understand that CR1’s condition is complex. One of the worst in the country and we didn’t feel as though we received specialist help. • CR1 needed protection as well. • Actions from Multi-Agency meetings were always ‘Pending’. • No one seemed to be in a position to give us constructive help. Needed someone to call for advice. Who? • No one made a difference.

25. Multi-agency recommendations • MSCB to strengthen and monitor the current pathway within the Multi-Agency Guidance for Safeguarding and Promoting the Welfare of Disabled Children and Young People • MSCB should require all partner agencies to identify a minimum number of representatives from their agency who should attend the MSCB Safeguarding Children with a Disability course annually

26. Multi-agency recommendations • MSCB to ensure that the Multi-Agency procedures and response to Children and Young People who display Sexually Harmful Behaviours towards others are completed • MSCB to organise the planning and delivery of a Multi-Agency training course designed to raise the awareness of professionals coming into contact with children and young people displaying sexually harmful behaviours

27. Multi-agency recommendations 5. MSCB should require all professionals engaged in any level of case planning for safeguarding and promoting the welfare of children, to meet together without family members being present on at least one occasion. 6. MSCB should require Greater Manchester Police to convene a ‘Task and Finish Group’ involving key partners to address the setting of bail conditions