Hillingdon Safeguarding Children Board Serious Case Review Why didn't anyone listen?

128 Pages·2017·1.62 MB·English

Hillingdon Safeguarding Children Board
Serious Case Review

Why didn’t anyone listen?

Sarah, Emma, Sophie and Ryan

B. Griffin CQSW BA (Hons) Accredited SCIE Lead Reviewer
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Forward
This serious case review was commissioned by Hillingdon Safeguarding Children Board after a
number of convictions were successfully brought against four men following an investigation known
as ‘Operation Baker’. During the investigation, significant concerns were identified about the way
four children had been safeguarded over a number of years prior to these convictions. This led the
Board to request a review that left no stone unturned.
As a result the report is detailed, it has analysed the multi-agency services provided to the children
and attempted to ‘stand in their shoes’ and hold their perspectives firmly in mind. Unfortunately, it
has not been possible to see all the children or their parents as part of this review. However, the
lead reviewer was fortunate to spend a number of hours with Sarah. Sarah spoke at length about her
experiences, her perspective is detailed later in this report. Sarah was asked what questions she
might have about the services that were provided, it is conceivable that she was speaking for all the
children when she asked: why didn’t anyone listen?
Whilst the impetus for conducting this review was a profound concern about how agencies
responded to sexual exploitation, this review has found that whilst there were very significant
missed opportunities to safeguard the children from being the victim or potential perpetrator of
sexual exploitation, of equal concern was the way these vulnerable children were protected from
other areas of harm. The children suffered significant harm in many areas of their lives, they were all
extremely vulnerable and the experiences they endured are shocking. For the children who were
looked after, the absence of containment by the adults in their lives was marked - they were lost in
the system- no one seemed able to hold them in mind.
Whilst a number of questions have been posed about the services that were provided, it is Sarah’s
question that is the key question for this review. The answer to Sarah’s question is complex. On the
surface, many of the illustrations described in the report can seem like professional indifference,
unconcern or ineptitude, and this would provide a quick and easy answer to Sarah’s question.
However, this review has found that the answer lies not in the way individual practitioners or
professionals responded to the children, the answer lies in the context within which professionals
were working. That is not to say this report has avoided appraising what happened, it has provided a
full and frank account of the nature of service provision. However, Sarah, Emma, Sophie and Ryan
deserve an answer that seeks to address the question at its core, not an answer vilifying individuals
or an answer that provides a veneer of assurances that it will never happen again. The answer they
deserve is one that seeks to understand the depth of complexity inherent within the systems that
professionals work, and it is only then that Sarah’s question will be answered. Hillingdon
Safeguarding Children Board sincerely hope this has been achieved.

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Contents

Executive summary p.4 -5

Structure of report P.5-6

Report : Part I p.6-19
Circumstances that led to this review p.6-7

Methodology, Process & Terms of reference p.7-9

Perspectives of Practitioners p.9

Perspectives of the children & family members p.9-10

Background: profile of the organisation p.10- 13

Background: child sexual exploitation in research, guidance and p.13
previous serious case reviews

Background: profiles of the children p.14-16

Assessment of practice and associated learning points - A summary p.16-18

Current Situation in Hillingdon & conclusion p.18-19

Report : Part II
How did professionals respond to the disclosures of sexual p.20-37
assault made by Sarah, Emma and Sophie?

How did professionals respond to information suggesting that p.37-59
Sarah, Emma and Sophie were having underage sex?

How did professionals respond to the other risks faced by all four p.60-79
children?

How well did the procedures governing work with looked after p.79-104
children function to protect Sarah, Emma and Ryan?

How well were the agencies fulfilling their corporate parenting p.104-116
responsibilities for Sarah, Emma and Ryan?

How effective was the operational model used during the joint p.116-117
police and social care investigation?

References p.118
Appendix I p.120
Appendix II p.120-126

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Executive Summary

Child sexual exploitation is an issue that has been receiving regular coverage in the national press; it
has also been the subject of recent research and a number of detailed serious case reviews. This
serious case review examines how agencies responded to three children, Sarah, Emma and Sophie,
who were the victims of child sexual exploitation in Hillingdon. A fourth child, Ryan1, is also
considered: Ryan was initially charged with sexual offences against a female and drug-related
charges. Following the trial for these offences, he was found not guilty of any sexual offence,
however was found guilty of drug-related offences. Therefore, Ryan would be the subject of concern
with regard to sexual exploitation.
The existence of child sexual exploitation in Hillingdon came to the attention of Hillingdon
Safeguarding Children Board at the end of 2013. A joint police and social care operation was
launched, this investigation (Operation Baker) was conducted to the highest standards by all the
agencies and professionals involved and resulted in successful prosecutions of some of the
perpetrators; not however before Emma, Sarah and Sophie had suffered significant harm as a result
of child sexual exploitation for a period of years. The timeframe under review is 01.01.11 to
06.08.14.
Sarah, Emma, Sophie and Ryan were known to many agencies and they came into contact with many
professionals. The Review Panel learnt that as many as twenty seven different professionals came
into contact with Sarah. Sarah was a looked after child throughout the period under review; Emma
was looked after for most of the review period: these two children were in the care of the local
authority and its corporate parenting partners at a time when they were experiencing ongoing
significant harm, including being sexually assaulted, groomed, threatened and intimidated by
abusive, predatory adults. Ryan also spent time in the care of the local authority. Sophie lived within
her birth family; she was in regular contact with sexual health services throughout the review period.
This is a long review; there is good reason for the detail it contains. The review encompasses the
lives of four children over a period of three and a half years; it is the result of careful analysis of a
wealth of information held by many agencies. The views and experiences of the professionals who
worked with Sarah, Emma, Sophie and Ryan have been considered; the views of the children
themselves and their families have also informed the review. The events, actions and practice areas
under review are complex; multiple and layered weaknesses in inter-agency communication,
assessment, decision making, planning and direct work are highlighted. These are weaknesses not
just in the understanding and tackling of child sexual exploitation, but in the safeguarding system as
a whole.
From a child sexual exploitation perspective, many of the themes of this review echo those already
contained in the existing body of research into child sexual exploitation. The abuse that Sarah, Emma
and Sophie were suffering was not recognised and assumptions were made about the three girls’
relationships with men, and their capacity to consent to them; insufficient professional curiosity
about their lives and experiences was shown. Child protection procedures and strategy meetings
were not used to investigate allegations of sexual assault and evidence of significant harm. Child
sexual exploitation was not being prioritised at a strategic level; neither were the patterns of

1 The children’s names have been changed to protect their confidentiality.
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children going missing from home or care. These are all familiar themes from previous serious case
reviews.
It is clear that enormous progress has been made in addressing child sexual exploitation in Hillingdon
since these children’s cases came to the attention of Hillingdon Safeguarding Children Board.
However, this review discusses wider concerns than those associated with child sexual exploitation
alone. There has been focus throughout the review process on the systems that were in place to
safeguard Sarah, Emma, Ryan and Sophie, not just from the risk of sexual exploitation but from all
risks. Questions have also been asked about the actions that were taken to achieve good outcomes
for them; how they were supported to live safe, happy and fulfilling lives.
The review has sought to understand how three children who were being looked after by the local
authority and its corporate parenting partners suffered significant harm over the course of years.
The children had many vulnerabilities. These were known about and were not difficult to perceive,
but these vulnerabilities were not assessed or conceptualised in a way that kept the children safe. In
seeking to understand why this was, systemic and practice issues associated with how the children
were looked after and their needs met have been examined.
The review concludes with a wider consideration of the standard of corporate parenting Sarah,
Emma and Ryan were offered. Panel Members found that the question ‘what would I do if this was
my child?’ was not routinely asked for Ryan, Sarah and Emma. As a result these children were not
always protected, cared for, valued and cherished as birth children would be. The author believes
that reflection on Sarah, Emma and Ryan’s experiences in the care system would tell us much about
how the state parents children.
Structure of the report
The first Annual Report of the National Panel of Independent Experts on Serious Case Reviews- SCRs
(which oversees the quality of reviews to ensure appropriate action is taken from the learning)
comments on SCRs being produced now. It has expressed concern about undue length. It warns
against a level of detail that would make publication difficult (and hence learning limited). It calls for
a ‘sharp focus’ and ‘concise accounts’. This SCR uses the case detail to illustrate findings rather than
describing all the events, wherever possible findings relate to the whole system not only those cases.
However, even though only illustrations of the children’s experiences are provided, the report is
lengthy. At the point of commissioning this review, concerns about the children’s experiences was so
great that Hillingdon LSCB wanted a detailed review that did justice to the children’s experiences.
Hillingdon LSCB are mindful that the length of this report risks its aim of being read impractical for
some readers. In order to allow this report to reflect the children’s experiences in detail and for the
report to be accessed by a wide audience, the report is presented in two parts.
Part 1 is a summary of the report and addresses the following areas:
 A description of the circumstances that led to this review
 Overview of review methodology and process
 The perspective of practitioners, family members and the children
 Key questions addressed within the review
 Organisational context
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 Summary of key learning points and improvements that have been realised since these
events took place
Part 2 presents a detailed analysis of the services provided to the children, and provides Hillingdon
LSCB with questions to promote debate and challenge to inform future service developments.
Part I

1.1 Circumstances that led to this review
In September 2013 the London Borough of Hillingdon began to identify concerns that organised child
sexual exploitation was taking place in the borough; this activity was linked to drug use and dealing.
A number of potential victims were identified, including Sarah, Emma and Sophie. In December 2013
a joint police and children’s social care investigation, Operation Baker, was commenced to
investigate these concerns. This led to the arrests and prosecutions of five individuals, four of whom
received custodial sentences for sexual offences, the fifth, a child looked after by the London
Borough of Hillingdon (Ryan), was given a suspended sentence for drugs offences.
During this investigation it emerged that two of the victims (Sarah and Emma), who were looked
after children, had both previously made allegations of rape implicating some of the individuals who
were sentenced. These allegations were not appropriately followed up at the times they were made.
Both of these girls had also given professionals extensive information to suggest that they were
involved in inappropriate and risky underage sexual activity throughout the review period; again this
was not followed up or understood as being an indicator that the two children were victims of child
sexual exploitation.
A third victim (Sophie) was not looked after but was known to children’s social care. Sophie had
regular contact with sexual health services and gave health professionals information suggesting
that she was sexually active from a young age. For the most part this information was not shared
with any other agencies and the indications that child sexual exploitation was taking place were not
recognised.
All three girls exhibited risky behaviours associated with child sexual exploitation, but these were not
always effectively identified, assessed or addressed by the agencies in possession of this
information.
Sarah, Emma and Ryan all spent time placed at a Hillingdon residential children’s home. Emma
alleged that she was raped by Ryan while living at this placement. Emma has said that when this
happened she was under the influence of cannabis supplied by Ryan; Ryan was later found to be
storing cannabis in the home. Concerns also emerged about the home of Sarah’s brother: Sarah
alleged that she was raped at this address and it was widely known to be a place where local
children went to use drugs and alcohol. This address was not appropriately checked and Sarah was
allowed to spend time there unsupervised throughout the review period.
In commissioning this review Hillingdon Safeguarding Children Board were conscious that the
decision to involve Ryan along with Sarah, Emma and Sophie may be questioned: Ryan was a subject
of concern with regard to sexual exploitation and was successfully prosecuted for drugs-related
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criminal offences. However, Ryan was placed at risk of significant harm as a result of his involvement
in drug use and criminal activity, and there is no doubt that he too was let down by the agencies and
services that should have diverted him away from this offending behaviour. This review has aimed to
understand Ryan as both a subject of concern with regard to sexual exploitation and a victim; the
focus throughout the review is on the actions of the agencies that should have safeguarded him
from the risks inherent in offending behaviour.
An Individual Management Review (IMR) of the cases of Sarah, Emma, Sophie and Ryan was carried
out in December 2014. This recommended that a serious case review should be undertaken. The
IMR identified
a number of missed opportunities to protect Sarah and Emma and that both were subject to
significant harm as a result of being subject to sexual exploitation. In addition some poor interagency
work was identified together with a failure to follow both local and national practice and procedure2.
This met the following criteria for undertaking a serious case review:
(a) Abuse or neglect of a child is known or suspected; and
(b) (ii) The child has been seriously harmed and there is cause for concern as to the way in which
the local authority, their Board partners or other relevant persons have worked together to
safeguard the child3.
1.2 Overview of review methodology and process
Introduction
Hillingdon Safeguarding Children Board selected the Welsh Model as a structure for the review. The
Welsh Model was identified as being the most appropriate serious case review model to highlight
the practice areas and learning points raised by this case. The questions posed in the Welsh Model
guidance are considered throughout this review.
A description of the Welsh Model is included at Appendix I.
Time frame
The time frame for this review is 01.01.11 to 06.08.14. This is longer than the two years
recommended by the Welsh Model guidance, but this extension allows the review to encompass all
the serious allegations that were made by Sarah and Emma, and ends with the trial and convictions
that resulted from Operation Baker.
Learning areas
Hillingdon Safeguarding Children Board defined the purpose of this review as follows:

22 Individual Management Review, p.5.
3 Working Together to Safeguard Children, Her Majesty’s Government, 2013, p. 68.
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To conduct a thorough review to establish understanding regarding this case and consider if
professionals could have taken any other steps to support these young people and diverted away
from sexual exploitation.
The following areas were identified by the Board as a focus for the review:
1. Review multi-agency involvement with Sarah, Emma, Sophie and Ryan, establishing how the
children were safeguarded, identifying missed opportunities to protect them from harm,
particularly in relation to child sexual exploitation.
2. Examine how the local authority and its multi-agency partners worked together when exercising
their duties as corporate parents, with particular emphasis on examining the role of Looked After
Reviews and Independent Reviewing Officers.
3. Comment on the operational model used during the criminal investigation.
4. Identify any learning that has taken place and make recommendations to inform areas of multi-
agency learning and development.

To answer these questions the review explores and assesses specific aspects of multi-agency
practice in the following areas:
 How did professionals respond to the disclosures of sexual assault made by Sarah, Emma
and Sophie?
 How did professionals respond to information suggesting that Sarah, Emma and Sophie were
having underage sex?
 How did professionals respond to the other risks faced by all four children?
 How well did the procedures governing work with looked after children function to protect
Sarah, Emma and Ryan?
 How well were the agencies fulfilling their corporate parenting responsibilities for Sarah,
Emma and Ryan?
 How effective was the operational model used during the joint police and social care
investigation?
Learning is identified throughout the review and the relevant learning is presented at the end of
each question. A number of other child sexual exploitation themed serious case reviews have been
undertaken during recent years and the learning from these has been considered. Where similar
themes, issues and practices were apparent in this case, this has also been highlighted.
The Review Panel
In line with the Welsh methodology, a review panel of senior managers representing multi-agency
services in Hillingdon were appointed to sit on a review panel, none of these managers had direct
line management responsibility for the services during the time under review. The panel met on five
occasions, during these meetings panel members collectively reviewed relevant documentation,
analysed emerging themes, set lines of enquiry, and provided both support and challenge to the
Lead Reviewers and the practitioners. Membership of the panel was as follows:
 Health: Chelvi Kukendra, Designated Doctor
 Health: Jenny Reid, Designated Nurse
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 Health: Lisa Crawshaw, Named Nurse
 Health: Tendayi Sibanda, Named Nurse, Hillingdon Hospital
 Police: DI Sean Stewart/DS Helen Rendell
 CSE Prevention Manager : Debbie Weissang
 Children's Social Care : Nikki Cruickshank, Interim AD
 LSCB Business Managers: Alan Critchley & Andrea Nixson
 LSCB Business Administrator: Julie Gosling
The Lead Reviewers were Bridget Griffin and Ghislaine Miller; both have considerable experience in
completing serious case reviews and are accredited as Lead Reviewers by the Social Care Institute
for Excellence. The final report was written by Bridget Griffin.
The Perspective of Practitioners
The practitioners who provided services to the children during the time under review, were invited
to contribute to this review. Two learning events were held, these events were well attended by
front line practitioners; over 36 professionals attended and 24 service areas were represented.
Where a more detailed perspective was needed from a particular service area, or when practitioners
were unable to attend the learning events, the Lead Reviewers met with these practitioners. The
perspectives of these front line practitioners are included throughout this report, their experiences
have made a significant contribution to how the Review Panel were able to understand the context
within which they were working, and to the learning detailed in this report . Hillingdon LSCB are
grateful to these practitioners for the time and commitment they have given to this review.
The Perspective of the Children and Family Members
It was hoped that the perspectives of family members could be fully represented in this review.
Regrettably, it has not been possible to gain all their perspectives4. Hillingdon Safeguarding Children
Board are thankful to those members who were able to participate and hope that the perspectives
of those who were unable to participate have been reflected within this report.
Sophie’s mother agreed to meet with the lead reviewer, she explained that although Sophie had
intended to be present at the meeting she had decided she wanted to put all the past behind her
and no longer wanted to be reminded of the very difficult and distressing experiences she had gone
through. Sophie’s mother told the lead reviewer that from her perspective when she most needed
the help of agencies in safeguarding Sophie, she felt she had not been listened to. She spoke about
the time when she noticed that Sophie’s behaviour had changed and how she felt very concerned
for her daughter’s wellbeing, she could not understand what was happening in Sophie’s life to
account for these changes. She spoke about making contact with Sophie’s school and children’s
services to explain her concerns, but felt her concerns were ignored or downplayed; she felt helpless
to bring about any changes for Sophie, and felt she had nowhere to turn. She felt that Sophie had
slipped through the net and been let down by the agencies involved.

4 A number of attempts were made to meet with all the children and their family members. However, three family
members are seriously ill and the current circumstances of two of the children meant that it was not possible for meetings
to take place
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Emma and Ryan’s particular circumstances at the time of this review meant that it was not possible
to meet with them. However, Emma was told about this review and passed the following question to
a member of the panel: why hasn’t (it) been closed down – they didn’t do anything about it. Emma
was referring to the residential establishment that she lived in during a period of time she was living
in Hillingdon. Both Emma and Sarah referred to this establishment and it was clear for them both
that they had felt particularly unsafe whilst living here. This is likely to be attributable to the same
issues that all services seemed to struggle with in recognising CSE and intervening successfully to
safeguard children, but was particularly compounded by the location of this establishment.5
Sarah was happy to meet with the lead reviewer and a meeting took place at her current home.
Sarah spoke at length about her experiences, and a number of clear messages resounded. The first
was on the question that is the title of this report: why didn’t anyone listen? This is a powerful
question that applies to the entire period under review. As can be seen on P. 37 & 38, the
documentation analysed reveals that there were over 30 occasions when professionals were given
information that should have suggested Sarah was at risk of sexual exploitation/was being exploited,
and for Emma there were over 25 occasions. Sarah said she told so many people that in the end: I
gave up.
Sarah also spoke about her experiences of being looked after, she spoke about how much she
missed her brother and wanted to be with him and of how difficult she found moving from one
foster placement to the next (Sarah experienced 7 placement moves over a 3 year period p. 87). She
said she found it particularly difficult to be placed with foster carers who spoke in their own
language in the home: A lot of my foster carers did not speak English at home- I felt uncomfortable
when they spoke to each other in their own language - I felt paranoid that they were speaking about
me – it is important that children feel comfortable and feel part of the family when they are living in
someone else’s home – I felt I did not belong. 6
Sarah is now living with the home of a couple where she clearly feels very contained and cared for-
living within this environment has allowed Sarah to reflect on the care she received during the
period under review. Sarah was very clear in saying she felt she was not cared for during this period
and that what she needed most during this time was very clear boundaries: I needed discipline I felt I
was allowed to do what I wanted – although people (carers) said that I shouldn’t do something –
such as go out late at night- or should do something – like go to school they would just say it but they
didn’t mean it and they didn’t follow it up when I ignored them – I just did not feel they really cared….
they were just saying the thing that they thought they should say – they should have been more
insistent. When Sarah was asked what would have helped her the most during this time she spoke
about being listened to and particularly recalled telling professionals that she was ‘seeing an older
man’: I told them I have a boyfriend and he is 26 …surely someone should have questioned
this…surely it was not right for me… no one seemed to be bothered…I just gave up in the end. Sarah
spoke positively about the support she received during the criminal trial, her views are reflected in
this section (p.117).
1.3 Background: profile of the organisation

5 Close to the home of one of the perpetrators
6 Sarah’s experiences as a Looked after child are explored from P.79 onwards
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